Burin Peninsula Community Health Needs Assessment Report, Navigating the Way Together by Eastern Health

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May 24, 2006

Ms. Joan Dawe Chair Eastern Health Dear Ms. Dawe: I am pleased to submit the Burin Peninsula Community Health Needs Assessment Report, Navigating the Way Together, to the Board of Trustees of Eastern Health. In its strategic plan, the Board of Trustees identified the completion of needs assessments as one of its strategic priorities. The completion of this first needs assessment is a significant step in Eastern Health achieving its vision Healthy People, Healthy Communities. This process has been overseen by a Steering Committee with input from an Advisory Committee comprised of individuals from the Burin Peninsula. Many individuals have contributed to this report and in particular, I acknowledge the people of the Burin Peninsula for their enthusiastic participation in this process. The report contains a number of recommendations. It is up to all of us and our community partners to work together to implement these recommendations and work toward achieving our vision. Yours sincerely,

George Tilley President and Chief Executive Officer Eastern Health

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ACKNOWLEDGEMENTS

We express sincere gratitude to the residents of the Burin Peninsula who were active and enthusiastic participants in this community health needs assessment process. An overriding comment throughout this process was about the strength of the people of the Burin Peninsula. Their passion and love of their community were evident in all aspects of this assessment. Many Eastern Health staff contributed to the process and were very helpful in providing information related to the Burin Peninsula. We acknowledge the following people, in particular, for their contributions: •

Focus group and telephone survey participants and key informants

•

Advisory Committee – Marilyn Hannam, Stella Hollett, Vivian Hollett, Andy Moriarity, Charles Penwell, Ellen Picco, Lisa Slaney, Alphonsus Ward

•

Steering Committee – Wayne Miller (Chair), Pat Coish-Snow, Beth Mayo, Mona RomaineElliot, Ian Kendall, Keith Bowden, Jane Macdonald, NadineWhelan, Susan Bonnell, Lisa Browne

•

IT Working Group: Ian Kendall, Rick Woodman, Gerard Gibbons, Judy-Lynn Wiseman, Chris Clarke, Kevin Durdle, Jamie Osmond

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Memorial University of Newfoundland Health Research Unit, particularly Dr. Veeresh Gadag, T. Montgomery Keough, E. Ann Ryan, Linda Longerich (since retired)

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Nadine Whelan, Focus Group Facilitator

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Wendy Bailey, Michele Keats, Theresa Keating, Doreen Spencer, Focus Group Recorders

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Management Engineering Services, particularly Patricia Rideout

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Library & Information Services, particularly Debra Kearsey, Jaime Jarrett and Barbara Reid

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Michele Keats, administrative support

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Greg Domineaux, Regional Planner, Rural Secretariat, Burin Peninsula

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Angela Benmore, graphic design

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Dr. Rick Singleton, Director of Pastoral Care

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Dr. Jane Green, Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland

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EXECUTIVE SUMMARY

The P r o cess Factors such as social, economic, cultural and physical environment play a role in the health of a community. These determinants of health and their interactions are important to consider when analyzing the health status of a community. For this reason, this needs assessment is based upon the determinants of health model. The Burin Peninsula Community Health Needs Assessment was overseen by a Steering Committee comprised of Eastern Health staff. A public expression of interest to serve on an Advisory Committee was called and people were invited to participate based on their link to a particular determinant of health. This committee provided advice and feedback on the process and outcomes of the needs assessment. Qualitative data was collected through 20 focus groups, 24 key informant interviews and 486 telephone interviews. Eleven written submissions from the public were received. Quantitative data was drawn together from several administrative databases and other sources of secondary data. The P l a ce The Burin Peninsula, located on the south coast of the province of Newfoundland and Labrador, has a population of 23,710, dispersed on a land mass 161 kilometres in length and 40 kilometres at its widest point. The Burin Peninsula has a strong and proud past with a history and culture based on the sea. The area is now in a time of transition. While the fishery is in a state of flux, there is potential in the oil and gas sector given the skilled workforce and the shipyard with its deep water port. Like other rural areas, the Burin Peninsula faces many challenges associated with increasing out-migration rates, decreasing employment levels, aging population, and diversifying its economy. Th e S i t u a t i on This report considers the determinants of health as they relate to the Burin Peninsula. They provide a picture of the peninsula as a whole and the factors that may be having an impact on the health of the people on the peninsula. Socio-Economic Environment - The socio-economic environment is comprised of several determinants of health: income and social status; employment and working conditions; education; social support networks; and social environment. There are many concerns expressed in the area of the socio-economic environment. Overwhelmingly, the lack of employment and out-migration dominate all aspects of the qualitative and quantitative research. The contributors to the research want help sustaining their communities

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through partnerships and networking opportunities in order to build community development and capacity. From an education perspective, there is a perception that there is a lack of focus on healthy living within the school system. There are health-related activities happening in the school system and more are anticipated given the recent release of the provincial wellness plan. Physical Environment - The Burin Peninsula highway is the main issue that arose in terms of the physical environment. Most people saw it as an isolating factor although some people noted that the highway resulted in the peninsula getting more services than they would have ordinarily, given their population. Personal Health Practices and Coping Skills and Gender and Culture - There is a strong desire by a broad cross section of the community to focus on health promotion, prevention and early intervention within the community, particularly for youth and seniors. Healthy Child Development - Parenting education and support is thought to be important for parents of children of all ages. Parenting education is offered on the peninsula and is a priority of the health promotion plan Healthy People, Healthy Communities, Healthier Future. Health Services - People want to see more intersectoral partnerships between government departments/agencies to address health issues in a more holistic and seamless manner. People want to see greater regional and provincial planning of the delivery of health and community services. There were many concerns expressed about primary health care, particularly inequitable access to primary health services on the peninsula. The Burin Peninsula North area does not have access to the same level of services as other areas on the peninsula. People want the best level of service available, particularly within the community. They want a seamless health system that provides collaborative care across the continuum to enhance accessibility, coordination and continuity. People also want an accountable and transparent organization to provide health services. Th e R e c ommen d a t i on s The recommendations arising from this needs assessment are categorized according to Eastern Healthâ&#x20AC;&#x2122;s lines of business as well as a general category of organizational/ administrative issues.

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O r g a ni z at i on a l /A d mi n i st ra tive R ecommendations 1. Ensure that the results of this community health needs assessment are broadly communicated to the public, participants in the focus groups, key informants, staff, and physicians. 2. Provide the Board of Trustees with a semi-annual written report on the status of the recommendations in this report. 3. Provide a public report two years from the release of this needs assessment on the progress made in implementing the recommendations of the report. 4. Enhance communications and actions that lead to increased public knowledge of why decisions are made. Eastern Health must continue to challenge itself to be accountable and transparent to the public. 5. Improve linkages between health providers to enhance client accessibility to available services. •

The management team of Eastern Health, Peninsulas Region, with the department of Health Information Services and Informatics, will investigate the feasibility of coordinated scheduling of specialists and diagnostic appointments.

•

The management team of Eastern Health, Peninsulas Region, will investigate new innovative uses of telemedicine on the Burin Peninsula to reduce the necessity of travel by patients/clients.

•

The management team of Eastern Health, Peninsulas Region, with the department of Health Information Services and Informatics, will investigate the feasibility of providing a toll-free telephone line for use on the Burin Peninsula.

6. Increase the user-friendliness of access to Eastern Health’s programs and services. •

Eastern Health will develop a guide to Eastern Health services available on the Burin Peninsula. This “What, Who and How” guide will facilitate ease of access and will be distributed to the residents of the Burin Peninsula.

•

The Corporate Communications Department will provide guidelines to Eastern Health staff on the development of user-friendly forms.

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7. Develop a Regional Health Services Plan along an integrated continuum within Eastern Health’s regional and provincial mandates and available resources. •

The components of this plan will include mental health; child health services; primary health care; single entry system for community support services; improved access to priority services throughout the region; and a regional plan to address wait lists.

8. Strengthen partnerships between Eastern Health and the Departments of Health and Community Services and Human Resources, Labour and Employment. •

The CEO will establish a committee to review Eastern Health policies in relation to policies established by the Department of Human Resources, Labour and Employment. The goal is to identify negative outcome policies in an effort to provide a more seamless level of care to clients and to foster awareness of each department’s policies and their impact on each other.

9. Partner with other regional integrated health authorities and provincial government departments to ensure awareness of the impact each of the departments has on developing healthy communities. 10. Review Eastern Health’s internal administrative and clinical policies to ensure consistency in the provision of programs and services throughout the region. 11. Eastern Health will finalize, in conjunction with the Department of Works, Services and Transportation and the Department of Health and Community Services, the plans for the redevelopment of the Blue Crest Nursing Home and the construction of the Grand Bank Community Health Centre. 12. Improve the integrity of data collected in the delivery of programs and services and work to integrate community and institutional data and apply it to a population health model. P r o m o t e Hea l t h a n d Wel l - Being R ecommendations 1. Strengthen the commitment to health promotion, prevention and early intervention. •

Continue to implement and communicate the results of the regional health promotion plan Healthy People, Healthy Communities, Healthier Future as well as the supporting document Health Promotion in Action. The priority areas for this plan are nutrition, smoking, physical activity, substance abuse, parenting, prenatal support and child and youth development.

•

Enhance the awareness of Eastern Health staff of the principles of health promotion and the Healthy People, Healthy Communities, Healthier Future and Health Promotion in Action documents.

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•

Increase membership of community groups and agencies on the Burin Peninsula on the Eastern Regional Wellness Coalition.

•

Explore opportunities to enhance parenting education and support within available resources.

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Increase the uptake of cervical screening on the Burin Peninsula through implementation of the rural Eastern Cervical Screening Program.

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Ensure regional input into the Department of Health and Community Services’ plan for Healthy Aging.

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Develop regional strategies for the Burin Peninsula that reflect the provincial government’s overarching strategic plan.

2. Partner with community groups to promote and enhance community development and capacity. •

Eastern Health will develop a model for community linkages on the Burin Peninsula and sponsor a fund, on a pilot basis, to increase community knowledge of the determinants of health and increase the impact people may have on these determinants and their quality of life.

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As an organization with a vision of Healthy People, Healthy Communities, Eastern Health recognizes its leadership and advocacy role within the province. Eastern Health will sponsor a forum, Celebrating Rural Health. This forum will bring partners together to develop creative and innovative solutions to issues facing all rural areas.

•

Eastern Health will promote the concept of establishing a Celebrating Rural Health Week with key partners to highlight and celebrate the innovations occurring in rural areas.

3. Strengthen and create more formal linkages with the Rural Secretariat, Burin Peninsula. •

Rural Secretariats have been established to develop regional visions and priorities, to identify barriers and assets available for attaining success, and to identify the policies and programs that are needed to help move the vision forward. Enhanced linkages with this group to discuss common issues will help to build sustainable communities.

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5. Examine and strengthen linkages at the senior management level with external partners such as school boards and post-secondary institutions to strengthen strategic planning and policy development. P r o v i d e Su p p ort i ve C a re Recommendations 1. Continue to ensure appropriate level of long-term care service by monitoring long-term care bed occupancy rates and wait lists. 2. Develop a marketing plan to increase the number of foster families and alternate family care homes on the Burin Peninsula. 3. Investigate the feasibility of providing home-based palliative care services in line with the regional plan. 4. Provide education opportunities for staff to increase knowledge about complex disabilities in order to provide a supportive role to families and caregivers providing home support. 5. Work with provincial educational institutions to determine the feasibility of providing a personal care home worker/support worker course/program. Tr e a t I l l ness a n d In ju ry Recommendations 1. Install and test CT Scanner at the Burin Peninsula Health Care Centre by August 2006. 2. Establish a Working Group to oversee the development of dialysis services on the Burin Peninsula. 3. Establish an integrated model for the delivery of primary health services on the Burin Peninsula. As part of the development of the model, primary health services currently delivered throughout the peninsula will be reviewed. 4. Establish a single community liaison committee to provide input for the entire peninsula into the community development and community capacity building components of the primary health model. 5. Develop an operational plan for submission to the Department of Health and Community Services to deliver primary health services through a centralized health centre in the Burin Peninsula North area. This would include community, medical and nurse practitioner services. Such services will help to improve the continuity and accessibility of care to patients/clients.

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6. Partner with local stakeholders to establish a Working Group to redesign ambulance services. This should address gaps in the ambulance system particularly in the areas of implementation of provincial policies/standards, advances in scope of practice, medical control, quality control and utilization of ambulance services. 7. Validate the appropriate allocation of inpatient beds using a clinical efficiency model. 8. Communicate to the Department of Health and Community Services and the Newfoundland and Labrador Medical Association the concerns about the one-complaint-per-visit practice. 9. Share outcomes of this needs assessment with community stakeholders to help identify strategies to attract another community-based dentist for the peninsula. 10. Prioritize the needs for capital and equipment resources of the Burin Peninsula as part of Eastern Healthâ&#x20AC;&#x2122;s strategic priorities. 11. Monitor speciality visiting clinics to ensure scheduled programs are consistently offered. 12. Continue to recruit an ophthalmologist to provide visiting clinics on the Burin Peninsula. 13. Implement the approved regional mental health plan within available resources. The underlying premise of the determinants of health is that communities have the knowledge and ability to impact the determinants and thus impact their health. This document is a comprehensive look at the Burin Peninsula as a whole. It is a document that can be used by individuals, communities and organizations to decide how to work on enhancing the health of the communities, not just next year or in five years from now, but in the generations to come.

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TABLE OF CONTENTS 1.

ACKNOWLEDGEMENTS................................................................................ 3

EXECUTIVE SUMMARY ................................................................................. 4

INTRODUCTION .......................................................................................... 18 3.1 What is a Community Health Needs Assessment?...................................................................19 3.2 Limitations ......................................................................................................................................20 3.3 Report Organization......................................................................................................................20

METHODOLOGY......................................................................................... 21 4.1 The Plan ..........................................................................................................................................21 4.2 Determinants of Health Model....................................................................................................23 4.3 Committees Struck ........................................................................................................................25 4.3.1 Steering Committee..............................................................................................................25 4.3.2 Advisory Committee.....................................................................................................................26 4.3.3 Information Technology Working Group.................................................................................26 4.4 Primary Research ...........................................................................................................................26 4.4.1 Focus Groups ................................................................................................................................26 4.4.2 Key Informant Interviews............................................................................................................27 4.4.3 Telephone Survey..........................................................................................................................27 4.4.4 Written Submissions .....................................................................................................................30 4.5 Secondary Research.......................................................................................................................30 4.6 Validating Results ..........................................................................................................................31 4.7 Comparison Areas .........................................................................................................................31 4.8 Communications Plan...................................................................................................................33 4.9 Conclusion ......................................................................................................................................33

THE BURIN PENINSULA: THE PEOPLE AND THE PLACE .............................. 34 5.1 History.............................................................................................................................................34 5.2 Population.......................................................................................................................................35 5.3 Today...............................................................................................................................................39

THE DETERMINANTS OF HEALTH................................................................. 42 6.1 Income and Social Status..............................................................................................................42 6.1.1 What it is and Why it is Important .............................................................................................42 6.1.2 Income and Social Status-Related Findings ..............................................................................43 6.1.3 Income and Social Status Conclusion ........................................................................................46 6.2 Employment and Working Conditions ......................................................................................46

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6.2.1 What it is and Why it is Important .............................................................................................46 6.2.2 Employment and Working Conditions-Related Findings.......................................................47 6.2.3 Employment and Working Conditions Conclusion.................................................................50 6.3 Social Support Networks..............................................................................................................51 6.3.1 What They Are and Why They Are Important.........................................................................51 6.3.2 Social Support Networks-Related Findings...............................................................................51 6.3.3 Social Support Networks Conclusion ........................................................................................53 6.4 Education........................................................................................................................................53 6.4.1 What it is and Why it is Important.....................................................................................53 6.4.2 Education-Related Findings ........................................................................................................54 6.4.3 Education Conclusion ..................................................................................................................56 6.5 Social Environment.......................................................................................................................57 6.5.1 What it is and Why it is Important.....................................................................................57 6.5.2 Social Environment-Related Findings........................................................................................57 6.5.3 Social Environment Conclusion .................................................................................................58 6.6 Physical Environment ...................................................................................................................59 6.6.1 What it is and Why it is Important.....................................................................................59 6.6.2 Physical Environment-Related Findings....................................................................................59 6.6.3 Physical Environment Conclusion .............................................................................................61 6.7 Personal Health Practices and Coping Skills .............................................................................62 6.7.1 What it is and Why it is Important .............................................................................................62 6.7.2 Our Findings..................................................................................................................................62 6.7.2.1 Health Status.....................................................................................................................62 6.7.2.2 Smoking.............................................................................................................................63 6.7.2.3 Alcohol/Drugs .................................................................................................................64 6.7.2.4 Gambling...........................................................................................................................64 6.7.2.5 Physical Activity ...............................................................................................................65 6.7.2.6 Healthy Eating..................................................................................................................65 6.7.2.7 Obesity...............................................................................................................................66 6.7.2.8 Heart Health .....................................................................................................................67 6.7.2.9 Health Practices................................................................................................................67 6.7.2.10 Sexual Health ....................................................................................................................68 6.7.3. Personal Health Practices and Coping Skills Conclusion.......................................................69 6.8 Healthy Child Development ........................................................................................................69 6.8.1 What it is and Why it is Important .............................................................................................69 6.8.2 Healthy Child Development-Related Findings .........................................................................70 6.8.3 Healthy Child Development Conclusion...................................................................................73 6.9 Biology and Genetic Endowment...............................................................................................73 6.9.1 What it is and Why it is Important .............................................................................................73 6.9.2 Biology and Genetic Endowment-Related Findings................................................................73 6.9.3 Biology and Genetic Endowment Conclusion .........................................................................74 6.10 Gender and Culture.......................................................................................................................74 6.10.1 What it is and Why it is Important.....................................................................................74

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6.10.2 Gender and Culture-Related Findings .....................................................................................74 6.10.3 Gender and Culture Conclusion ...............................................................................................77 7.

HEALTH SERVICES....................................................................................... 77 7.1 What It Is and Why It Is Important ...........................................................................................77 7.2 Overview of Health Service Available on the Burin Peninsula ..............................................78 7.3 Health Promotion..........................................................................................................................81 7.3.1 Perception of Health Promotion ................................................................................................81 7.3.2 Health Promotion: What Is Available ........................................................................................82 7.3.3 Health Promotion Conclusion ....................................................................................................83 7.4 Primary Health Services................................................................................................................84 7.4.1 Primary Health Services Perceptions..........................................................................................84 7.4.2 General Practitioner Services: What is Available.....................................................................86 7.4.3 Community Health Nursing and Nurse Practitioner Services: What is available..............90 7.4.4 Dental Care Services: What is Available ...................................................................................94 7.4.5 Ambulance Services: What is Available .....................................................................................94 7.4.6 Primary Health Services Conclusion ..........................................................................................94 7.5 Secondary Health Services............................................................................................................97 7.5.1 Perception of Secondary Health Services ..................................................................................97 7.5.2 Secondary Health Services: What is Available ..........................................................................98 7.5.3 Secondary Health Services Conclusion................................................................................... 101 7.6 Mental Health Services and Addictions Services ................................................................... 102 7.6.1 Perceptions of Mental Health Services and Addictions Services ........................................ 102 7.6.2 Mental Health Services and Addictions Services: What is Available.................................. 102 7.6.3 Mental Health Services and Addictions Services Conclusion.............................................. 105 7.7 Long-Term Care ......................................................................................................................... 105 7.7.1 Perception of Long-Term Care................................................................................................ 105 7.7.2 Long-Term Care: What is Available ........................................................................................ 105 7.7.3 Long-Term Care Conclusion.................................................................................................... 107 7.8 Home supports ........................................................................................................................... 107 7.8.1 Perception of Home Supports ................................................................................................. 107 7.8.2 Home Support: What is Available ........................................................................................... 107 7.8.3 Home Supports Conclusion ..................................................................................................... 109 7.9 Child, Youth and Family Services ............................................................................................ 109 7.9.1 Perception of Child, Youth and Family Services................................................................... 109 7.9.2 Child, Youth and Family Services: What is Available ........................................................... 109 7.9.3 Child, Youth and Family Services Conclusion....................................................................... 112 7.10 Palliative Care .............................................................................................................................. 112 7.10.1 Perception of Palliative Care .................................................................................................. 112 7.10.2 Palliative Care: What is Available........................................................................................... 112 7.10.3 Palliative Care Conclusion ...................................................................................................... 112 7.11 Accessibility and Waitlist ........................................................................................................... 113 7.11.1 Perception of Accessibility and Wait List ...................................................................... 113

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7.11.2 Accessibility and Wait List Status .......................................................................................... 113 7.11.3 Accessibility and Wait List Conclusion................................................................................. 119 7.12 Health Services Conclusion....................................................................................................... 119 8.

DETERMINANTS OF HEALTH SUMMARY OF THE BURIN PENINSULA ........ 121

THE CHALLENGES OF SETTING PRIORITIES AND MAKING DECISIONS... 123

10. ISSUES, RECOMMENDATIONS AND ACTIONS ........................................ 124 10.1 Organizational/Administrative Issues ..................................................................................... 125 10.2 Promote Health and Well-Being .............................................................................................. 128 10.3 Provide Supportive Care............................................................................................................ 131 10.4 Treat Illness and Injury .............................................................................................................. 133 11. CONCLUSION .......................................................................................... 137 12. APPENDICES............................................................................................. 138 12.1 Appendix A - Terms of Reference – Steering Committee ................................................... 138 12.2 Appendix B - Terms of Reference – Advisory Committee.................................................. 139 12.3 Appendix C – Representatives/Organizations Invited to Attend Focus Group Sessions ........................................................................................................................................ 140 12.4 Appendix D - Listing of Key Informants ............................................................................... 145 12.5 Appendix E – Burin Peninsula Health and Community Needs Assessment Telephone Survey Results Fall 2005 ........................................................................................ 146 12.6 Appendix F - Written Submissions Request........................................................................... 147 12.7 Appendix G - Written Submissions Received........................................................................ 148 12.8 Appendix H - Secondary Sources............................................................................................. 149 12.9 Appendix I - Listing of Eastern Health Staff Consulted On Issues Arising from the Community Health Needs Assessment................................................................................... 154 12.10 Appendix J – Newsletters .......................................................................................................... 155 12.11 Appendix K - Community Accounts ....................................................................................... 156 13. ENDNOTES ................................................................................................ 157

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TABLE OF FIGURES Figure 1: Figure 2: Figure 3: Figure 4: Figure 5: Figure 6: Figure 7: Figure 8: Figure 9: Figure 10: Figure 11: Figure 12: Figure13: Figure 14: Figure 15: Figure 16: Figure 17: Figure 18: Figure 19: Figure 20: Figure 21: Figure 22: Figure 23: Figure 24: Figure 25: Figure 26: Figure 27: Figure 28: Figure 29: Figure 30: Figure 31: Figure 32: Figure 33: Figure 34: Figure 35:

Eastern Health’s Geographic Region................................................................................. 18 Steps in the Community Health Needs Assessment Process ................................................... 21 Map of Burin Peninsula ................................................................................................. 22 The Determinants of Health............................................................................................ 25 Burin Peninsula Telephone Survey Population Age Distribution ............................................ 28 Burin Peninsula Telephone Survey Age Group and Gender of Survey Respondents..................... 29 Burin Peninsula Telephone Survey Yearly Household Income Distribution ............................... 29 Rural Secretariat Regions ............................................................................................... 32 Burin Peninsula Population Change 1996-2001 ................................................................ 35 Burin Peninsula Population Projections, Medium Scenario, 2002-2019 .................................. 36 Primary, Elementary, Junior and Senior High School Student Enrolment Burin Peninsula ......... 37 Population Pyramid, Burin Peninsula, Census 1986 – Burin Peninsula Rural Secretariat Region.......................................................................................................... 38 Population Pyramid, Burin Peninsula, 2011 (projected) - Burin Peninsula Rural Secretariat Region.......................................................................................................... 38 Median Ages of Rural Secretariat Regions ......................................................................... 39 Infrastructure of Map of Burin Region............................................................................... 41 Personal Income Per Capita By Rural Secretariat Regions 2003 ............................................ 43 Self-Reliance Ratios, Rural Secretariat Regions................................................................... 44 Comparison of Percentage of Social Assistance Recipients at Some Point in 2003 ...................... 45 Burin Peninsula Telephone Survey Low Income Cut-Off by Area........................................... 46 Firms on the Burin Peninsula ........................................................................................ 47 Decline in number of firms on the Burin Peninsula from 1999-2004 ...................................... 48 Burin Peninsula Telephone Survey Top Five Community Problems by Area ............................. 49 Percentage of Burin Peninsula Population that Worked Full Year in 2000 (50+ weeks) ........... 50 Burin Peninsula Migration Rate 1991-1996 .................................................................... 52 Burin Peninsula Rural Secretariat Region, Highest Level of Education, Aged 20+ 2001, Population 20+................................................................................... 54 Education Attainment, Rural Secretariat Regions, 2001...................................................... 55 Percentage of Population Aged 25-29 Not Completed High School......................................... 56 Burin Peninsula Telephone Survey Self-Reported Health Status ............................................. 63 Weekly Cost of Eating in NL in 2003 for a Family of Four................................................ 65 Burin Peninsula Telephone Survey Body Mass Index (BMI) by Gender .................................. 66 Burin Peninsula Telephone Survey Self-Reported Health Rating by Body Mass Index (BMI) ...... 66 Dialogue on Heart Health, Eastern Newfoundland Health and Community Services Region....... 67 Burin Peninsula Telephone Survey Self-Reported Incidence of Chronic Disease by Area .............. 68 Initiating Breastfeeding as a Percentage of Live Births........................................................... 71 Program Participation 2004/05 – Number of different individuals who participated in at least one session...................................................................................................... 72

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Burin Peninsula Telephone Survey Self-Reported Preventative Tests – Gender Specific ................ 75 Burin Peninsula Telephone Survey Time of Last PAP Test .................................................. 75 Grace Sparkes Home, Shelter Statistics............................................................................. 76 General Practitioners on the Burin Peninsula...................................................................... 86 Burin Peninsula Telephone Survey General Practitioner Utilization Per Person Per Visit Per Year........................................................................................................ 87 Burin Peninsula Telephone Survey Respondents Who Have a Regular Family Doctor by Area .... 88 Burin Peninsula Telephone Survey Respondents Able to See Regular Family Doctor by Area ...... 89 Burin Peninsula Telephone Survey Time Needed to Schedule an Appointment with a “Particular Family Doctor” by Area.............................................................................. 89 Number of Home Visits by Community Health Nurse from Burin Peninsula Worksites 2003-2005................................................................................................... 92 Number of Clinic Visits to Burin Peninsula Community Health Offices.................................. 93 Number of Registrations for Nurse Practitioner Services, Grand Bank and St. Lawrence ........... 93 Health Care Facilities and Distances from Neighbouring Communities ................................... 95 Specialists on the Burin Peninsula .................................................................................... 98 Burin Peninsula Telephone Survey Specialist Utilization Rate By Area................................... 99 Occupancy levels at the Burin Peninsula Health Care Centre, 2002-03, 2003-04, 2005-06 ...... 99 Speciality Clinics Offered on the Burin Peninsula with Number of Patients Seen ..................... 100 Burin Peninsula Telephone Survey Household Members who Needed to Travel Outside Burin Peninsula for any Health Service by Area ............................................................... 101 Wait list and New Referrals for Mental Health Services, Burin Peninsula ............................. 103 New Clients and Waiting Lists for Addictions Services, Burin Peninsula, 2002/03 – 2004/05 ................................................................................................. 103 Services Provided through the Burin and Grand Bank Offices .............................................. 104 Number of Visits to Psychiatrists on the Burin Peninsula During Past Three Years ................ 104 Occupancy Rates and Waiting Lists for Long-Term Care Facilities, Burin Peninsula............... 106 Personal Care Homes, Location, Subsidized Beds and Total Bed Numbers, Burin Peninsula.... 106 The Number of Requests for Home Support Versus the Number of Approvals....................... 108 Annual Cost of Home Support for the Burin Peninsula for the Past Three Years .................... 108 Number of Children in Care and Number of Foster Homes, Average per Month .................... 110 Child, Youth and Family Services, Community Corrections, Number of Youth on Probation and Number of Youth in Custody, Average Per Month........................................ 110 Child, Youth and Family Services, Community Corrections, Number of Long Term Protection Cases, Average Per Month ............................................................................. 111 Child, Youth and Family Services, Community Corrections, Number of Referrals to Child, Youth and Family Services............................................................................................ 111 Burin Peninsula Telephone Survey Respondents Able to Obtain Services When Needed............ 113 Burin Peninsula Telephone Survey Prevented Service .......................................................... 114 Burin Peninsula Telephone Survey Barriers/Obstacles to Receiving Health Services.................. 114

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Burin Peninsula Telephone Survey Respondentsâ&#x20AC;&#x2122; Biggest Barrier to Obtaining Health Services by Area ............................................................................................... 115 Burin Peninsula Telephone Survey Respondents by Area Who Have Regular Family Doctor by Length of Time Cared For .............................................................................. 115 Wait Lists in Weeks for Speciality Services at the Burin Peninsula Health Care Centre and the Dr. G.B. Cross Memorial Hospital, Clarenville..................................................... 116 Eastern Healthâ&#x20AC;&#x2122;s Vision Statement and Lines of Business .................................................. 124 Organizational/Administrative Issues by Source Grid ....................................................... 126 Promote Health and Well-Being Issues by Source Grid....................................................... 129 Provide Supportive Care Issues by Source Grid ................................................................. 132 Treat Illness and Injury Issues Grid................................................................................ 134

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INTRODUCTION

Eastern Health was formed on April 1, 2005, from the merger of seven health care organizations. Eastern Health provides the full continuum of health services, including community, acute and longterm care. It is the largest health services organization in the province of Newfoundland and Labrador and has both regional and provincial responsibilities. As seen in the figure below, the Eastern Health region extends west from St. Johnâ&#x20AC;&#x2122;s to Port Blandford and includes all communities on the Avalon, Burin and Bonavista Peninsulas. Figure 1: Eastern Healthâ&#x20AC;&#x2122;s Geographic Region

Prior to the founding of Eastern Health, two health boards were responsible for health and community services on the Burin Peninsula: the Eastern Health and Community Services Board (EHCSB) and the Peninsulas Health Care Corporation (PHCC). The EHCSB offered a broad range of health and social work services and programs to the communities of its catchment area while the

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PHCC offered institutional acute care and long-term care services. In the past, both the EHCSB and PHCC conducted needs assessments on the Burin Peninsula. These two separate activities were completed in 2000 and 2001. The creation of Eastern Health provided the opportunity to complete a community health needs assessment based on the full continuum of health and community services. The Board of Trustees has identified needs assessments as one of its strategic priorities, and the Burin Peninsula is the first area of the Eastern Health region to have a needs assessment completed. Understanding the needs of communities will ultimately provide Eastern Health with evidencebased knowledge to help it work towards its vision of Healthy People, Healthy Communities.

3.1

What is a Community Health Needs Assessment?

A community health needs assessment gathers information about the health of a particular area from both a factual and an opinion perspective. Once issues are identified, they are prioritized and recommendations are made around the issues. A needs assessment has a number of benefits, including: •

Enhanced Understanding – A needs assessment provides the Board of Trustees with a better understanding of what a community feels it needs in order to be healthier. In addition to asking for opinions and perceptions (qualitative information), a needs assessment typically includes quantitative information such as demographics and health services utilization rates. This data helps to build a comprehensive picture of the geographic area.

•

Increased Dialogue - One of the main advantages of the health needs assessment is the initiation of dialogue with many individuals and groups from the community. Such dialogue can strengthen community participation and engagement in the health of their region and lead to stronger partnerships between the community and its health board.1

•

Enhanced Community Capacity - The Board of Trustees of Eastern Health recognizes that communities have the capacity to identify and respond to issues that are of concern to them. Eastern Health is committed to working with communities to address the needs identified through the assessment process. In several circumstances the solutions to the issues that have been identified require multi-sectorial partnerships and will require considerable collaboration over an extended period of time.

Health is very much affected by factors outside of the health system. This community health needs assessment report will be of interest to many sectors, as it provides an overview of the Burin Peninsula from a variety of perspectives. There are opportunities to link with other sectors to affect change.

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Limitations

One of the challenges associated with a community health needs assessment is ensuring that there are opportunities for people to provide input into the process. While it is impossible to speak with everyone regarding health needs, various mechanisms were used to provide people with an opportunity to participate. Statistical information is used throughout the report to provide as comprehensive a picture of the Burin Peninsula as possible. Such data has a lag time between when the data was collected and when it was released. The last Census, for example, was in 2001 so information from that source will be five years old. In addition, the process of conducting a comprehensive needs assessment must be carried out over several months during which the process itself and other external events will impact the results of the research. During the data collection and report writing phases of this report two significant announcements related to health services were released; the allocation of $11 million to construct a new primary health clinic in Grand Bank and to redevelop the Blue Crest Inter-Faith Home and the provision of a dialysis unit. Other economic events such as the conclusion of a major project at the Marystown shipyard and fears related to the restructuring of FPI directly impact the context in which the research was conducted.

3.3

Report Organization

This report is organized as follows: Section 1 acknowledges the people who provided support to the needs assessment process. Section 2 is the executive summary of the report. Sections 3 and 4 focus on community needs assessments in general and the specific methodology used to complete a needs assessment on the Burin Peninsula. Section 5 provides a context for the report by providing the history of the Burin Peninsula, its population and its current situation. Sections 6 and 7 consider the determinants of health, their impact on health and the finding of the needs assessment as they pertain to each determinant of health. Section 8 provides a summary of the determinants of health as they are on the Burin Peninsula. Section 9 provides the context for decision-making of health care workers and the expectations of the public. Section 10 reviews the issues arising from the needs assessment and lists recommendations by Eastern Healthâ&#x20AC;&#x2122;s lines of business.

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METHODOLOGY The Plan

On September 21, 2005, an external stakeholder meeting was held in Marystown, coinciding with the Eastern Health monthly Board of Trustees meeting. The stakeholder meeting provided the opportunity to give background information on Eastern Health and present general information about community health needs assessments and the process to be used on the Burin Peninsula. The plan for the needs assessment, as visualized in the figure below, included collecting data from primary and secondary qualitative and quantitative sources, prioritizing issues and developing a plan of action.2 At the completion of the Burin Peninsula needs assessment, the process is to be reviewed and evaluated. This evaluation will assist Eastern Health with future needs assessments in other areas of the region. Figure 2: Steps in the Community Health Needs Assessment Process3

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To understand the needs of the various areas of the Burin Peninsula and to gain greater local focus for some data collection, the peninsula was divided into four geographic areas as indicated in Figure 3 below. Figure 3: Map of Burin Peninsula

Burin Peninsula North Population 4,130 17.4%

Grand Bank/Fortune Area Population 5,280 22.2%

Marystown/Burin Area Population 11,520 48.5%

St. Lawrence Area Population 2,775 11.7%

The communities in these areas are as follows: Burin Peninsula North –English Harbour East; Grand Le Pierre; Terrenceville; Harbour MilleLittle Harbour; Boat Harbour; Little Bay; Bay L’Argent; St. Bernard’s-Jacques Fontaine; Jean De Baie; Red Harbour; Rushoon; Baine Harbour; Parker’s Cove; Petit Forte; Southeast Bight; Brookside; Monkstown; Davis Cove Marystown/Burin Area – Spanish Room; Marystown; Beau Bois; Fox Cove/Mortier; Port au Bras; Burin; Epworth-Great Salmonier; Lewin’s Cove; Winterland; Frenchman’s Cove; Garnish Grand Bank/Fortune Area – Grand Beach; Grand Bank; Fortune; Point May; Lamaline; Point au Gaul St. Lawrence Area – Lord’s Cove; Lawn; St. Lawrence; Little St. Lawrence

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Determinants of Health Model

There are a number of models that can be used to develop a health needs assessment report. For this report, the World Health Organization’s (WHO) definition of health will be used. This definition states that health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.4 In 1974, A New Perspective on the Health of Canadians (Lalonde Report) promoted the idea that the health and well-being of Canadians involves more than the health care system. The report suggested that adoption of healthier lifestyles and improvements in the social and physical environments in which people live would be the principal means of improving the health of Canadians. That report established a framework for the key factors that determine health status.5 A 1986 report, Achieving Health for All: A Framework for Health Promotion, expanded on the 1974 report and helped to focus society on the underlying prerequisites or determinants of health and illness. It suggested that a number of influences and their interaction had major impacts on the health and well-being of a population. Factors such as social, economic, cultural and physical environment play a role -for better or worse- in the health of a community. This means that making improvements in the health and well-being of Canadians must go beyond delivery of health care services and include action on the broad determinants of health. 6 There are two key beliefs for working with the determinants of health: 1) Communities have the strengths, knowledge and skills necessary to originate programs which influence the determinants of health and which promote overall health and well-being. 2) Individuals have an important role to play in making communities a healthier place to live.7 The determinants of health as outlined by Health Canada are briefly defined below.8 examined in more detail in Section IV: The Determinants of Health.

They are

•

Income and social status – The healthiest populations are those in societies which are reasonably prosperous and have an equitable distribution of wealth. Income also affects health by increasing opportunities and providing individuals with a sense of control.

•

Employment and working conditions – Unemployment, underemployment, stressful or unsafe work are associated with poorer health.

•

Social support networks – Support from families, friends and communities is associated with better health and helps to give people a sense of control over life circumstances.

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•

Education – People who are more educated usually have better health status. They have more job opportunities, greater job security, higher job satisfaction and higher incomes.

•

Social environments – A cohesive community can provide a supportive society that reduces or avoids many potential risks to good health.

•

Physical environments – Contaminants in the air, water, food and soil can cause a variety of adverse health effects and housing, indoor air quality and design of communities and transportation systems can impact health.

•

Personal health practices and coping skills – Individual actions that support healthy choices and lifestyles are key influences on health.

•

Healthy child development – Before a child is born and up to the age of five is an important time in a child’s development when they learn skills and personal health practices that will be used throughout their lives.

•

Biology and endowment – Genetic endowment provides an inherited predisposition to a wide range of individual responses that affect health status.

•

Gender and culture – Women and men have different health issues and can be impacted by the same issues in different ways. Society’s expectations of gender roles and differences in power and control can also impact health.

•

Health services – Health services have an impact on health, particularly those designed to maintain and promote health, prevent disease and to restore health and function.

Some of these determinants can be controlled by individuals and some cannot. Each of the determinants and their interactions are important when analyzing the health status of a community. As seen in Figure 4, the determinants of health are inextricably bound.

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Figure 4: The Determinants of Health

4.3

Committees Struck

4.3.1 Steering Committee A Steering Committee comprised of staff of Eastern Health was struck to oversee the development of the community health needs assessment. The committee approved the plan for the needs assessment, reviewed each step in the process and developed the recommendations and actions for the report. The Terms of Reference for this Steering Committee are in Appendix A.

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4.3.2 Advisory Committee To engage the community in the needs assessment, an Advisory Committee comprised of individuals from the Burin Peninsula was established to give advice and feedback on the process and outcomes of the needs assessment. A public invitation was extended for interested individuals to submit an expression of interest to sit on the committee. Individuals were requested to indicate their linkage to one or more of the determinants of health and were then invited to participate on the committee based on their link to a particular determinant of health. The Advisory Committee provided input into the plan for the needs assessment, provided feedback on sections of the report and discussed the findings and recommendations. The Terms of Reference for the Advisory Committee are in Appendix B. 4.3.3 Information Technology Working Group An Information Technology Working Group was established to explore linkages between various sources of health information. Membership of this group consisted of staff from Eastern Healthâ&#x20AC;&#x2122;s departments of Information Management and Technology, Health Information Services and Informatics, and Corporate Strategy and Research. This group reviewed utilization information and statistics from two software applications and embedded the information into COGNOS, a business intelligence tool for the purpose of improved analysis.

4.4

Primary Research

Primary data refers to original research completed for a specific issue.9 In this case, primary research was conducted to help determine the community health needs of the Burin Peninsula. Within the time and financial resources of the assessment, a primary research plan was developed to include focus group sessions, key informant interviews and telephone surveys. 4.4.1 Focus Groups A focus group session provides an opportunity for a small number of participants to get together in a facilitated discussion. Because participants respond to each other's comments as well as to questions posed by the facilitator, a rich and dynamic conversation can occur.10 For each of the four geographic areas of the peninsula, focus group sessions occurred with community stakeholders (civic, business, active residents and community leaders); health providers (staff of Eastern Health and health providers in the community); partners (government and community-based organizations who address various aspects of the determinants of health) and municipal leaders of Burin Peninsula towns. In addition, a peninsula-wide focus group was held with partners of Eastern Health such as the RCMP and Brighter Futures. The Advisory Committee took part in a focus group as did the family practice group and the specialist group of the Burin Peninsula Health Care Centre. In total, twenty

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focus group sessions were held. Organizations invited to attend the focus group sessions are listed in Appendix C. Telephone contact was made with potential participants inviting them to take part. Each focus group consisted of 12-14 participants and sessions lasted between 90-115 minutes with questions addressing community issues, health concerns, current capacity, perceived service gaps and areas/opportunities for improvement. The same questions were asked at each focus group session. In addition to the facilitator, each focus group was attended by a recorder to capture comments from participants, and most sessions were audiotaped for use by the facilitator and recorder to ensure the accuracy of the data captured. Participants signed consent forms prior to taking part in the sessions. 4.4.2 Key Informant Interviews A key informant interview is a one-on-one discussion with a community resident who is in a position to know the community as a whole, or has knowledge of a relevant subject, in this case, a determinant of health.11 For the Burin Peninsula needs assessment, twenty-four people were identified as key informants. These key informants were staff of Eastern Health and external individuals who were identified for their leadership or knowledge of various determinants of health. The interviews provided overall general perspectives about the Burin Peninsula, the determinants of health and the health of the community. Interviews took place in person or by phone. A listing of key informant participants is included in Appendix D. 4.4.3 Telephone Survey The Health Research Unit, Division of Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, developed a telephone survey tool in consultation with the Steering Committee. The survey was based upon a previous Health Research Unit survey instrument for the Grenfell Regional Health Services Community Needs Assessment and the General Practice Assessment Survey.12 Some of the questions asked were applicable to the respondent only, while others related to the entire household the respondent represented. Verbal consent was obtained from eligible household residents, those 19 years or older and knowledgeable about the health care utilization and issues of the household. Residential telephone numbers were obtained from a computer database within the four areas of the Burin Peninsula. Numbers were randomized to produce the working telephone contact list. A maximum of seven attempts were made for each telephone number at different times of the day and days of the week. The peninsula was divided into four geographic areas (see Figure 3). Trained telephone interviewers solicited interviews from the phone list until the required proportional sample from each area of the region was completed. Of the 595 residents contacted and eligible, 486 consented to be interviewed, for an 82% response rate. This sample size, distributed proportionally to the regional population

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size, allows for cross comparison among the four areas at the stated level of significance. A 5% significance when applied to statistical tests means that the stated conclusions are true 19 times out of 20. The sample size for the four geographic areas of the peninsula were calculated to be: Burin Peninsula North: 85; Marystown/Burin Area: 235; St. Lawrence Area: 108; Grand Bank/Fortune Area: 58. A pilot of nine surveys was conducted and no major changes to the survey were required after the pilot. The 486 surveys represent a total of 1239 household members. Completed surveys were entered into the statistical software package SPSS and analyzed by the Health Research Unit at Memorial University. Open-ended questions and comments were coded before data entry. Health services utilization is based on the respondentâ&#x20AC;&#x2122;s recall of events in the year previous to the interview (November 2004 â&#x20AC;&#x201C; November 2005). All health and lifestyle responses are self-reported. Figure 5 shows the telephone survey sample compared to age group percentages from 2001 Census data for the province and Canada. Seventy-nine (78.9%) percent of the household members in the sample were 19 years of age and older. The percentage of population 20 years of age and older for the province and Canada is 75.0% and 75.4%, respectively.13 Since the Burin Peninsula data is for those 19 years of age and older, and the provincial and national data is for those 20 years of age and older, statistical tests to compare the populations are not possible. However, there is some similarity with respect to the data. Figure 5: Burin Peninsula Telephone Survey Population Age Distribution A ge

B u r in S amp l e

N e w f o un d l a n d & L a b r a do r *

C a n ad a *

Under the age of 19 19 years and older

262 (21.2%) 977 (78.9%) 1239 (100.0%)

128 (25.0%) 384 (75.0%) 512 (100.0%)

785 (24.6%) 2407 (75.4%) 3192 (100.0%)

Total

NL and Canada number x 103. Community Accounts 2001 census data (website: www.communityaccounts.ca). Sampling based on those under the age of 20 and 20 years and older.

Of the 486 respondents, 76.3% were females while 23.7% were males (one respondent would not provide this information). Figure 6 shows the distribution of age and gender for the respondents. Although the total number of female respondents is greater than male, there is similar age distribution for the two genders.

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Figure 6: Burin Peninsula Telephone Survey Age Group and Gender of Survey Respondents G e nd e r Male Female Total

A ge 20 to 34

A ge 35 to 64

A ge 65 & o l de r

T o ta l

10 (9%) 46 (13%) 56 (11.6%)

86 (75%) 260 (70%) 346 (71.5%)

19 (17%) 63 (17%) 82 (16.9%)

115 (100%) 369 (100%) 484* (100.0%)

*Two respondents did not either indicate age or how many lived in household.

There were significantly more people between the ages of 35 and 64 in the Burin sample when compared to provincial and national data.14 There were also more females than males in the Burin sample; however, this finding is not uncommon, as men tend to participate in surveys less frequently than women.15 Ninety percent (90%) of respondents provided detailed household income information. All income brackets were represented in the sample population (see Figure 7). Figure 7: Burin Peninsula Telephone Survey Yearly Household Income Distribution I nc ome Lev e l Less than 4,000 5,000 to 9,999 10,000 to 14,999 15,000 to 19,999 20,000 to 29,999 30,000 to 39,999 40,000 to 59,999 60,000 to 79,999 80,000 or more Total

Ć&#x2019; (%) 1 (0.2%) 14 (3.2%) 51 (11.6%) 34 (7.8%) 67 (15.3%) 94 (21.5%) 92 (21.0%) 48 (11.0%) 37 (8.4%) 438 (100.0%)

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The Burin Peninsula Health and Community Needs Assessment Telephone Survey Results Fall 2005 completed by the Health Research Unit at Memorial University of Newfoundland is in Appendix E. The survey instrument is included in that document. 4.4.4 Written Submissions A public request for written submissions was made to provide the opportunity for as many stakeholders as possible to have input into the needs assessment. An advertisement was placed in the local newspaper, the Southern Gazette, posted on cable stations and forwarded to the Marystown/Burin Chamber of Commerce and the Rural Secretariat â&#x20AC;&#x201C; Burin Peninsula, for distribution. The advertisement was forwarded to Eastern Health employees and Burin Peninsula general practitioner offices. The advertisement was also provided to focus group participants. A copy of the advertisement is in Appendix F. Eleven submissions were received and the general topics of the submissions are included in Appendix G.

4.5

Secondary Research

Secondary research is information or data that has been collected for a purpose other than the issue currently being studied.16 For example, a broad study about the health status of the province can provide some insight into how the Burin Peninsula compares to the province. While the study was not completed for this needs assessment, it can assist in broadening the understanding of the subject matter. There is a substantial amount of existing information about health and health care issues in Newfoundland and Labrador. Significant research was completed by two of Eastern Healthâ&#x20AC;&#x2122;s founding boards, the Peninsulas Health Care Corporation (PHCC) and the Eastern Health and Community Services Board (EHCSB). This secondary information is of particular interest since these two former health organizations provided services to the Burin Peninsula. The Province of Newfoundland and Labradorâ&#x20AC;&#x2122;s Community Accounts (www.communityaccounts.ca), an information system that monitors indicators of well-being in communities and provides information on a wide variety of topics, provided excellent secondary research on the Burin Peninsula. Utilization information and statistics from two internal information management software applications (Meditech and Client Referral Management System) were collected and reviewed. An environmental scan also helped to provide insight into general trends that impact on the determinants of health. For example, while the needs assessment was being completed, one of the largest employers on the Burin Peninsula, Fishery Products International, announced an operational review. This prompted much speculation in the media and among the residents of the peninsula

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about the future of the FPI plants on the peninsula. Employment levels in the area will obviously be greatly affected by any FPI changes in operations. A listing of the secondary sources reviewed is in Appendix H.

4.6

Validating Results

Once the primary and secondary research had been collected, the Advisory Committee and the Steering Committee were provided with the results. In addition to these two committees, internal Eastern Health staff were consulted to gain further understanding and insight into the issues referenced in the data collection stage and the subsequent recommendations. A listing of the people consulted is in Appendix I.

4.7

Comparison Areas

The provincial governmentâ&#x20AC;&#x2122;s Community Accounts, an information system that monitors indicators of well-being in communities, provided the opportunity to compare the determinants of health on the Burin Peninsula with other areas of the province. This helped to benchmark the Burin Peninsula as compared with other areas of the province. The Burin Peninsula is a Rural Secretariat region and, for most comparisons, the Rural Secretariat regions in the province are used. These regions are outlined on the map in Figure 8.17

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Figure 8: Rural Secretariat Regions

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Communications Plan

A communications plan was developed to support the needs assessment, to actively engage community leaders in communicating the importance and outcomes of the assessment, and to provide opportunities for all stakeholders to participate in the assessment. The local media on the Burin Peninsula and Eastern Healthâ&#x20AC;&#x2122;s internal newsletter published ongoing information about the needs assessment. Burin Peninsula Community Health Needs Assessment Newsletters were distributed on a monthly basis beginning November 2005. These newsletters were distributed internally within Eastern Health and forwarded to focus group participants. Distribution occurred electronically whenever possible. Copies of the newsletters are in Appendix J.

4.9

Conclusion

The plan for this community health needs assessment was very comprehensive and attempted to ensure significant opportunities for broad participation from internal and external individuals. In addition to broad participation, another goal of the process was to identify multiple sources that indicate similar trends and issues, a process known as triangulation of the data. The overall plan and process was extensive and comprehensive.

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THE BURIN PENINSULA: THE PEOPLE AND THE PLACE

Located on the south coast of the island of Newfoundland, the Burin Peninsula is 161 kilometres in length and 40 kilometres at its widest point. The shape of the peninsula gives it the nickname â&#x20AC;&#x153;The Bootâ&#x20AC;?.

5.1

History

Traditionally, the Burin Peninsula has been the heart and soul of the Grand Banks fishery. Since the 1500s, people there have been catching, producing and marketing fish. The fishery still plays a role in the economy of the region. It is adjacent to the only remaining cod fishery in the province, 3PS. Fish plants are currently located in Fortune, Grand Bank, Marystown and Burin although as this report is being written, significant restructuring appears imminent in fish processing on the peninsula. Not surprisingly, given such a marine tradition and history, there have been many sea tragedies which have been woven into the history of the peninsula. In November 1929, a tsunami killed 27 people and destroyed many houses, boats and stages along with fish harvest, food, and fuel oil supplies along the coast from Fortune to Port au Bras. At the time, the tsunami had a devastating impact on the economy of the area. 18 In addition to the many schooners leaving Burin Peninsula ports and becoming lost at sea, there have been many ships from other lands that have run into trouble off the Burin Peninsula. The most well known is the 1942 sinking of two American ships, the Truxton and Pollux off Chambers Cove near St. Lawrence. Over 200 sailors died and over 180 were saved, thanks to the heroism of the people of St. Lawrence, who risked their lives by getting the sailors over steep and dangerous cliffs. The relationship with the people of St. Lawrence and the survivors of that disaster continues to this day. In gratitude to the town for their assistance, the American government built a hospital in St. Lawrence, a predecessor to the current U.S. Memorial Health Centre.19 While the fishing sector has historically been the main employer for the people of the Burin Peninsula, mining was introduced in 1933 when a fluorspar mine in St. Lawrence opened. While the mining brought prosperity to the town, it also brought disease. The dust in the mines, (silica dust) accumulated on the lungs and other bronchial areas of the miners, and built up scar tissue, causing a condition known as "silicosis".20 In the early 1960s, it was noticed that there were a number of miners who had been diagnosed with cancer. A team of federally-appointed experts confirmed the presence of high levels of radon gas in many underground areas. This gas was released during mining operations and built up in non-ventilated areas. In 1969, a Royal Commission appointed to investigate and make recommendations on the St. Lawrence situation released its report. The report documented the history of industrial disease in the area, and made key recommendations concerning

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safety and compensation. In the 1970s, competition from Mexico and South America resulted in lower prices for ore and in 1979, the mine closed down.21 Another industry began to take shape in Marystown in the mid-1960s when Quebec-based Canadian Vickers began construction of a shipyard to repair steel ships. The shipyard began operating in 1967, building and servicing the ships engaged in the offshore fishing industry. Since then, the shipyard has had a number of different owners, most recently Kiewit Offshore Services. The platforms for the White Rose offshore oil project were built at the Marystown shipyard. 22

5.2

Population

The Burin Peninsula has a population of 23,710 dispersed throughout 39 municipalities and local service districts. Almost half of the population of the peninsula is centred in the Burin/Marystown area. Like most of the province, the Burin Peninsula has a declining population. From the 1996 Census to the 2001 Census, the peninsula had a population decline of 12% (from 26,955 people in 1996 to 23,710 in 2001) as seen in Figure 9 below.23 Figure 9: Burin Peninsula Population Change 1996-2001

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That trend is expected to continue with a projected population of 18,891 in the year 2019 as seen in Figure 10.24 Figure 10: Burin Peninsula Population Projections, Medium Scenario, 2002-2019

The changing population can also be seen in the enrolment numbers for primary, elementary, junior and senior high students on the Burin Peninsula. Figure 11 shows there has been a decrease in enrolment of 58% from 1996-97 to 2004-05.25

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Figure 11: Primary, Elementary, Junior and Senior High School Student Enrolment Burin Peninsula

The change in population of the Burin Peninsula is illustrated in population pyramids. In Figures 12 and 13, the change in population pyramid from 1986 to 2011 (projected) visually shows the aging of the population. While the 1986 pyramid demonstrates a typical population pyramid with a wide base of young people, the 2011 projected pyramid strongly shows that base eroding with a large decrease in the number of people under the age of 20. The aging baby-boomer numbers can be seen in Figure 13 resulting in more of an inverted pyramid shape.26 These shifts in population have important and profound impacts upon communities and their institutions.

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Figure 12: Population Pyramid, Burin Peninsula, Census 1986 â&#x20AC;&#x201C; Burin Peninsula Rural Secretariat Region

Figure13: Population Pyramid, Burin Peninsula, 2011 (projected) - Burin Peninsula Rural Secretariat Region

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In 2001, the Burin Peninsula—and the province—had a median age of 38 years. Figure 14 indicates where the Burin Peninsula fits in relation to other Rural Secretariat areas in the province. The range of median ages is 32-40.27 Figure 14: Median Ages of Rural Secretariat Regions R u r al Se c re t a ri a t R eg i on s Labrador Avalon Burin Peninsula Grand Falls-Windsor-Baie Verte-Harbour Breton Clarenville - Bonavista Corner Brook – Rocky Harbour Gander – New Wes Valley Stephenville – Port aux Basques Province

5.3

2001 Median Age 32 37 38 39 40 40 40 40 38

Today

The economy of the Burin Peninsula today is mostly in the service and public sectors. The fishery still plays a role in the economy although it is currently an uncertain one, particularly given anticipated changes for Fishery Products International (FPI) plants on the peninsula. In its three-year business plan (May 1, 2005-April 20, 2008), the Schooner Regional Development Corporation identified manufacturing/oil and gas, and fisheries as the two primary priority sectors for the Corporation. Trade and export and small business development were also identified as key areas.28 The Burin Peninsula has been identified in A Special Place A Special People: The Future of Newfoundland and Labrador Tourism as a tier three regional destination meaning that it has latent potential and longterm possibilities as a tourist destination.29 One of the tourist draws referenced in the report is the peninsula as a gateway to the islands of St. Pierre and Miquelon, France’s oldest remaining overseas territory. The ferry terminal in Fortune is the entry to this piece of Europe where the islands have a population of about 6,500.30 From a recreational perspective, the Burin Peninsula is very well-known for its commitment to and talent for soccer. The Burin Peninsula is home to one provincial park at Frenchman’s Cove and several privately run campgrounds and the Burin Peninsula highway borders the Bay Du Nord Wilderness Reserve. Many hiking and walking trails exist around the peninsula and a golf course is located at Frenchman’s Cove.

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Just west of the town of Fortune is a portion of rock section exposed along the cliffs at Fortune Head which has been designated by the Internal Union of Geological Scientists as a global stratotype, representing the boundary between the Precambrian era and the Cambrian period, approximately 530 million years ago. Two other world class examples of this PrecambrianCambrian boundary stratotype are in Siberia (Russia) and Meischum (China) but the International Union of Geological Scientists chose to designate Fortune Head as the best example in the world of this significant global stratotype. The 2.21 km2 Fortune Head Ecological Reserve was created to protect this important area.31 In terms of infrastructure, the peninsula has 16 primary, elementary and high schools, which are managed by the Eastern School District. A campus of the College of the North Atlantic is located at Salt Pond. First year Memorial University of Newfoundland courses can be completed at the College. The peninsula is also home to two private college campuses: Centrac College of Business Trades and Technology and Keyin College.32 An airstrip is operated by the Department of Works, Services and Transportation. It is used mainly for small aircraft and medivac transports.33 Ferry services are operated by the provincial government from Petit Forte to South East Bight and from Bay Lâ&#x20AC;&#x2122;Argent to Rencontre East and Poolâ&#x20AC;&#x2122;s Cove.34 Broadband internet is available in many communities but not all.35 An infrastructure map provides a picture of the location of some services on the Burin Peninsula (note community health offices are not shown).36 See Figure 15.

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Figure 15: Infrastructure of Map of Burin Region

In summary, the Burin Peninsula has a strong and proud past with a history and culture based on the sea. The peninsula, like much of rural Newfoundland and Labrador, is now in a time of transition. While the fishery is in a state of flux, there is much potential in the oil and gas sector given the skilled workforce, and the shipyard, with its deep water port. Like other rural areas, the Burin Peninsula faces many challenges associated with out-migration and employment levels.

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THE DETERMINANTS OF HEALTH

The 1986 report Achieving Health for All: A Framework for Health Promotion focused on the underlying prerequisites or determinants of health and illness. It suggested that a number of influences and their interaction had major impacts on the health and well-being of a population. Factors such as social, economic, cultural and physical environment play a role—for better or worse—in the health of a community. This means that making improvements in the health and well-being of Canadians must go beyond delivery of health care services and include action on the broad determinants of health.37 These determinants of health, as they exist on the Burin Peninsula, and the impact they are having on the health of the region, will be examined in this section of the report. The determinants are: • • • • • • • • • •

Income and social status Employment and working conditions Social support networks Education Social environments Physical environments Personal health practices and coping skills Healthy child development Biology and endowment Gender and culture

The health services determinant of health will be featured in Section 7: Health Services.

6.1

Income and Social Status

6.1.1 What it is and Why it is Important Research has shown that the healthiest populations are those which are reasonably prosperous and have an equitable distribution of wealth, regardless of the amount governments spend on health care.38 Income determines living conditions such as safe housing and the ability to buy necessities such as food and clothing. Income also affects health by providing individuals with a sense of control. The degree of control people have, particularly in stressful situations, and their discretion to act, are key influences of health. Higher income and status generally result in more control and discretion. 39 In Canada, life expectancy and average income have increased in all age groups over the past 25 years. However, health status differences between income groups continue. Higher income

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individuals have better health than middle-income individuals, who in turn have better health than lower income individuals. Canadians with low levels of income often have poor health.40 6.1.2 Income and Social Status-Related Findings Lack of consistent income is impacting mental health and well-being. Key informants and focus group participants referenced the stress of having inadequate incomes. They expressed concern with the impact that low incomes have on mental health and well-being in terms of stress, anxiety and self-esteem levels. In particular, they cited the economic viability of individuals, families and communities as having a significant impact on health and well-being. As indicated in Figure 16, the 2003 personal income per capita on the Burin Peninsula was $17,300, compared to $19,800 for the province, ranking the Burin Peninsula in the lower half of the nine Rural Secretariat regions.41

The Burin Peninsula: Income and Social Status at a Glance -

The Burin Peninsula is in the lower half of the 9 Rural Secretariat regions in terms of per capita income.

The Burin Peninsula is the second most reliant of the 9 Rural Secretariat regions on government transfers.

The Burin Peninsula has the second highest number of social assistance recipients of all Rural Secretariat regions.

Figure 16: Personal Income Per Capita By Rural Secretariat Regions 2003

Half of the couple families on the Burin Peninsula had incomes of more than $46,400 in 2001 as compared to $50,200 for the province. Half of the lone-parent families on the Burin Peninsula had incomes of less than $21,100 compared with half of the lone-parent families in the province at less than $22,200. 42

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A measure of a communityâ&#x20AC;&#x2122;s self-reliance can be seen when looking at the communityâ&#x20AC;&#x2122;s dependency on government transfers such as Canada Pension, employment insurance and social assistance. The higher the percentage of income that comes from transfers, the lower the self-reliance ratio. The 2003 self-reliance ratio for the Burin Peninsula was 68%, while the provincial self-reliance rate was 77%. 43 Figure 17 shows the self-reliance ratios for all Rural Secretariat regions with the Burin Peninsula tied for the second most reliant on government transfers of all the Rural Secretariat regions. Figure 17: Self-Reliance Ratios, Rural Secretariat Regions

Financial cost associated with making healthy decisions. A number of participants in the needs assessment referenced the cost associated with making healthy decisions. They saw the cost of eating healthy foods and having children participate in organized recreational activities, such as hockey, as a barrier for many. The Burin Peninsula ranked the second highest of the Rural Secretariat regions in terms of the percentage of social assistance recipients at some point in time in 2003 as seen in Figure 18.

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Figure 18: Comparison of Percentage of Social Assistance Recipients at Some Point in 2003

As part of the needs assessment, a telephone survey was conducted by the Health Research Unit at Memorial University. The income levels reported by the respondents were used in the calculation of their status with respect to Low Income Cut-Off. Statistics Canadaâ&#x20AC;&#x2122;s Low Income Cut-Offs (LICO) convey the income level at which a family may be in strained circumstances because it has to spend a greater proportion of its income on necessities than the average family of similar size. Specifically, the threshold is defined as the income below which a family is likely to spend 20 percentage points more of its income on food, shelter and clothing than the average family.44 For this report, the values calculated by Statistics Canada for a population size of under 30,000 were used. As seen in Figure 19, the incidence of low income in the Burin Peninsula households was 24.2%. The St. Lawrence area had the highest prevalence of low income with 34%. According to Statistics Canada Low Income Rate (2000 income), the prevalence of low income families is 16.3% for the province as a whole.45

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Figure 19: Burin Peninsula Telephone Survey Low Income Cut-Off by Area A re a Burin Peninsula North Area Marystown/Burin Area Grand Bank/Fortune Area St. Lawrence Area Total

LICO B el ow 19 (25.3%) 44 (20.6%) 24 (25.8%) 19 (33.9%) 106 (24.2%)

A bove 56 (74.7%) 170 (79.4%) 69 (74.2%) 37 (66.1%) 332 (75.8%)

T o ta l 75 (100.0%) 214 (100.0%) 93 (100.0%) 56 (100.0%) 438 (100.0%)

6.1.3 Income and Social Status Conclusion There are many challenges associated with the income and social status determinant of health on the Burin Peninsula. Low or inconsistent incomes can make it very difficult to live as healthy a life as possible. Everything from eating healthy to having appropriate housing can be impacted by income. It can also affect mental health and well-being in terms of stress, anxiety and self-esteem levels. The impact of poverty becomes clear when using the United Nations Office of the High Commissioner for Human Rights definition of poverty: â&#x20AC;Śa human condition characterized by the deprivation of the resources, capabilities, choices, security and power necessary for the enjoyment of an adequate standard of living and other civil, cultural, economic, political and social rights.46

6.2

Employment and Working Conditions

6.2.1 What it is and Why it is Important Unemployment, underemployment, stressful or unsafe work are associated with poorer health. People who have more control over their work circumstances and fewer stress-related job demands are healthier and often live longer than those in more stressful or riskier work and activities. 47 Stable employment does not simply impact a personâ&#x20AC;&#x2122;s financial situation. Regular employment can increase social life, self-esteem, and personal development. 48 People who are unemployed may have feelings of failure, guilt and anger causing mental and physical health problems. In some jobs, people have work overload, boredom, physical hazards and job insecurity which can also impact on their health. 49

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6.2.2 Employment and Working Conditions-Related Findings The workforce of the peninsula as a major strength. Key informants consistently referenced employment and working conditions as being a very important determinant to address. They rated the workforce of the peninsula as a major strength and cited as evidence the skilled labour force at the shipyard and the recent completion of the White Rose project on time and on budget. Make-up of the economy. Just over 60% of firms on the Burin Peninsula are in wholesale/retail trade, public services and professional services. Figure 20 shows that the Burin Peninsula is more heavily reliant on the public service and much less reliant on professional/business services than the province.50

The Burin Peninsula: Employment and Working Conditions at a Glance -

The Burin Peninsula and South Coast had an employment rate of 35.5% in February 2006.

The Burin Peninsula had 29.2% of its population working 50+ weeks in 2000 versus 45.2% for the province.

Telephone survey respondents identified unemployment as the main community problem within each area of the peninsula.

The boom or bust cycle of the Burin Peninsula economy is a major concern for people and is leading to large numbers of out-migration.

Figure 20: Firms on the Burin Peninsula

There has been a significant decline in the number of firms on the Burin Peninsula from 1999 to 2004 as seen in Figure 21. This is due in part to the consolidation of industry, particularly the fishery, and public sector centralization. There is also a smaller local consumer base for goods and services. 51

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Figure 21: Decline in number of firms on the Burin Peninsula from 1999-2004

The cyclical nature of the economy as a major threat. Key informants and focus group participants expressed concern about the seasonality of work and the uncertainty of the economy. They frequently used the terms “boom or bust” to describe the employment situation on the peninsula. Key informants felt that this inconsistent employment situation was having an impact on individuals, families and communities, particularly on mental health well-being and the ability to lead healthy lifestyles. As one key informant said, “Self-esteem comes from going to work. People build a lot of relationships from work.” The loss of a job can have a severe toll on an individual, not only financially but also emotionally and mentally. The inability to provide for a family has an impact on self-esteem. Many focus group participants referenced the resulting out-migration that comes with inconsistent employment levels as taking a toll on family life. Within the focus group sessions, participants saw employment as having a significant impact on formal and informal support systems such as schools, municipal infrastructure and services and utilization of health and community services. The concern about employment levels was seen in the answers from the telephone survey respondents. When asked to rate a number of common community issues as problems, 68.3% of telephone respondents viewed unemployment as a major problem and 23.3% of respondents identified it as a minor problem. Unemployment was the main community problem identified within each region as indicated in Figure 22.

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Figure 22: Burin Peninsula Telephone Survey Top Five Community Problems by Area Region

Unemployment

Outmigration

Burin Peninsula North Marystown/Burin Area Grand Bank/ Fortune Area St. Lawrence Area

32 (37.6%) 81 (34.5%) 53 (49.1%) 19 (32.8%) 185 (38.1%)

23 (27.1%) 41 (17.4%) 18 (16.7%) 5 (8.6%) 87 (17.9%)

Total

Lack of Health Services 7 (8.2%) 24 (10.2%) 8 (7.4%) 7 (12.1%) 46 (9.5%)

Availability of Rec. Facilities 8 (9.4%) 19 (8.1%) 3 (2.8%) 5 (8.6%) 35 (7.2%)

Cancer 2 (2.4%) 20 (8.5%) 9 (8.3%) 5 (5.2%) 34 (7.0%)

85 235 108 58 486

The Newfoundland and Labrador Statistics Agency puts the employment rate for the Burin Peninsula and South Coast for February 2006 (a three-month moving average unadjusted) at 35.5% compared with the Avalon Peninsula at 52.9%, the West Coast, Northern Peninsula and Labrador at 44.9% and Central Newfoundland, North East Coast at 37.4%.52 The employment rate for the province for the year 2005 was 49.8%.53 The provincial governmentâ&#x20AC;&#x2122;s Community Accounts divides the Burin Peninsula into eight subregions (see Appendix K). When considering these sub-regions in Figure 23, the percentage of the population that worked the full year in 2000 (50+ weeks) was much lower than the provincial average of 45.2%. For the Burin Peninsula as a whole, the rate was 29.2%. 54

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Figure 23: Percentage of Burin Peninsula Population that Worked Full Year in 2000 (50+ weeks)

6.2.3 Employment and Working Conditions Conclusion The Burin Peninsula has a talented workforce but the lack of consistent levels of employment is having a major impact on the health of its people and communities. In addition to mental health and well-being pressure on individuals and families, there is the resulting impact on communities as family members make decisions to leave the area. “One of the strengths of the peninsula is its workforce. It is highly skilled and has proven itself with the White Rose Project.” - Key informant

“There’s so much uncertainty even when people are working.” - Key informant “The more people are unemployed, the more time they spend in the health care system.” - Key informant

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Social Support Networks

6.3.1 What They Are and Why They Are Important Support from family, friends and communities is associated with better health. In addition to support networks helping people solve problems, they help them to have a sense of control over life circumstances. Caring relationships can provide people with a sense of satisfaction and well-being. This is particularly the case during times of The Burin Peninsula: Social Support Networks stress or crisis. Having social networks to discuss challenges can help 55 at a Glance make a situation more manageable. People who have supportive family and friends actually get sick less often and live longer than people who don’t have strong networks. Communities where jobs are secure and where few people leave are more likely to have good social support networks. 56

6.3.2 Social Support Networks-Related Findings People and sense of community as a key strength. In the key informant interviews, the number one strength of the Burin Peninsula that was consistently referenced was its people and the sense of community. As one key informant said, “There is a tradition of looking out for neighbours—an informal caring network, which is a social strength.”

A key strength of the Burin Peninsula is its people and its sense of community.

The Burin Peninsula migration rate from 1991-1996 was -7.6% compared with the provincial rate of -5.1%.

Telephone respondents identified out-migration as a major community problem in all four areas of the peninsula.

Concern about the sustainability of communities. The strength of the Burin Peninsula and its people is being challenged by unemployment and outmigration. Focus group participants and key informants expressed - Out-migration is concern for the future. They described communities where changing the social unemployment levels have resulted in out-migration and where a fabric of families and declining and aging population are changing communities. This communities, as one dynamic is seen when families (usually with young children) move away parent or whole for the long-term, or when one parent moves away from the families move away, community for sporadic, shorter-term periods. They described a leaving an aging population behind. number of effects of this out-migration, including communities filled with older people (which impacts the financial viability of communities), a breakdown of the traditional rural Newfoundland family with a core nuclear unit and supportive extended family, parent and caregiver stresses due to the absence of a partner, a lack of supports for seniors, declining school enrolment, and lack of appropriate peer groups and social activities for children and youth.

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For the period 1991-1996, the Burin Peninsula had a migration rate of -7.6% compared with the provincial rate of -5.1%. As seen in Figure 24, the Burin Peninsulaâ&#x20AC;&#x2122;s migration rate from 1991-1996 demonstrates itself in most age groups and is particularly prevalent in the 15-19 and 20-24 age groups. There is also a fairly high amount of out-migration in the age group 75-79.57 Figure 24: Burin Peninsula Migration Rate 1991-1996 58

In the telephone survey, when asked to rate a number of community issues, 79.4.% of respondents identified out-migration as a major problem. When asked to choose the single most important problem in the community, out-migration was ranked second to unemployment in three areas of the peninsula (Burin Peninsula North, Marystown/Burin, Grand Bank/Fortune) and third in the St. Lawrence area (see Figure 23). Concern about seniors and the impact of out-migration. There were many references in focus group sessions to elderly seniors, mainly women, living alone. Participants expressed concern with how they cope, particularly in situations where their families have moved due to out-migration. This was validated in the 2003 report A Housing Strategy for Newfoundland and Labrador, which indicates that three of every four senior women live alone in Newfoundland and Labrador.59 Similarly, the lack of family networks and the resulting isolation of seniors in communities were referenced in the Strategic Social Plan â&#x20AC;&#x201C; Eastern Region Town Halls Forum Report of 2002.60

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6.3.3 Social Support Networks Conclusion Rural Newfoundland has traditionally been known for strong social support networks due to large, extended family networks and the closeness of communities. These traditional values are now challenged with low employment and income levels resulting in out-migration. “I went for a walk and counted 33 vacant homes.” - Focus group participant

“The economy of this area is making it very difficult for people to hold marriages together. When a spouse goes away for three months, there is a lot of stress on the one left behind.” - Key informant

6.4

Education

6.4.1 What it is and Why it is Important Health status improves with level of education. People who are more educated usually have more job opportunities, greater job security, higher job satisfaction and higher incomes. In addition, education gives people more control over their lives. This allows people to evaluate options, make choices and take action to improve health.61 Literacy is one of the major influences of health status. Low literacy plays a role in a person’s ability to understand their health care needs and their ability to care for others. Individuals with limited literacy skills may not be aware of appropriate health services, and studies have shown that low literacy causes increased visits to health care providers as well as increased hospital admissions. 62 The 2003 International Adult Literacy and Skills Survey indicated that participants aged 16 to 65 who reported being in poor physical health scored lower in document literacy than did those reporting better health. The Survey also found that people with low proficiency in literacy tend to have lower rates of employment and work in occupations with lower skill requirements. 63

Burin Peninsula Community Health Needs Assessment

6.4.2 Education-Related Findings Importance of emphasising healthy living in the school system. A number of focus group participants and key informants expressed satisfaction with the primary and secondary school system. Individuals felt that the school system is serving their children well. There were, however, a number of concerns expressed regarding the lack of emphasis on healthy living in the school system. Focus group participants and key informants expressed concern at the lack of flexibility within the school curriculum to allow for presentations or education sessions about health-related issues. They also felt that health needed to play more of a major role earlier in the curriculum. A number of individuals expressed concern about the nutritional value of food available in the schools. As this report was being written, the Government of Newfoundland and Labrador released its Provincial Wellness Plan. One of the goals of the plan is to develop and expand wellness initiatives which will emphasize creating school environments that support healthy living in the school system.64

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The Burin Peninsula: Education at a Glance -

The Burin Peninsula population has educational attainment levels similar to the province.

The Burin Peninsula had 30% of its population aged 2029 without a high school diploma in 2001.

There is frustration with the lack of emphasis on health in the education curriculum and the lack of focus on healthy living.

Newfoundland and Labrador ranks below average in terms of literacy and numeracy scores.

Recognizing the importance of education. In terms of post-secondary education, focus group participants and key informants identified the College of the North Atlantic as a good resource for the peninsula. Considering the education levels of the Burin Peninsula population, Figure 25 shows that 52.5% of people aged 20 and up have a high school diploma compared with 60.4% provincially, ranking the Burin Peninsula fourth out of nine Rural Secretariat regions in terms of the percentage of population with a high school diploma.65 Figure 25: Burin Peninsula Rural Secretariat Region, Highest Level of Education, Aged 20+ 2001, Population 20+

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The educational attainment of Burin Peninsula residents in comparison to other Rural Secretariat Regions can be seen in Figure 26. The Burin Peninsula is similar to the province as a whole in terms of educational attainment. Provincially, 9.5% of the population has a degree or higher, 11.2% do not have a degree completed, 27.5% have trades or non-university, 42.2% are without a high school diploma, 9.4% have a high school only.66

Level of education

Burin Peninsula

Clarenville Bonavista

Avalon

Labrador

St. Anthony Port au Choix

Corner Brook Rocky Harbour

Stephenville Port aux Basques

Grand FallsWindsorHarbour Breton

Gander New Wes Valley

Figure 26: Education Attainment, Rural Secretariat Regions, 2001

Degree or higher

15%

Degree not completed

14%

10%

11%

Trades or nonuniversity

31%

28%

31%

39%

25%

30%

25%

27%

High school only

10%

Without high school

48%

50%

31%

33%

53%

42%

54%

50%

The percentage of the population aged 25-29 that have not completed high school is significantly above the provincial average of 20.7% in some sub-regions of the Burin Peninsula as seen in Figure 27.

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Figure 27: Percentage of Population Aged 25-29 Not Completed High School

Over half (52.9%) of telephone respondents did not view literacy as a problem on the Burin Peninsula and 34.0% saw it as a minor problem. The 2003 Internal Adult Literacy and Skills Survey (IALSS) found that the average of all provinces in Canada for literacy and numeracy scores was at level 3 (the proficiency level required for the modern economy and knowledge-based society) with the exception of Quebec, New Brunswick, Newfoundland and Labrador, and Nunavut. Newfoundland and Labrador had averages at level 2 on prose, document and numeracy. 67

6.4.3 Education Conclusion Education levels for the Burin Peninsula mirror those of the province. Most participants in the needs assessment process seemed content with the school system but perceived a lack of emphasis on healthy living in the system.

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Social Environment

6.5.1 What it is and Why it is Important The importance of social support extends from family and friends to the broader community. Civic vitality refers to the strength of social networks within a community, region, province or country. It is reflected in the institutions, organizations and informal giving practices that people create to share resources and build attachments with others. 68 Communities have their own values and norms and these can influence the health and well-being of their population. A supportive society that emphasizes social stability, safety, and good working relationships can benefit the health of its citizens.69 6.5.2 Social Environment-Related Findings Volunteers as a key strength. In all focus groups, the role of volunteers in sustaining rural communities emerged as a significant strength. Everyone recognized that without citizen commitment and involvement, outcomes for communities would be much worse. This was seen as a core strength on which to build. Participants saw the need for more institutionalized support for the projects/programs that were working well. They perceived a role for government and the formal health system to provide concrete, dedicated resources to help sustain their projects/programs. They identified the need for Eastern Health to partner with communities by making meaningful investments in health and well-being.

The Burin Peninsula: Social Environment at a Glance -

The Burin Peninsula has a strong reputation for volunteer support and the ability to work together.

People increasingly see the ability of Burin Peninsula citizens working together as a region as very important to the future of the peninsula.

People want to see more inter-sectoral partnerships to address health issues in a holistic and seamless manner.

Similarly, in the Strategic Social Plan â&#x20AC;&#x201C; Eastern Region Town Halls Forum, participants recognized the role of volunteers and thought that more incentives and fewer bureaucratic barriers were needed to increase volunteerism motivation.70 The need to enhance community partnerships. Key informants and focus groups identified the ability to work together as a key strength for the Burin Peninsula. A number of key informants indicated that it is this cohesiveness that allows the peninsula to lobby to have their needs met. At the same time, however, people expressed concern with the competitiveness of towns on the peninsula. A number of comments were made about public conflicts and disagreements between towns which weakened the position of the peninsula as a whole. People felt that communities on the peninsula must think and act as a whole region if the peninsula is to survive.

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6.5.3 Social Environment Conclusion The commitment to volunteerism on the peninsula is recognized as a strength. It is felt that communities must continue to work together for the benefit of the whole peninsula.

“There are pockets of communities that are very strong. They can come together to support a cause but I’m not sure the sense of community works as a collective for the peninsula. There are a lot of rivalries.” - Key informant “The people of the Burin Peninsula are very organized from a community perspective. They know how to develop a strategy and can make things happen. They have to be that way because of their isolation.” - Key informant Success Story: Sharing Services When speaking about the future of the Burin Peninsula, participants in focus group sessions constantly stressed the importance of partnerships and collaboration. The towns of Grand Bank and Fortune provide one example of successful partnerships. For a number of years, the two towns have shared ambulance, waste disposal and fire protection and emergency services. The two towns have a joint winter carnival. Recreation activities such as the Figure Skating Club, Swim Club and Minor Hockey Association consist of members from both communities. “The Towns of Grand Bank and Fortune have shared a number of services for many years, and are always looking for new and innovative ways to work together,” says Mayor Rex Matthews of Grand Bank. “Whether it be in health, education or municipal services, sharing services between the two communities has become a way of life and a common goal. Our Towns and citizens are more enriched because of this co-operation, which we hope will continue to grow and expand in the years ahead for the common good and benefit of our people.”

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Physical Environment

6.6.1 What it is and Why it is Important Contaminants in the air, water, food and soil can cause a variety of adverse health effects such as respiratory illness and cancer. Housing, indoor air quality and the design of communities and transportation systems can significantly influence our well-being. This makes the physical environment an important determinant of health. 71 The ecosystem and environmental changes also have an impact on health. Pressure on the environment and resulting changes such as the depleting ozone layer and climate change, can have an impact on the health of people.72 6.6.2 Physical Environment-Related Findings The highway as a dominating concern. Many focus group participants and key informants commented on the highway as a concern, from the road conditions to closures that often happen due to weather conditions. One of the main issues regarding travelling on the Burin Peninsula is visibility. In particular, the areas of Mile Hill (leaving Swift Current) to Terrenceville, Terrenceville to Bay L'Argent, Rushoon to Red Harbour, St. Lawrence to Lord's Cove, and Point May to Fortune, are areas where travelling can be challenging in bad weather due to a lack of visibility. The Department of Transportation and Works does not keep statistics on road closures due to weather, however, it was noted that the highway would not be closed more than 24 hours after any storm. For example, if a storm lasted two days then the road would be open on the third day. 73 There is also the uncertainty of weather that can be encountered on the peninsula during travel. While conditions may seem fine in Lamaline, a drive mid-way up the peninsula can result in a very different situation. In the case of individuals who must travel for services unavailable on the peninsula, it can mean travelling a day or two in advance of an appointment in order to take weather conditions into account and incurring extra travel costs.

The Burin Peninsula: Physical Environment at a Glance -

The Burin Peninsula highway is the main isolating factor, particularly during winter when highway visibility is an issue due to weather.

The Burin Peninsula has 13 boil water orders.

With a dispersed population throughout the peninsula, people in smaller towns must rely on the larger centres for goods and services, highlighting the importance of available transportation.

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Mixed opinions about the status of infrastructure. Some key informants positively referenced the infrastructure on the Burin Peninsula while others cited areas for improvements. They noted the highway in particular as well as the lack of broadband technology throughout the peninsula. In terms of housing, there are just over 8,500 dwellings on the Burin Peninsula; 85.5% of those are owned by the homeowner while the remainder are rented. Of the 85.5% who own a house, 70.4% are without a mortgage. The average gross rent is $464.74 Some focus group and key informant participants referenced the difficulty there had been in terms of affordable housing when the shipyard was at its peak but most people did not currently see it as an issue. In the telephone survey, 89.1% of respondents did not see housing as a problem. Degrees of isolation. The Burin Peninsula also has the challenge of a dispersed population in an area of 161 kilometres in length by 40 kilometers in width. Within rural areas there are various degrees of isolation. On the Burin Peninsula, there are population and service centres such as the Marystown/Burin area and the Grand Bank/Fortune areas. Smaller towns rely on the larger towns for many services. For people in smaller towns, there was concern that access to services such as support groups or recreational activities was not always possible due to distances from larger centres and the lack of available transportation. In the telephone survey, however, 70.6% of respondents indicated that transportation was not a problem in their community. Some concern regarding water quality. In focus group sessions, a few participants referenced water quality in Grand Bank and St. Lawrence as being problematic. A review of water boil orders by the Department of Environment, Government of Newfoundland and Labrador indicates that there are 13 communities on the Burin Peninsula with boil orders representing a population of 5,812. A number of boil orders are due to a lack of funding for malfunctioning systems or lack of constant chlorination.75 In the telephone survey, 76.7% indicated that air or water pollution was not a problem in their community.

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6.6.3 Physical Environment Conclusion The most dominant issue regarding the physical environment determinant for the Burin Peninsula is the highway. For some people it is seen as an isolating factor. Others see it as resulting in the peninsula having more services than its population would ordinarily dictate.

The Impact of Isolation: One Family’s Story On April 1, 2005, Olive Fancy of Burin began dialysis. Until January 2006, she travelled to Clarenville three times a week for this service and relied on family and good friends to drive her the 200 kilometres to Clarenville since her husband Edgar is working. Travelling to Clarenville meant that Olive left her home at 6:15 a.m. and returned at about 3:30 p.m. In a nine month period, her gas receipts totalled approximately $5,000. On Friday, January 6, 2006, Olive and Edgar moved to St. John’s for a three month period to avoid travelling the Burin Peninsula highway during the winter months. “The highway can be very difficult and dangerous to drive on during the winter months,” said Olive. “You never know when you leave Burin what weather conditions you may encounter.” The Fanceys are staying with their son and his wife while in St. John’s. The move to St. John’s means that Edgar had to take three months off work. On March 1, 2006, the provincial government announced that dialysis services will be provided on the Burin Peninsula.

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6.7 Personal Health Practices and Coping Skills 6.7.1 What it is and Why it is Important Individual actions that support healthy choices and lifestyles are key influences on health. People can take actions to prevent diseases and promote self-care, cope with challenges, develop self-reliance, solve problems and make choices that can enhance their health. These are referred to as personal health practices and coping skills. 76 Personal health practices develop from a number of factors such as the impact of each of the determinants of health. For example, the ability of people to adopt healthy practices can be formed as a result of their experiences in childhood and is either enhanced or constrained by those determinants such as education and healthy childhood development.77 6.7.2 Our Findings Feeling that the Burin Peninsula is similar to other areas. While some key informants and focus group participants cited lifestyles, such as smoking, drinking, lack of physical activity and eating habits, as negative issues on the peninsula, the majority indicated that they didnâ&#x20AC;&#x2122;t feel that personal health practices and coping skills on the Burin Peninsula were any different than any other area of the province. 6.7.2.1 Health Status As indicated in Figure 28, 37.2% of telephone respondents classified their health as good with 28.6% classifying it as very good and 20.0% as fair. According to the Canadian Health Survey 2003, for the Eastern Region of the province, 18.4% of respondents classified their health as excellent with 47.5% indicating it was very good; 22.1% as good and 11.9% as fair or poor.78

The Burin Peninsula: Personal Health Practices and Coping Skills at a Glance -

66% of telephone respondents reported participating in physical activity 2-3 times a week.

24% of telephone respondents indicated smoking daily compared with 25% in the province and 22% in the country.

41.5% of telephone respondents were overweight (based on Body Mass Index calculations) compared with a national rate of 34%.

26% of telephone respondents were obese (based on Body Mass Index calculations) compared with 15% nationally.

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Figure 28: Burin Peninsula Telephone Survey Self-Reported Health Status

6.7.2.2 Smoking The telephone survey asked respondents a number of questions about lifestyle practices. Twentyfour per cent (24%) of respondents smoke cigarettes daily. This is consistent with the 2002 Health in our Community: A Profile of the Eastern Region in which 28% of males and 25% of females reported being current smokers and the 2001 Peninsulas Health Care Corporation Needs Assessment where 23% of respondents indicated that they regularly or sometimes smoke cigarettes.79 In the 2002 Dialogue with Youth About Risk and Resilience, Eastern Newfoundland Health and Community Services Region, 41% of youth reported smoking and 29% reported smoking everyday.80 When asked to rate community problems, 27.6% of telephone survey respondents saw smoking as a major problem and 37.2% saw it as a minor problem while 26.5% did not see it as a problem. Exposure to environmental tobacco smoke is also a health threat. In 2002, approximately 21% of children up to the age of 11 in the province were regularly exposed to tobacco smoke compared with 16% in the country.81 Tobacco control is one of the wellness priorities established in the provincial governmentâ&#x20AC;&#x2122;s Wellness Plan.82

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6.7.2.3 Alcohol/Drugs Nine percent of telephone survey respondents indicated they drink alcoholic beverages on average more than 7 drinks a week. Twenty-eight percent (28.4%) of telephone respondents indicated that they did not see alcohol abuse as a problem, 32.3% saw it as a minor problem, 11.1% saw it as a major problem while 26.1% reported they didnâ&#x20AC;&#x2122;t know. The 2000 Dialogue with Youth About Risk and Resilience revealed that a third of youth drink about once a week or more often. One-third reported having used illegal drugs once in their lives with 27% indicating they used illegal drugs at least once in the last six months.83 6.7.2.4 Gambling When asked whether or not they take part in gambling or gaming for money on average once a week or more, 23% of telephone respondents said yes. When asked to identify problems from a list of common community issues, gambling was identified as a major problem by 24.1% of respondents, a minor problem by 36.2% of respondents, not a problem by 18.1% and 19.5% didnâ&#x20AC;&#x2122;t know. Focus group participants, particularly mayors, expressed concern about VLTs and the impact on individuals within their communities with one mayor commenting that if municipalities could ban VLTs, theyâ&#x20AC;&#x2122;d be gone from his community. The 2005 Newfoundland and Labrador Gambling Prevalence Study revealed that provincially, 84% of respondents have gambled at least once in the past year. Of these respondents, 6.1% were classified as low-risk gamblers, 2.2% as moderate-risk gamblers, and 1.2% as problem gamblers.84 The Study indicated that there is evidence of a close relationship between VLT use and problem gambling. Regarding VLT use, 80% of problem gamblers have played in the past 12 months, and 26% of problem gamblers remembered the VLT as their first gambling experience. In addition, 9.7% of VLT players can be considered moderate-risk gamblers and 8.6% problem gamblers. The Study also indicates that moderate-risk and problem gamblers represent distinct segments of the population. Problem gamblers were mostly males (67%) between the ages of 25-34 (40%), with at least some post-secondary education (49%), and incomes of $20,001 to $40,000 (33%). Moderaterisk gamblers were mostly males (67%) between the ages of 35-44 (39%), with a high school education or less (51%), and incomes of $20,001 to $40,000 (30%). Combined, this rate is significantly higher than the provincial moderate-risk and problem gambling prevalence rate.

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6.7.2.5 Physical Activity When telephone survey respondents were asked if they participated in regular physical or recreational activities at least 2-3 times a week, 66% of respondents said yes. The 2001 Dialogue on Heart Health indicates 24% of respondents in the Eastern Region participate in physical activity once or twice a week; 20% of respondents participate in physical activity three or four times a week with 27% indicating more than four times a week.85 The Peninsulas Health Care Corporation Needs Assessment in 2001 revealed that 84.5% of respondents regularly or sometimes participated in physical exercise.86 Physical activity is one of the wellness priorities in the Provincial Wellness Plan.87 6.7.2.6 Healthy Eating In the telephone survey, 76% of respondents indicated they believe that they eat a healthy diet while 23% did not think they eat a healthy diet. When asked what prevented them from eating a healthy diet, personal choice (67.2%) and cost (15.5%) were the main reasons provided. A number of participants in the focus groups and key informant interviews expressed concern regarding the cost of healthy eating. People were discouraged at the low cost of unhealthy food such as colas compared to healthy food such as milk. This is confirmed in The Cost of Eating in Newfoundland and Labrador 2003 Report, which indicates that food insecure low-income families tend to buy cheaper high-calorie foods out of necessity rather than choice over more expensive healthy foods.88 The Newfoundland Nutritious Food Basket includes a list of foods which can be priced to estimate the cost of healthy eating for different age and gender groups. It provides the weekly cost of eating in the province for 2003 for a family of four. As seen in Figure 29 below, the Eastern region is the second highest in terms of the cost of healthy eating.89 Figure 29: Weekly Cost of Eating in NL in 2003 for a Family of Four Health Region Prior to April 1, 2005 Grenfell Eastern St. Johnâ&#x20AC;&#x2122;s Western Central

Cost per week $132.17 $130.96 $130.44 $128.53 $127.19

Healthy eating is one of the priorities of the Provincial Wellness Plan.90

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6.7.2.7 Obesity Obesity received some mention throughout the needs assessment process, particularly from health providers. In the telephone survey, 46.5% of respondents identified obesity as a minor problem, 28.6% as a major problem and 18.1% as not a problem. While not seen as a major problem, the telephone survey revealed that the majority of respondents were in fact overweight. Survey respondents were asked for weight, height and gender to determine body mass index. As seen in Figure 30, the majority of respondents, 41.5% are in the overweight category. In terms of gender, most respondents in the overweight category were males while a majority of women were in the obese category. Figure 30: Burin Peninsula Telephone Survey Body Mass Index (BMI) by Gender BMI

Males

Females

All

Underweight/Normal < 24.9 Overweight 25.0 â&#x20AC;&#x201C; 29.9 Obese >30.0

20 (17.4%) 68 (59.6%) 26 (22.8%)

134 (36.9%) 130 (35.8%) 99 (27.2%)

154 (32.3%) 198 (41.5%) 125 (26.2%)

Totals

114

363

477*

*9 respondents did not provide adequate data

When considering Body Mass Index (BMI) with self-rated health level, a greater percentage of respondents who rated their health as good, very good, or excellent fell within the normal BMI range while a greater percentage of respondents who rated their health as fair fell within the overweight BMI range. As seen in Figure 31, of the respondents who rated their health as poor, a greater percentage fell within the overweight and obese BMI range. Figure 31: Burin Peninsula Telephone Survey Self-Reported Health Rating by Body Mass Index (BMI) Health Rating

BMI

Underweight/Normal <24.9 Overweight 25.0 â&#x20AC;&#x201C; 29.9 Obese >30.0 Total

Poor

Fair

Good

4 (18.2%) 9 (40.9%) 9 (40.9%)

22 (23.2%) 39 (41.1%) 34 (35.8%)

61 (33.9%) 75 (41.7%) 44 (24.4%)

Very Good 46 (34.1%) 55 (40.7%) 34 (25.2%)

180

135

*10 respondents did not provide adequate data

Excellent 21 (47.7%) 20 (45.6%) 3 (6.8%) 44

Total 154 198 124 476*

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6.7.2.8 Heart Health In the 2001 Dialogue on Heart Health, Eastern Newfoundland Health and Community Services Region, areas of the Eastern Region were analyzed to indicate levels of physical activity, consumption of fried food, and having two or more risk factors for heart disease. Figure 32 reveals that Burin did poorly in these aspects compared with other areas in the region.91 Figure 32: Dialogue on Heart Health, Eastern Newfoundland Health and Community Services Region

6.7.2.9 Health Practices In terms of personal health practices, 97% of telephone respondents reported having their blood pressure checked within the last two years from the date of the survey. Eighty-three percent (83%) reported having their cholesterol checked within the last two years. In terms of diabetes, the 2000/01 Canadian Community Health Survey (CCHS) reported 5.8% of Newfoundland and Labradorâ&#x20AC;&#x2122;s population aged 12 years and older had been diagnosed with diabetes by a health care professional. In the Burin Peninsula telephone survey, 15.2% of respondents indicated that they have received a diagnosis of diabetes.

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There were 376 respondents (77.4%) who reported a health professionalâ&#x20AC;&#x2122;s diagnosis of diabetes, high blood pressure, or high cholesterol. Overall, 15% had diabetes, 33% had high blood pressure, and 29% had high cholesterol. Burin Peninsula North had the lowest self-reported incidence (12%) of diabetes while St. Lawrence had the highest self- reported incidence (24%) of diabetes. Incidence of high blood cholesterol was highest in Grand Bank/Fortune (35%) and Burin Peninsula North (34%) and lowest in Marystown/Burin (27%). The incidence of high blood pressure ranged between 30% and 36% in the four areas as seen in Figure 33. Figure 33: Burin Peninsula Telephone Survey Self-Reported Incidence of Chronic Disease by Area

There was no significant difference between the regions with respect to diabetes, high blood pressure or high cholesterol. 6.7.2.10 Sexual Health The topic of sexually transmitted infections (STI) received mixed thoughts from focus groups and key informant interviews. While some people thought that it was an issue, others did not. In the telephone survey, 40.3% of respondents did not see sexually transmitted infections as a problem, while 54.1% did not know. In the 2000 Dialogue With Youth About Risk and Resilience, 17% of youth reported having sex with at least one person in the last six months and did not always use a condom.92 A School Health Team on the Burin Peninsula recognized the need to provide students

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with knowledge about safe sexual practices. Their report in 2003 Health in our Schools: The Issue of Making Condoms Available to Youth provided support for the installation of condom machines in the high school bathrooms. Due to school board restructuring and timing issues this has not yet occurred. The importance of this initiative was also validated in the 2004 Adolescent Sexual DecisionMaking in Newfoundland and Labrador report which recommended “providing adolescents with access to affordable birth control options including condom machines in the school or in other places frequented by youth.”93 6.7.3. Personal Health Practices and Coping Skills Conclusion The people of the Burin Peninsula face many of the same challenges as do people in other areas of the province in terms of personal health practices and coping skills. Evidence has indicated that the residents of the Burin Peninsula face particular challenges associated with obesity and diabetes rates which can be impacted by personal health practices. The Government of Newfoundland and Labrador’s Provincial Wellness Plan has established a number of health priorities in the area of personal health practices and coping skills: healthy eating; physical activity; tobacco control.94 “With VLTs, we’re benefiting ourselves due to someone else’s misery.” - Focus group participant

“Obesity is the root cause of many problems. People are less aware of the complications caused by obesity.” - Focus group participant

6.8

Healthy Child Development

6.8.1 What it is and Why it is Important Happy and healthy babies have the best chance of growing up to be happy and healthy adults. Before a child is born and up to the age of five is the most important period in a child’s development. In addition to it being a time when children learn skills they will use throughout their life, it is also a time when they learn personal health practices that set the foundation for the choices they will make as they grow older.95 A good start in the early years of life is critical to long-term well-being because of the development and learning that occurs during this period.96

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A strong start in childhood depends on a number of factors, including the prenatal health of the child and mother, nutrition, parenting, social supports and simulative interaction with others. 97 6.8.2 Healthy Child Development-Related Findings Importance of pre-natal and post-natal care. People participating in the needs assessment primary research stressed the importance of giving children the best possible start in life. In the June 2000 Examining Prenatal Services, Eastern Newfoundland Health and Community Services Region, a survey of 750 mothers who had given birth in the past three years confirmed that attendance at prenatal classes is low. Mothers attended classes in less than a third of pregnancies (31%). Women with lower education levels and lower income are less likely to attend prenatal classes. The main reason given for not attending prenatal classes was that the women felt they did not need or want to attend (28%). Nearly a third of women reported taking multivitamins or folic acid before the pregnancy. Almost three-quarters (72%) took folate during pregnancy and 41% took iron during pregnancy. Over two-thirds (68%) of women said they changed their diet during pregnancy. Almost all of them (98%) reported eating a more healthy diet. Nearly all the women (87%) said they exercised before pregnancy, and slightly less (81%) reported that they exercised during pregnancy. Less than half the babies (48%) were started on breastfeeding. Looking directly at exclusive breastfeeding by age of the child at the time of the survey, only a fifth of all children were being exclusively breastfed among those 0-3 months old. When examining factors related to breastfeeding, it was found that more educated mothers and women from a higher income household (over $15,000 per year) are more likely to initiate breastfeeding. Also, women who attend prenatal classes are more than twice as likely to initiate breastfeeding than those who do not. About a quarter of those that start breastfeeding, stop within the first month, and women who are younger and women with less education are more likely to stop breastfeeding in the first month.

The Burin Peninsula: Healthy Child Development at a Glance -

Burin Peninsula immunization rates for two-year olds and kindergarten students have been at 99-100% for the past three years.

Breastfeeding rates on the Burin Peninsula range from 41-49%.

The number of referrals for Child, Youth and Family Service has decreased by about 9% from 2004 to 2005.

The number of children on the Burin Peninsula in long-term protection has decreased from 75 in 2003 to 34 in 2005.

As seen in Figure 34, breastfeeding initiation rates on the Burin Peninsula have ranged from 4149%, similar percentages to the former Eastern Health and Community Services Board geographic region covering from Holyrood to the Burin and Bonavista Peninsulas. Within the four community

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health offices on the Burin Peninsula, the St. Bernard’s office had the lowest rate of breastfeeding initiation, ranging from 17-30%. Figure 34: Initiating Breastfeeding as a Percentage of Live Births

Excellent immunization rates. The Burin Peninsula has had excellent participation in immunizations for children. For the past three years, immunization statistics for two-year children are at 100% while immunizations for kindergarten students have been at 99-100% for the past three years. Positive feelings toward Family Resource Centre - A number of focus group participants and key informants referenced the positive impact of the Burin Peninsula Brighter Futures. This organization operates Family Resource Centres out of Terrenceville, Grand Le Pierre, Bay L’Argent, St. Bernard’s/Jacques Fountaine, Marystown, Burin, St. Lawrence, Lawn, Lamaline, Grand Bank and Fortune. Healthy Baby Clubs are operated out of Terrenceville, Grand Le Pierre, Marystown, Burin, St. Lawrence, Lawn, Lamaline, Grand Bank, Fortune and English Harbour East. Figure 35 indicates that in 2004/05 over 1200 adults and children had some level of involvement with the Family Resource centre programs in the region. This figure represents an increase of approximately 30% from 2003/04. The Healthy Baby Club Program served 74 different parents in pre-natal programs and 84 in post-natal programs. These figures also represent an increase from 2003-04 by approximately 25% and 21%, respectively.

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Figure 35: Program Participation 2004/05 – Number of different individuals who participated in at least one session.

FAMILY RESOURCE CENTRE

FRC Program

Health Baby Club

Adults

Children

Pre-natal

Post-natal

Lamaline

Lawn

St. Lawrence

14(14)*

St. Bernard’s

Bay L’Argent

Grand Le Pierre

Terrenceville

Marystown

112

135

4(18)

Burin

11(17)

Fortune/Grand Bank

226

162

English Harbour East

660

609

53(49)

TOTAL

*Bracketed numbers refer to additional individuals who attended Rock and Talk, a post natal program for families with babies older than six months. This is considered a bridging program from HBC to FRC.

Need for parenting skills. Focus group participants expressed concern regarding a lack of parenting skills. There was particular mention of discipline and the sense that parents did not always know or feel confident in what age-appropriate discipline to use. A Parenting Committee established by the former Health and Community Services Eastern Board has the Burin Peninsula within its catchment area. The parenting programs currently available include Nobody's Perfect which targets parents of children up to the age of five. This program is offered by Eastern Health staff and the Family Resource Centre. There are also four programs for

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older children and teens: Hey Who's In Control, Parenting Teens and Pre-teens, Ready or Not and Smooth Sailing. They are available to parents of youth in the area. While Smooth Sailing has been available for some time the other programs have been around since Fall 2004. Staffing issues have resulted in the need to restrict the offerings of these programs. Importance of healthy living in the school system. Many focus group participants and key informants indicated a frustration with a perceived lack of focus on healthy living within the educational system. Cafeterias at schools were targeted for providing easy access to junk food and people indicated disappointment with the lack of physical activity for students. A number of people also felt that health-related courses should be offered at the primary level. 6.8.3 Healthy Child Development Conclusion To enhance the already positive aspects of healthy child development that exist, the residents of the Burin Peninsula see parenting education sessions and further emphasis on healthy living in schools as areas for improvement. â&#x20AC;&#x153;Schools are a good place to start. Get good food and gym time in the schools and the kids will get the message to their parents.â&#x20AC;? - Key informant

6.9

Biology and Genetic Endowment

6.9.1 What it is and Why it is Important Basic biology and organic make-up of the human body are a fundamental determinant of health. Genetic endowment provides an inherited predisposition to a wide range of individual response that affects health status.98 6.9.2 Biology and Genetic Endowment-Related Findings The province of Newfoundland and Labrador has typically been of interest from a genetics perspective. There are pockets in the province that have been studied due to the incidence of inherited diseases and the Burin Peninsula is no The Burin Peninsula: exception. Biology and Genetic Perhaps the most significant of the genetic discoveries on the Burin Peninsula is of the inherited disease Multiple Endocrine Neoplasias (MEN-1). Individuals who inherit the mutated gene for MEN-1 have an increased chance of developing overactivity and enlargement of certain endocrine glands, particularly the pituitary, pancreas and

Endowment at a Glance -

Multiple Endocrine Neoplasias (MEN-1) has been identified on the Burin Peninsula.

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parathyroid glands. Children of an affected parent have a 50% chance of developing the disease. On the Burin Peninsula, genetic researchers from Memorial University of Newfoundland have traced this disease back at least six generations and believe that the disease originally descended from one ‘founder’ family. Members of these MEN-1families are offered genetic testing to determine if they need to be in a clinical screening program. Screening programs are important for early diagnosis and treatment as MEN-1 does result in a predisposition for tumours, some of which may be malignant. In the past, researchers at Memorial University have offered education sessions about MEN-1for physicians and family members. The need for education and counseling continues with each generation to ensure optimal health. Other genetic issues exist on the Burin Peninsula similar to other areas of the province and the country, such as retinitis pigmentosa, familial adenomatous polyposis, Batten’s disease and spondyloepiphyseal dysplasis.99 6.9.3 Biology and Genetic Endowment Conclusion Like a number of isolated areas in the province, the Burin Peninsula has incidences of inherited disease which stresses the need for appropriate health screening and education for that population.

6.10 Gender and Culture 6.10.1 What it is and Why it is Important Women and men have different health issues and can be impacted by the same issues in different ways. Heart disease, for example, affects men and women differently. The health of both genders is affected by society’s expectations and assigned roles, and differences in power and control can also impact health. Some persons or groups may face additional health risks due to a socio-economic environment, which is largely determined by dominant cultural values.100 6.10.2 Gender and Culture-Related Findings Importance of health promotion. Focus group participants and key informants articulated the importance of health promotion activities for the genders. The telephone survey provides some insight into incidence of mammograms, pap tests and prostatespecific antigen (PSA) tests. As seen in Figure 36, 67% of female telephone respondents reported having a breast exam in the last two years, 50% reported having a mammogram in the last two years and 65% reported having a pap test in the last two years. The breast exam and mammogram

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numbers are consistent with provincial and national reporting numbers. The pap test number, 65%, compares with a provincial figure of 70% and a national figure of 68%.101 For men, 43% of them reported having a PSA test in the last two years, compared with 37% provincially and 38% nationally. Figure 36: Burin Peninsula Telephone Survey Self-Reported Preventative Tests â&#x20AC;&#x201C; Gender Specific Test in last 2 years (Females = 370)

Burin Peninsula Telephone Survey f (%)

Canada

Breast Exam

248 (67%)

63%

Mammogram

184 (50%)

49%

PAP test

242 (65%)

70%

68%

PSA test in last 2 years (Males = 115)

50 (43%)

37%

38%

More specifically, while 65% of female respondents indicated they had a PAP test within the last two years, 6% reported a PAP test done within the last three years, and 22% reported a PAP test done more than three years ago (see Figure 37). Figure 37: Burin Peninsula Telephone Survey Time of Last PAP Test

n = 370

PAP Test

Table 29: When was the last time you had a PAP test done? More Less than 3 than a Within 2 Within 3 Donâ&#x20AC;&#x2122;t Never Other years years years Know year ago ago 165 (44.6%)

77 (20.8%)

23 (6.2%)

82 (22.2%)

13 (3.5%)

8 (2.2%)

2 (0.5%)

Total

370 (100.0%)

According to the provincial cervical screening program, the rate per 100 population women aged 15 and up being screened for cervical cancer was 34.6% in 2001 and 2002 and 36.1% in 2003 in the former Peninsulas Health Care Corporation region (Burin and Bonavista Peninsulas).102 Based on information from the Canadian Cancer Society regarding clinical breast examinations and mammograms as well as the National Cancer Institute, the American Cancer Society, and the American College of Radiology recommendations for annual mammograms, the ages provided by

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respondents were divided into three groups - less than 40, between 40 and 64, and 65 or older - and applied to all prevention practices.103 For the female preventative practices (i.e., breast exam, mammogram, and PAP test) there was a significant difference between the three age groups. Women older than 65 were less likely to have had a breast exam or a PAP test. For the male preventative practices (i.e., PSA test) there was a significant difference among the age groups. Men under the age of 40 were less likely to have had a PSA test done. Violence against women. When looking at the gender and culture determinant of health, violence against women must be considered. In the Burin Peninsula telephone survey, when asked if marital difficulties/violence in the home was a problem, the majority of respondents (41.6%) indicated that they didnâ&#x20AC;&#x2122;t know and 32.3% did not see it as a problem. Grace Sparkes House, a shelter for women and children in need, opened its doors on the Burin Peninsula in October 2000. This initiative came about as a result of an identified need within the community. From October 2000 to March 31, 2005, Grace Sparkes House has had 476 admissions. In addition to providing shelter for women and children, staff also provide community outreach activities to educate the public about violence and abuse.104 As indicated in the graph below, the shelter has provided a number of services since it has opened. Figure 38: Grace Sparkes Home, Shelter Statistics

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Eating habits as a part of culture. Traditionally, Newfoundlanders have eaten a diet that is very high in salt. Eating food such as salt cod, sruncheons and salt beef are often a part of a culture and can be difficult to break. Today, people recognize the importance of healthy eating but cost can sometimes be a factor in the types of foods that people eat. 6.10.3 Gender and Culture Conclusion The theme of health promotion, prevention and early intervention arises in the gender and culture determinant of health in terms of ensuring that women and men have appropriate screening to ensure optimal health.

7. 7.1

HEALTH SERVICES What It Is and Why It Is Important

Health services have a direct impact on the health of a community. These services are particularly designed to maintain and promote health, to prevent disease, and to restore health and function. Health services contribute to the overall health of a population. The health services continuum of care includes treatment and secondary prevention. 105 Prior to the creation of Eastern Health, health and community services on the Burin Peninsula were offered by the Eastern Health and Community Services Board and institutional health care services were offered by the Peninsulas Health Care Corporation. Eastern Health is now responsible for the full continuum of health services on the Burin Peninsula. This section of the report will review health services under the following themes: Health Promotion; Primary Health Services; Secondary Health Services; Mental Health Services and Addictions Services; Long-Term Care; Home Supports; Home-Based Palliative Care; Child, Youth and Family Services; and Accessibility and Wait Lists. These are the main themes that arose through the needs assessment process related to the health services determinant of health. Within each of these themes, needs assessment participantsâ&#x20AC;&#x2122; perceptions of the service will be presented, current services will be described, and a conclusion will be drawn. This section will focus on the main themes that arose through the needs assessment process and will not focus on all of the services/programs that Eastern Health offers.

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7.2 Overview of Health Service Available on the Burin Peninsula Eastern Health offers health and community services on the Burin Peninsula through communitybased offices, medical clinics, hospitals and long-term care facilities. From a community health perspective, there are five worksites from which programs and services are provided. These worksites are the Dodge Building, Burin; the Burin Peninsula Health Care Centre, Burin; the Buffett Building, Grand Bank; the Council Building, St. Bernardâ&#x20AC;&#x2122;s; and the U.S. Memorial Health Centre, St. Lawrence. From an institutional care perspective, primary care services are offered at the Burin Peninsula Health Care Centre, Burin; the U.S. Memorial Health Centre, St. Lawrence; and the Grand Bank Community Health Centre, Grand Bank. The Burin Peninsula Health Care Centre also offers secondary services. A recent review of these health facilities by an external consulting firm that specializes in infrastructure assessments revealed that the Burin Peninsula Health Care Centre and the U.S. Memorial Health Centre are amongst the best physical condition of Eastern Health facilities. The remaining two institutional facilities, the Grand Bank Community Health Centre and the Blue Crest Nursing Home, were identified as having considerable deficiencies. In November 2005, the provincial government announced $6.7 million to construct a new primary health clinic in Grand Bank and $4.3 million for the redevelopment of the Blue Crest Nursing Home. Eastern Health operates primary care clinics in the following communities: Terrenceville, Petit Forte, Parkers Cove, South East Bight, Grand Le Pierre Clinic, English Harbour East. Frequency of service varies by clinic. Blood collection services are available at Terrenceville, Parkerâ&#x20AC;&#x2122;s Cove, South East Bight and Petit Fort. Long-term care is offered at the Blue Crest Nursing Home, Grand Bank and the U.S. Memorial Health Centre, St. Lawrence, which also offers protective care. Eastern Health operates Blue Crest Cottages, Grand Bank, owned by Newfoundland and Labrador Housing, for level one and two senior citizens. Figure 39 provides a snapshot of the services offered on the Burin Peninsula.

Figure 39: Services Offered on the Burin Peninsula

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Health Promotion

Health promotion is a comprehensive range of population health and community development programs aimed at enabling and fostering individuals, families and communities to take control of and improve their health. This is accomplished through the use of a variety of strategies including information sharing, community mobilization and capacity building, group facilitation, advocacy, the provision of resource materials and the improvement of health status in our communities.106 7.3.1 Perception of Health Promotion The majority of focus group participants and key informants were very aware of the importance of health promotion and early intervention. They understood that the typical view of health as illness was not appropriate. Focus group participants identified that investments are needed to address the underlying causes and factors contributing to health problems in order to affect long-term health outcomes. Although they recognized the need to prioritize health promotion, prevention and early intervention to affect long-term population health, participants did not want to see a shift of resources away from intervention/treatment services in the short-term. Participants expressed a need for earliest possible engagement with children and youth and targeted efforts towards known population health concerns. A number of people were concerned with what they saw as a lack of emphasis on health and physical activity within the school system. There was an acknowledgement that health promotion is important for seniors, particularly given the impact that out-migration is having on extended families. People recognized that health problems are not the sole responsibility of the formal health system. They identified the need to address the barriers that keep government departments, agencies and community groups from working together to address the determinants of health. It was felt that a silo approach was not sustainable, effective, nor efficient and that community-based partnerships were the only way to effect change. Needs assessment participants described decisions made in isolation of the community which negatively impact on addressing health problems and finding solutions pertaining to health service delivery issues. Focus groups identified the need for ongoing and consistent communication in order to develop workable partnerships in the best interest of communities. Many people stressed the importance of empowering communities to take responsibility for the health of their residents and the importance of co-operation across geography and sectors. There was frustration expressed regarding the lack of co-ordination between government services and the negative impact that some government departmental policies can have on the client. One example provided was of young parents who wanted to have their newborn immunized. The Department of Human Resources, Labour and Employment would not pay for transportation costs

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for them to travel from their home community to the community health office and the community health nurse was not permitted to travel to see them. These types of policies in isolation, without overall regard for the health of the client, may result in negative outcomes or they may encourage people to attempt to find ways around the system. Participants expressed an interest in harmonizing government department/agencies to meet client needs in a seamless and holistic approach. 7.3.2 Health Promotion: What Is Available One of the founding boards of Eastern Health, the former Eastern Health and Community Services Board had an approved health promotion plan, Healthy People, Healthy Communities, Healthier Future, that covers the time period 2004-2007. The document Health Promotion in Action is a supporting document that provides detailed action plans for each of the priority areas including objectives, action, outcome and indicators. Both of these documents include the Burin Peninsula within the catchment area and ongoing implementation of the objectives will continue through to the end of 2007. The former Eastern Health and Community Services Board recognized the need for a coordinated approach to the delivery of school-based programs and services. Building on the concepts of coordination, collaboration and multi-disciplinary team work, the Model for the Delivery of School-Based Programs and Services was implemented in October 2001. School teams, comprised of Eastern Health staff, were established to facilitate work with the school population. A school team has been assigned to each school on the Burin Peninsula. The school team members provide individual client services and/or school health promotion programs and services designed to enhance the health and well-being of children, youth and their families. Another part of this model involves the identification of a school liaison for each school. This person is a link from the school to the school team as it relates to general school population health issues, such as smoking or bullying; and communication in general such as arranging for the school team presentation or distributing information/resources. In 2003, a school health team on the Burin Peninsula wrote the report Health in our Schools: the Issue of Making Condoms Available to Youth and has been advocating for the installation of condom machines in schools. Eastern Health, in partnership with the Eastern School District, recently hired two School Health Promotion Liaison Consultants. These positions are not based on the Burin Peninsula but have responsibility for the schools on the peninsula. In March 2006, the Government of Newfoundland and Labrador released a provincial wellness plan, Achieving Health and Wellness: Provincial Wellness Plan for Newfoundland and Labrador. The plan focuses on improving the health of the population and helping them achieve their optimal state of wellness. Phase I of the plan will focus on some key areas, including: healthy eating, physical activity, tobacco control, and injury prevention. Phase II will consider other wellness priority areas such as mental

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health promotion, child and youth development, environmental health and health protection.107 Eastern Health will be working with government to achieve the goals of the provincial wellness plan. Eastern Health is part of the Eastern Regional Wellness Coalition, a network of government and non-government groups, community groups, agencies and individuals with an interest in promoting wellness and improving health and well-being in communities, including those on the Burin Peninsula. The mission of the group is to promote wellness and improve health and well-being in the Eastern Region through improved partnership and co-ordination. The wellness coalitions across the province will play a role in the implementation of the Provincial Wellness Plans. From a community engagement perspective, there is a Community Enrichment Committee on the Burin Peninsula. The function of this committee is to create and increase public awareness regarding mental health, child protection, family violence, community support services and facilitate the maintenance, enhancement and development of services for these areas on the Burin Peninsula. The goals of this group centre on advocacy, public education/professional education, information sharing and resource sharing. 7.3.3 Health Promotion Conclusion One of the key beliefs of the determinants of health is that communities have the strengths, knowledge and skills necessary to originate programs which influence the determinants of health and which promote overall health and well-being. Communities sometimes need assistance to build capacity and reach the potential that they have.108 This point was echoed by Roy J. Romanow who was appointed to head the Commission on the Future of Health Care in Canada in 2002. In a speech to the Pan-American Health Organization (PAHO) in September 2003, he made the following statements about community capacity building: Actively engaging citizens in shaping the policies and programs that will affect them is critical to their success. Given an opportunity to contribute, and given access to the hard facts, to the trade-offs and choices, people can be trusted to make the right and responsible decision. I have no doubt whatsoever on this point and I hold this to be a universal truth, equally relevant to all nations and peoples, regardless of their level of development, wealth or demographic realities.109 With a vision of Healthy People, Healthy Communities, Eastern Health recognizes its role to continue to partner with community groups to promote and enhance community development and capacity. The organization also has a leadership role to work with other government agencies/departments to develop inter-sectorial co-operation to benefit the client. Throughout the needs assessment process, people referred to a lack of education sessions offered in their communities. They spoke about wanting sessions about healthy eating and information about diabetes as two examples. A very detailed and specific health promotion plan Healthy People, Healthy Communities, Healthier Future and a supporting document Health Promotion in Action are in place. The priority areas for this plan are nutrition, smoking, physical activity, substance abuse, parenting,

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prenatal support and child and youth development. The plan does not include seniors health promotion and this should be addressed. From the acute and long-term care side of services, a health promotion role has not been emphasized due to the separate mandates of the two founding organizationsâ&#x20AC;&#x2122; boards. In the past, health promotion was viewed more as the mandate of the health and community services boards. The former Eastern Health and Community Services Board has been offering Health Promotion 101 courses to its staff for a number of years. With the integration of the boards, it is necessary to explore the possibility of integrating health promotion in the mandate of the Board. Work is ongoing with the school system through the Eastern Health school teams, School Health Promotion Liaison Consultants, a regional health promotion plan and most recently, the Provincial Wellness Plan. It is important that this work continue and receive some profile within the community.

7.4

Primary Health Services

Primary health services offers first-contact services by providers such as family physicians, nurse practitioners, pharmacists and community health nurses. In September 2003, the provincial government released its framework for primary health care renewal, Moving Forward: Mobilizing Primary Health Care.110 Since then, a number of primary health care models have evolved across the province. There are two main elements in primary health care renewal. These are: the provision of a model of service based on the needs of the region that it serves, and a focus on providing integrated care to a client as that client moves through the services that he or she requires. This model for primary health care moves beyond the traditional health care system as we know it.111 At present, primary health care services on the Burin Peninsula are not offered in this integrated, multi-disciplinary way. In this section, general practitioner services, community health nursing and nurse practitioner services, dental health and ambulance services will be considered. 7.4.1 Primary Health Services Perceptions All focus groups cited primary health services, specifically physician services, as the basic level of health services for their populations. Participants recognized that a lack of services at that level would contribute to problems in the future such as advanced disease processes and higher, unsustainable costs to the healthcare system.

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Throughout focus group sessions and key informant interviews, participants referenced the inequitable distribution of primary health care services in the Burin Peninsula North area. People felt that other areas of the peninsula have greater access to services compared with the Burin Peninsula North area. References were made about some family physicians advising patients they could have one complaint per visit only. Focus group participants expressed frustration about this policy and did not feel that it was in their best interests. Their understanding of the policy was if they visited a family physician with a headache and a stomachache, for example, they could only mention one complaint to the physician. There was a lot of support for the work of the community health nurse although people expressed frustration regarding the trend of the community health nurse to see clients in the office rather than travelling to their homes. Participants were confused regarding the geographic boundaries of the community health nurse and were puzzled that a nurse could make a home visit in one community but not in the community next door. These comments were often made in relation to using health care workers to their full scope of practice. Similarly, there was a lot of support for nurse practitioner services throughout the peninsula. Participants have embraced the nurse practitioner role and want to see them working to their full scope of practice. A number of concerns were raised about dental health. Health providers in particular expressed concern about dental care services with general practitioners and emergency room physicians indicating they are now seeing patients about dental concerns. In the telephone survey, when asked about satisfaction levels for dental services, 47% of respondents indicated they were very satisfied with dental services; 28.1% were somewhat satisfied and 24.9% were not at all satisfied. Significantly more respondents from the St. Lawrence area (46.8%) indicated that they were not satisfied. Ambulance services received a number of comments from focus group participants and key informants. Concern about the waiting times for ambulances in some communities led to speculation that ambulances may be based in the wrong communities. Some towns expressed concern with having to oversee ambulance services and not being fully comfortable or knowledgeable to do so. Some people wondered about the maintenance of ambulances. Telephone survey respondents were asked about their satisfaction with ambulance services and 84.7% of them indicated they were very satisfied.

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7.4.2 General Practitioner Services: What is Available General Practitioners are a first point of contact for many people. Figure 40 indicates that there are 18 funded positions for general practitioners on the peninsula with the majority of them in the Burin/Marystown area and the Grand Bank/Fortune area. Figure 40: General Practitioners on the Burin Peninsula Locations Bay L’Argent Clinic Terrenceville Medical Clinic Marystown Burin Medical Clinic Burin U.S. Memorial Health Centre St. Lawrence Grand Bank Community Health Centre Grand Bank

Grand Bank Medical Clinic Grand Bank TOTAL

Number of General Practitioners 1 1 (vacant as of August 2005) 3 5 3 4 (1 vacancy as of March 24, 2006) 1 18

The Burin Peninsula has a population of 23,710 and there are 18 funded positions for general practitioners who provide service to that population. This puts the number of general practitioners on the Burin Peninsula per 100,000 at 75.9. According to the Canadian Institute of Health Information (CIHI), there were 121 General Practitioners per 100,000 population as of December 31, 2004 in the province of Newfoundland and Labrador and 98 per 100,000 in Canada.112 The CIHI calculation for general physicians includes all physicians who maintain their licences. This number includes individuals who work in other fields, are semi-retired, or are on leave from their practises. Eastern Health also operates primary health care clinics in the following communities: Terrenceville, Petit Forte, Parkers Cove, South East Bight, Grand LaPierre Clinic, and English Harbour East. Frequency of General Practitioner or Nurse Practitioner service varies by clinic. Blood collection services are available at Terrenceville, Parker’s Cove, South East Bight and Petit Fort. In the Burin Peninsula telephone survey, respondents estimated that the 1239 household members represented in the survey utilized the services of a general practitioner an estimated 6095 times during the previous year. This represents an average utilization rate of general practitioner services of approximately 5 visits per person per year. This compares with recent Health Research Unit, Memorial University of Newfoundland reports that found utilization rates of 4 visits per person per year for both the downtown area of St. John’s and for Bell Island.113

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As indicated in Figure 41 below, there was a significant difference between the regions regarding general practitioner visits. The Burin Peninsula North area had the highest general practitioner utilization rate at 6.2 visits per person per year while the other three areas ranged from 4.2 to 4.9 visits per person per year. Figure 41: Burin Peninsula Telephone Survey General Practitioner Utilization Per Person Per Visit Per Year

In the telephone survey, 88.7% of respondents reported having a regular family doctor as indicated in Figure 42. This compares with a recent provincial report indicating 85% of Newfoundlanders and Labradorians have a regular family doctor.114 The percentages in three areas of the peninsula are consistent with the St. Lawrence area reporting significantly fewer respondents (54%) having a family doctor.

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Figure 42: Burin Peninsula Telephone Survey Respondents Who Have a Regular Family Doctor by Area Area Burin Peninsula North Marystown/Burin Area Grand Bank/Fortune Area St. Lawrence Area Total

Have a Regular Family Doctor Yes No 81 4 (95.3%) (4.7%) 231 4 (98.3%) (1.7%) 88 20 (81.5%) (18.5%) 31 27 (53.4%) (46.6%) 431 55 (88.7%) (11.3%)

Total 85 (100.0%) 235 (100.0%) 108 (100.0%) 58 (100.0%) 486 (100.0%)

The 55 respondents who indicated they did not have a regular family doctor were asked why they did not have a regular family doctor and where they went for general practitioner services. Fiftythree percent (53%) indicated retention and recruitment of general practitioners was the main reason they did not have a regular family doctor. The vast majority indicated they went to a hospital or clinic for general practitioner services. Respondents with a regular family doctor were asked the length of time needed to drive from their home to their doctorâ&#x20AC;&#x2122;s office. Respondents from the Grand Bank/Fortune area indicated a driving time of less than 10 minutes while the driving times in the other areas were between 10-30 minutes. The mean driving time was 19.04 minutes. To obtain a more representative mean, the 5 highest scores were removed from the calculations. This yielded an average driving time of 17.56 minutes. Respondents rated the convenience of their doctorâ&#x20AC;&#x2122;s office as mostly good and excellent, 51% and 31% respectively. When respondents with a family doctor were asked how often they were able to see their own family doctor and not some other doctor in the same clinic, 91% indicated that they were able to see their regular family doctor always/most of the time. This holds true for the different areas as seen in Figure 43.

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Figure 43: Burin Peninsula Telephone Survey Respondents Able to See Regular Family Doctor by Area

Area

Burin Peninsula North Marystown/Burin Area Grand Bank/Fortune Area St. Lawrence Area Total

Able to See Regular Family Doctor Always/Most Sometimes/ of the Time Rarely 65 7 (90.2%) (9.8%) 224 4 (98.2%) (1.8%) 77 6 (92.8%) (7.2%) 28 1 (96.6%) (3.4%) 394 18 (100.0%) (100.0%)

Total 72 (17.5%) 228 (55.3%) 83 (20.1%) 29 (7.1%) 412 (100.0%)

As seen in Figure 44 below, the majority of respondents (46%) were able to get an appointment with a particular family doctor within a week while 29% could get an appointment in a day and 25% within two weeks or more. There was a significant difference between the regions with respect to time needed to schedule an appointment with a particular family doctor with 70% of respondents from the Burin Peninsula North able to get an appointment in a day while 60% of respondents from the St. Lawrence area wait two weeks or more. Fifty-nine percent (59%) rated the time needed to schedule an appointment as good/excellent. Figure 44: Burin Peninsula Telephone Survey Time Needed to Schedule an Appointment with a â&#x20AC;&#x153;Particular Family Doctorâ&#x20AC;? by Area Time Needed Area Burin Peninsula North Marystown/Burin Area Grand Bank/Fortune Area St. Lawrence Area Total

Same day/ Next day 53 (69.7%) 46 (20.1%) 10 (11.4%) 10 (35.7%) 119 (28.3%)

Within the Week 15 (19.7%) 142 (62.0%) 25 (28.4%) 13 (46.3%) 195 (46.3%)

Two weeks or more 8 (10.5%) 41 (17.9%) 53 (60.2%) 5 (17.9%) 107 (25.4%)

Total 76 (100.0%) 229 (100.0%) 88 (100.0%) 28 (100.0%) 421 (100.0%)

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When the length of time options were categorized into less than two weeks and two weeks or longer, significantly more respondents from Grand Bank/Fortune indicated it took two weeks or more to schedule an appointment with a particular family doctor. However, on March 30, 2006, the wait list at the Grand Bank Community Health Clinic to see a general practitioner was one to two days and for the nurse practitioner it was one to two weeks. At the U.S. Memorial Health Centre, appointments were available for the following day. Respondents, regardless of having a regular family doctor or not, were asked how quickly they were able to obtain an appointment with any family doctor. Overall, 62% of respondents indicated they were able to obtain an appointment within a day. When asked the length of time it took to get an urgent appointment to see a family doctor or general practitioner, 58% of respondents indicated they were able to obtain an appointment on the same day (note: no other time limits were asked). For all areas, significantly less respondents from the Grand Bank/Fortune area reported being able to schedule an urgent appointment the same day. Thirty-six per cent (36%) of respondents indicated a wait time in their doctorâ&#x20AC;&#x2122;s waiting room in excess of 45 minutes followed by 32% who waited for up to 30 minutes and 18% who waited up to 15 minutes. When the length of time options were categorized into less than 30 minutes and more than 30 minutes, significantly more respondents from the Grand Bank/Fortune Area indicated wait times of more than 30 minutes. Fifty-one percent (243/479) of respondents rated the wait time in the doctorâ&#x20AC;&#x2122;s waiting room as good/excellent. 7.4.3 Community Health Nursing and Nurse Practitioner Services: What is available Community health nurses provide services under health promotion and protection, they complete assessments on clients requiring home support services, and they work with staff and clients in personal care homes to provide health education, direct to nursing care and consultative services. They provide nursing care to all residents of the region of any age group who require such service. This nursing care is provided through ambulatory clinics at the nursing offices or in the clientâ&#x20AC;&#x2122;s home. In addition to the provision of care, nurses support, educate and encourage individuals to be independent in meeting their long-term care needs. Community health nurses have a role to help mobilize communities and participate in a number of projects, such as school teams. A nurse practitioner (primary health care) is a registered nurse with advanced preparation in nursing and health services. Nurse practitioner activities are within the scope of guidelines set by the Nurse Practitioner (Primary Health Care) Regulations under the Registered Nurses Act. Within guidelines established by the Registered Nurses Act, nurse practitioners can provide prenatal care and wellwomen services, including pap smears, clinical breast exams, as well as educating people about birth control, osteoporosis, menopause and sexually transmitted diseases. They also treat acute illnesses such as flus, sore throats, ear infections and sprains in addition to managing stable chronic conditions such as diabetes, thyroid disease, hypertension and asthma for up to a year.

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Community health nursing is available from four work sites on the Burin Peninsula. The communities covered by these offices are the following: St. Lawrence: Little St. Lawrence, St. Lawrence, Lawn Burin: Winterland, Lewins Cove, Salt Pond, Salmonier, Mortier, Bulls Cove, Burin, Black Duck Cove, Parker's Cove, Baine Harbour, Jean de Baie, Rock Harbour, Garnish/Frenchman's Cove, Epworth, Big Salmonier, Burin Bay Arm, Burin Bay, Fox Cove, Port Au Bras, Ship Cove, Collins Cove, Rushoon, Red Harbour, Spanish Room, Mooring Cove, Creston North, Long Cove, Kirbys Cove, Marystown, Creston South. St. Bernardâ&#x20AC;&#x2122;s: St. Bernards, Little Bay East, Jacques Fontaine, Bay L'Argent, Terrenceville, Harbour Mile, Grand LaPierre, Little Harbour. East, Brookside, South East Bight, English Harbour East, Monkstown, Petit Forte, Boat Harbour. Grand Bank: Grand Bank, Fortune, Lamaline, Point au Gaul, Grand Beach, Point May, Taylors Bay, Lord's Cove. Currently, nurse practitioner services are available at the Grand Bank Community Health Centre and the U.S. Memorial Health Centre, St. Lawrence. In the Burin Peninsula telephone survey, there were a reported total of 685 visits to a public health nurse, community health nurse, or nurse practitioner representing less than one visit per person per year. Figure 45 indicates the number of home visits made by community health nurses from 2003 to 2005. The visits have declined in Burin and St. Lawrence while home visits from the St. Bernardâ&#x20AC;&#x2122;s office have increased and are at constant levels from the Grand Bank office. For the Burin Peninsula as a whole, the number of home visits from 2003 to 2005 has declined by 14%.

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Figure 45: Number of Home Visits by Community Health Nurse from Burin Peninsula Worksites 2003-2005

These declines in the number of home visits by community health nurses coincide with increased numbers of clinics offered at community health offices. Figure 46 indicates the number of community health clinics that have been held on the Burin Peninsula for the past three years (these clinic visits are for acute care and other services such as flu vaccines and international travel clinics). The number of clinics offered have increased in the Grand Bank, St. Bernardâ&#x20AC;&#x2122;s and St. Lawrence offices while the Burin office increased in 2004 but not in 2005. The number of clinics offered on the Burin Peninsula as a whole from 2003 to 2005 has increased 55%.

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Figure 46: Number of Clinic Visits to Burin Peninsula Community Health Offices

Figure 47 indicates the number of registrations for nurse practitioner services for the past two years. The number of registrations has increased almost 17% in Grand Bank from 2004/05 to 2005/06. Figure 47: Number of Registrations for Nurse Practitioner Services, Grand Bank and St. Lawrence Nurse Practitioner Grand Bank Community Health Centre, Grand Bank U.S. Memorial Health Centre, St. Lawrence

April 1, 2004 â&#x20AC;&#x201C; March 31, 2005

April 1, 2005 â&#x20AC;&#x201C; March 16, 2006

1,963

2,264

1,631

497*

*Nurse Practitioner on leave from September 2005 onward.

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7.4.4 Dental Care Services: What is Available There are two dentists on the peninsula. They are located in Grand Bank and Burin. The Grand Bank Dental Office is open one week on Monday, Tuesday and Wednesday 9:00 a.m. – 8:30 p.m. The second week it’s open Tuesday and Wednesday 9:00 a.m. – 8:30 p.m. For the dental office located in Marystown, the clinic is open Monday, Tuesday, Thursday and Friday from 9:00 a.m. to 5:00 p.m. and Wednesday 9:00 a.m. to 1: 00 p.m. The Grand Bank Dental Office has not accepted new patients for the past year. If a current patient of the clinic has an emergency, the office tries to fit them into the schedule. The office in Marystown does accept new patients. If a new patient called the office on March 28, 2006 he/she could get an appointment for July 2006. The office has an emergency list and as regular appointments are cancelled, emergency patients are given appointment times. According to the Canadian Institute of Health Information, the number of active registered dentists per 100,000 population in Newfoundland in 2002 was 29.2, the lowest in Canada. The Canadian average for 2002 was 57.1 dentists per 100,000 population.115 With two dentists on the Burin Peninsula for a population of 23,710, that equates to 8.43 dentists per 100,000 population. The CIHI calculation for dentists includes all physicians who maintain their licences. This number includes individuals who work in other fields, are semi-retired, or are on leave from their practises. 7.4.5 Ambulance Services: What is Available Private ambulance services for the Burin Peninsula are based in Burin, Marystown, Lawn and Terrenceville. Ambulance services based in Grand Bank and Bay L’Argent are operated by the Towns. 7.4.6 Primary Health Services Conclusion Over 88% of the respondents in the Burin Peninsula telephone survey have a family physician. This number is slightly above the provincial rate. Despite this, there are opportunities to enhance the primary health services available on the peninsula. The Burin Peninsula North area has 17.4% of the population on the peninsula, and St. Lawrence, which has a primary health care facility, has 11.7% of the population, indicating that an inequity in access to primary health services exists. The distances of surrounding communities that would use a primary health facility is also an indication of the inequity of primary health services on the peninsula as shown in Figure 48.116

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Figure 48: Health Care Facilities and Distances from Neighbouring Communities Distances from Surrounding Communities to U.S. Memorial Health Centre, St. Lawrence Community Little St. Lawrence St. Lawrence Lawn Lordâ&#x20AC;&#x2122;s Cove Point au Gaul Lamaline Point May

Distance to St. Lawrence * 3 km 14 km 27 km 36 km 40 km 50 km

Estimated Driving Distance Based on Speed Limit * 2 minutes 14 minutes 28 minutes 36 minutes 40 minutes 50 minutes

Distances from Surrounding Communities to Grand Bank Community Health Centre, Grand Bank Community Garnish Frenchmanâ&#x20AC;&#x2122;s Cove Grand Beach Grand Bank Fortune Lamaline Point May

Distance to Grand Bank * 38 km 31 km 20 km 7 km 40 km 31 km

Estimated Driving Distance Based on Speed Limit * 38 minutes 31 minutes 20 minutes 7 minutes 40 minutes 31 minutes

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Distances from Surrounding Communities to Burin Peninsula Health Care Centre, Burin Community Epworth-Great Salmonier Burin Port au Bras Fox Cove/Mortier Beau Bois Marystown Winterland Lewin’s Cove Spanish Room Jean de Baie Red Harbour Rushoon Baine Harbour Parkers Cove Boat Harbour Brookside Petit Forte South East Bight Monkstown English Harbour East Grand Le Pierre Terrenceville Harbour Mille-Little Harbour Little Bay Bay L’Argent St. Bernard’s – Jacques Fontaine

Distance to Burin Peninsula Health Care Centre * 20 km 6 km 10 km 27 km 21 km 19 km 11 km 28 km 30 km 41 km 60 km 59 km 57 km 61 km 65 km 82 km 90 km 130 km 132 km 119 km 111 km 97 km 83 km 81 km 79 km

Estimated Driving Distance Based on Speed Limit * 20 minutes 7 minutes 10 minutes 27 minutes 21 minutes 19 minutes 11 minutes 28 minutes 30 minutes 41 minutes 1 hour 1 minute 1 hour 1 minute 58 minutes 1 hour 1 minute 1 hour 6 minutes 1 hour 10 minutes 10 hours 20 minutes+ 2 hours 10 minutes 2 hours 12 minutes 1 hour 59 minutes 1 hour 51 minutes 1 hour 37 minutes 1 hour 23 minutes 1 hour 21 minutes 1 hour 19 minutes

* Involves ferry ride so it is difficult to provide an accurate estimation of length of time. The number provided is by the Newfoundland and Labrador Statistics Agency Road Distance Database.

There were a significant number of respondents to the telephone survey from the St. Lawrence area without a family physician. When people call the U.S. Memorial Health Centre for an appointment with a general practitioner, they are given the next available appointment. This does not enable good continuity of care. The one-complaint per visit practice of general practitioners is causing concern for people who do not feel it is in their best interest.

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The provincial government is developing a dental health strategy for the province and Eastern Health will have input into the strategy. As of March 31, 2006, ambulance services devolved to the regional health authorities. This provides an opportunity to partner with local stakeholders to review the ambulance situation on the peninsula. A primary health care model for the Burin Peninsula would help to provide integrated care to the residents of the peninsula. Such a model would consider the Burin Peninsula as a whole in order to offer seamless care to the people of the peninsula.

7.5

Secondary Health Services

Secondary services are offered at the Burin Peninsula Health Care Centre. These include general surgery, pediatrics, internal medicine, obstetrics/gynaecology, mammography, anaesthesiology, critical care, psychiatry, pulmonary function, stress testing/EKG, preadmission-surgical care and holter monitoring. CT scanning will be available on the peninsula in 2006 and provision of dialysis service on the Burin Peninsula was announced by the provincial government on March 1, 2006. 7.5.1 Perception of Secondary Health Services In the focus group sessions, there was a general understanding that by virtue of living in rural areas, it was not reasonable to expect all secondary and specialty services in communities. Participants did expect standards related to primary health care and highlighted the benefits of the establishment of provincial location of service standards for primary, secondary and tertiary care. They identified the need for creative solutions and partnerships with stakeholders to develop a health care system that was as seamless as possible. A number of comments were made about the Burin Peninsula Health Care Centre. Some key informants and focus group participants questioned the institutionâ&#x20AC;&#x2122;s bed numbers. Comments were made about the hospital converting patient rooms into offices and people questioned whether or not the facility is being used to its optimal effectiveness. A number of people expressed the desire that the hospital continue to have the best medical equipment available, not only for the benefit of patients but also to help recruit and retain physicians. A number of people wondered why speciality clinics were not offered on the peninsula. Ophthalmology was mentioned as a particular concern.

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7.5.2 Secondary Health Services: What is Available In the Burin Peninsula telephone survey, the sample of 1,239 household members utilized the services of a specialist physician a reported 1,140 visits during the previous year. This represents an average utilization rate for a specialist physician of approximately one visit per person per year. There are 15 specialists on the Burin Peninsula. Their speciality and numbers are noted in Figure 49 below. Figure 49: Specialists on the Burin Peninsula

Physicians - Specialty

Number of Physicians

Surgeon

Pediatrician

Emergency Room

OBS/GYN

Radiologist

Internist

Anesthetist

Psychiatrist

TOTAL

According to the Canadian Institute of Health Information, in 2004 there were 71 specialists in Newfoundland and Labrador per 100,000 population compared with 91 in Canada.117 The Burin Peninsula has 15 specialists for a population of 23,710 which equates to 63.3 specialists per 100,000. The CIHI calculation for specialists includes all physicians who maintain their licences. This number includes individuals who work in other fields, are semi-retired, or are on leave from their practises. The Burin Peninsula North area had the highest self-reported utilization of general practitioners and had the lowest self-reported specialist utilization rate.

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Figure 50: Burin Peninsula Telephone Survey Specialist Utilization Rate By Area

Figure 51 reviews the Burin Peninsula Health Care Centre occupancy rates for the past three years and shows that occupancy levels have seen a slight increase. Figure 51: Occupancy levels at the Burin Peninsula Health Care Centre, 2002-03, 2003-04, 2005-06

Total Inpatient Days for a period x 100 Total inpatient bed days x number of days in the period

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Over the past three years, the Burin Peninsula Health Care Centre, as the primary and secondary centre for the Burin Peninsula, has received over $1.1 million in capital equipment additions. Much of this equipment was achieved through the funding from the provincial government as well as the work of the Burin Peninsula Health Care Foundation and its many donors. Capital equipment additions in the past three years include but are not limited to: digital radiography machine, stress test machine, fetal monitor, hearing screener, video colonoscope, neonatal dash monitor, holter monitor system, incubator transport system, opthologist lensmeter. A 16-slice CT scanner is scheduled to be operational in the summer of 2006 and the provincial government recently announced dialysis services for the Burin Peninsula. The Burin Peninsula Health Care Centre is also connected with the Provincial Archiving Communications System (PACS) which permits digital images to be sent and received from other health facilities with the same technology. Speciality clinics at the Burin Peninsula Health Centre are offered in cardiology, nephrology, oncology and behaviour management. An internal medicine speciality clinic is offered at the Grand Bank Community Health Centre by an internist from the Burin Peninsula Health Care Centre. In terms of the speciality clinics offered at the Burin Peninsula Health Care Centre, Figure 52 shows that cardiology, nephrology and oncology clinics have been offered two â&#x20AC;&#x201C; three times a year with over 400 patients seen each year. Behaviour management clinics from the Janeway have been offered twice in the past three years with almost 60 patients seen. Figure 52: Speciality Clinics Offered on the Burin Peninsula with Number of Patients Seen 2003-04

2004-05

2005-06

Speciality

Number of Clinics

Number of Patients

Number of Clinics

Number of Patients

Number of Clinics

Number of Patients

Cardiology

137

160

138

Nephrology

176

174

187

Oncology

143

117

Behaviour Specialist

Total

482

452

442

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In the telephone survey, when asked if any member of the household had travelled off the Burin Peninsula for any health service, test, treatment, or medical advice, 63% of respondents indicated that at least one household member had travelled outside the Burin Peninsula in the past year. As seen in Figure 53, St. Lawrence area reported the highest percentage of respondents indicating some member of their household leaving the Burin Peninsula for health services but there was no significant difference between the regions. Figure 53: Burin Peninsula Telephone Survey Household Members who Needed to Travel Outside Burin Peninsula for any Health Service by Area

Area Burin Peninsula North Marystown/Burin Area Grand Bank/Fortune Area St. Lawrence Area

Travelled Outside the Burin Peninsula for any Health Service Yes

51 (60.0%) 151 (64.3%) 62 (57.4%) 45 (77.6%)

34 (40.0%) 84 (35.7%) 46 (42.6%) 13 (22.4%)

The 309 respondents who indicated they had travelled off the Burin Peninsula for service were asked where they travelled for services, the type of services they received and why they travelled off the peninsula. The vast majority travelled to St. Johnâ&#x20AC;&#x2122;s, mostly for specialist services, because those services werenâ&#x20AC;&#x2122;t available on the peninsula. 7.5.3 Secondary Health Services Conclusion The Burin Peninsula Health Care Centre is a well-equipped hospital with occupancy rates that do not suggest over-capacity. Ophthalmology as a speciality clinic has not been offered on the Burin Peninsula since 2003-04 when 431 patients were seen. Specialist screening for various eye conditions in the adult and paediatric population is a very important part of each personâ&#x20AC;&#x2122;s medical care. For example, there are clinical guidelines for screening for diabetic retinopathy. All Type 2 diabetic patients should have an annual screening and more frequent screening if abnormalities are detected. Given the rates of diabetes on the Burin Peninsula, this is particularly important. Eastern Health is currently trying to recruit an ophthalmologist. As part of the contract, the ophthalmologist would provide speciality clinics on the Burin Peninsula.

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The behaviour management clinic from the Janeway has not visited the Burin Peninsula in 2005/06 as in other years. This clinic plays an important supportive role. Other speciality clinics are offered on a consistent basis.

7.6

Mental Health Services and Addictions Services

Mental health offers assessment, intervention, health promotion and education and consultative services on a variety of mental health issues, including mental illness. There is currently a staff complement of four on the Burin Peninsula, including a nurse, social worker, psychologist and a case manager. These professionals work as a team in the provision of mental health services. Services are primarily based in Burin and are also offered via visiting clinics at other locations. Addictions services offers alcohol, drug and gambling prevention and treatment services. These services are offered to individuals, family members, groups, organizations and other professionals. There is currently one addictions co-ordinator position located in Burin providing both clinical services, and health promotion and prevention. Addictions services are provided primarily in the Burin office and are offered in Grand Bank via weekly clinics. Two psychiatrists are available at the Burin Peninsula Health Care Centre. There are no psychiatric beds designated at the Burin Peninsula Health Care Centre although the psychiatrists do have admitting privileges. 7.6.1 Perceptions of Mental Health Services and Addictions Services Many key informants and focus group participants expressed concerns regarding mental health, especially relating to the impact the determinants of health such as employment and working conditions have on people. They talked about the importance of providing people with coping strategies and cognitive therapy. There were concerns expressed regarding addictions, particularly around gambling and VLTs. There was some reference to mental illness and concern about the lack of dedicated mental illness resources on the peninsula such as acute care beds, community programming and cognitive therapy. 7.6.2 Mental Health Services and Addictions Services: What is Available In terms of mental health services, the wait list and new referrals for mental health services on the Burin Peninsula is seen in Figure 54. The wait list has been between 60-70 people for the past three years with the number of referrals fairly constant. These people are clients waiting to see a mental health social worker, psychologist or nurse.

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Figure 54: Wait list and New Referrals for Mental Health Services, Burin Peninsula 2002-03

2003-04

2004-05

Wait List for Mental Health Services

New Referrals for Mental Health Services

242

251

221

Wait lists represent the total number of people waiting for services. New referrals are the number of new people referred for service during the year. They may or may not be placed on the waiting list depending on the priority of service required. As seen in Figure 55, the number of new addictions clients over the past three years has ranged from 51 to 74. In 2004-05, a realignment in staff was made to focus more on the health promotion and prevention aspect of addictions services, resulting in a higher waiting list for new clients. As of March 31, 2006, the wait list for addictions services is 31 people, which equates to a waiting time of at least one year. Figure 55: New Clients and Waiting Lists for Addictions Services, Burin Peninsula, 2002/03 â&#x20AC;&#x201C; 2004/05 2002-03

2003-04

2004-05

Wait List for Addictions Services

New Referrals for Addictions Services

As indicated in Figure 56, the major issue is alcohol. The numbers are broken down into the following services provided through the Burin and Grand Bank offices:

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Figure 56: Services Provided through the Burin and Grand Bank Offices Services Provided

2002-03

2003-04

2004-05

Alcohol

Concurrent disorders

Family member

Gambling

Illicit drugs

Impaired drivers

Over the counter meds

Prescription drugs

Solvents

Poly drug use

Smoking

TOTALS

Figure 57 indicates that the number of patient visits to psychiatrists during the past three years have ranged from 3,349 to 3,528. Figure 57: Number of Visits to Psychiatrists on the Burin Peninsula During Past Three Years Number of Visits to Psychiatrists at the Burin Peninsula Health Care Centre *April 1, 2005 â&#x20AC;&#x201C; February 28, 2006

2003-04

2004-05

2005-06*

3,349

3,711

3,528

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The wait list for a new patient to see a psychiatrist on the Burin Peninsula on March 31, 2006 was four weeks. In comparison, the wait list for a new patient to see a psychiatrist at the Dr. G.B. Cross Memorial Hospital, Clarenville, on March 31, 2006 was three weeks. Although the Burin Peninsula Health Care Centre has no designated psychiatric beds, the psychiatrists do have admitting privileges. The number of admissions in 2003/04 was 81; 2004/05 was 64; and in 2005/06 the number of psychiatric admissions was 75. 7.6.3 Mental Health Services and Addictions Services Conclusion A mental health needs assessment was conducted in the Eastern Region in 2005. Arising from this was the development of a mental health strategy for the Eastern Region that has been approved and will be implemented as approved funding is received. The Eastern plan is a part of the Department of Health and Community Servicesâ&#x20AC;&#x2122; provincial mental health plan, Working Together for Mental Health: A Provincial Policy Framework for Mental Health and Addictions Services.

7.7

Long-Term Care

Long-term care facilities are for those people who have been assessed as having high level needs. Personal care homes provide lower level care and are operated by private owners. These personal care homes are monitored and licensed by Eastern Health. 7.7.1 Perception of Long-Term Care In the needs assessment process, some people wondered if the number and location of long-term care beds were appropriate on the peninsula. 7.7.2 Long-Term Care: What is Available Eastern Health operates two long-term care facilities on the Burin Peninsula. Blue Crest Nursing Home, Grand Bank, has 61 beds (includes respite and 30-day assessment bed) offering long-term care and the U.S. Memorial Health Centre, St. Lawrence, has 20 beds for long-term care (including respite/palliative care) and 10 beds offering protective care (including respite). A total of 91 longterm care beds are available on the peninsula. For comparison purposes, in the Bonavista Peninsula-Clarenville area there are 13 protective care beds and 80 long-term care beds (including respite) for a total of 93 beds. A new long-term care facility adjoining the hospital in Clarenville will increase that number by 30. A review of the long-term care occupancy rates and waiting lists of long-term care facilities on the Burin Peninsulas is seen in Figure 58. For the U.S. Memorial Health Centre, occupancy rates for the past three years have ranged from 83.11% to 96.2% while rates for Blue Crest Nursing Home were

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slightly higher, ranging from 94.78% to 97.7%. For both facilities, the trend for wait lists have ranged from two to five residents or potential residents. Figure 58: Occupancy Rates and Waiting Lists for Long-Term Care Facilities, Burin Peninsula Indicator

Blue Crest Nursing Home 2002-03

Blue Crest Nursing Home 2003-04

Blue Crest Nursing Home 2004-05

U.S Memorial 2002-03

U.S Memorial 2003-04

U.S Memorial 2004-05

94.78%

95.77%

97.7%

96.2%

83.11%

93.5%

Occupancy Rate By Location* Waiting List Long-term care Facilities+

Total resident days for a period x 100 Total resident bed days x number of days in a period +The total number of residents or potential residents waitlisted for each facility. Caution should be exercised when interpreting LTC wait list as individuals may be simultaneously listed for more that one facility. *

Figure 59 reveals that the Burin Peninsula has 99 personal care beds, 20 of which are subsidized. For comparison purposes, the Bonavista Peninsula to Clarenville area, which has similar population numbers as the Burin Peninsula, has 275 total personal care beds with 87 of them subsidized. Figure 59: Personal Care Homes, Location, Subsidized Beds and Total Bed Numbers, Burin Peninsula Personal Care Home Marystown* Retirement Centre Mount Margaret Manor

Location

Total # Subsidized Beds

Total # Beds

Number of Beds Occupied (%)

Marystown

46 (68%)

St. Lawrence

27 (87%)

Totals

73 (74%)

*opened October 2005

The occupancy rate for personal care beds on the Burin Peninsula is 74% as of March 31, 2006. For personal care homes on the Bonavista Peninsula and in Clarenville, the occupancy rate is 55%.

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7.7.3 Long-Term Care Conclusion The occupancy rates and waiting lists for long-term care facilities on the peninsula do not suggest that there is currently a lack of long-term care beds. This will continue to be monitored. The number of personal care home beds, with a combined occupancy rate of 74% also does not suggest that there is a gap in this service.

7.8

Home supports

The purpose of the home support program is to assist eligible clients through financial subsidies to purchase personal care, household management and respite services in their home. It is designed to supplement and not replace the family care giving role. 7.8.1 Perception of Home Supports There was some reference to the lack of home support funding for individuals and families. There were also comments about the lack of home support workers in the area. People felt that this work was extremely important but worried about the lack of available and trained competent home support workers. 7.8.2 Home Support: What is Available As of March 2006, there were 257 active clients on the Burin Peninsula receiving $5,172,901 in home support funding. This means the Burin Peninsula receives $218 per capita in home supports (based on the population of 23,710 provided by Community Accounts from Mile Hill down the peninsula). In comparison, as of March 2006, in the Clarenville-Bonavista area, there were 177 active clients receiving $3,462,141 in home support funding. Figure 60 indicates the number of requests and the number of approvals and cost in the past three years on the Burin Peninsula. The number of requests has been constant between 75-79 with the approvals ranging between 48-59.

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Figure 60: The Number of Requests for Home Support Versus the Number of Approvals

For comparison purposes, the Clarenville-Bonavista area had a range of requests for home support for the past three years from 78 to 112 requests, with the number of approvals ranging from 43 to 49. Figure 61 indicates the annual cost of home support provided to the approved requests for home support on the Burin Peninsula for the past three years. Figure 61: Annual Cost of Home Support for the Burin Peninsula for the Past Three Years

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7.8.3 Home Supports Conclusion The number of requests and the number of approvals for home support have remained fairly constant. It can be difficult to secure home support workers on the Burin Peninsula as well as alternate family care homes. If alternate family care homes are not available, people must leave the peninsula for service or a private agency is used. Another challenge around home support workers is the continuity of maintaining home support workers. The professional support provided by Eastern Health employees to caregivers and families is extremely important, particularly given the increased complexity of disabilities. Eastern Health can play a role in enhancing home support by providing support to the families and caregivers.

7.9

Child, Youth and Family Services

Child, Youth and Family Services offer a range of services and interventions to children, youth and their families. Under the Child, Youth and Family Services Act, Eastern Health employees are mandated to respond to referrals of child maltreatment, assess risk and provide protective intervention services. The adoptions program and the community corrections program are also provided. 7.9.1 Perception of Child, Youth and Family Services There was some reference made in key informant interviews and focus groups to the lack of daycares on the peninsula, particularly in the more rural areas of the peninsula. There were a few comments during the needs assessment process about the fact that there are not enough foster homes on the Burin Peninsula. These comments have come from health care providers and not from the general public. 7.9.2 Child, Youth and Family Services: What is Available There are two licensed daycares on the Burin Peninsula. These daycares are monitored by Eastern Health. One, in Creston South, can accept 26 children ranging from 24 to 69 months, and one in Marystown can accept 56 children ranging in age from 24 months to 144 months. There are no wait lists for these daycares. Figure 62 below indicates that there have been five foster families on the peninsula for the past three years with requirements for three to four homes. While the statistics provide the sense that there are sufficient numbers of foster homes for the demand, they do not tell the whole story. One home, for example, will be closing, another home provides occasional respite and two are dedicated to a specific child or youth. Of the current five homes, only one accepts youth aged 12 and above.

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Figure 62: Number of Children in Care and Number of Foster Homes, Average per Month

In comparison to the Burin Peninsula, the Bonavista Peninsula/Clarenville area currently has 17 foster families available. Figure 63 indicates that the number of youth on probation was halved from 2003 to 2005 while the number of youth in custody has remained fairly constant. Figure 63: Child, Youth and Family Services, Community Corrections, Number of Youth on Probation and Number of Youth in Custody, Average Per Month

Similar trends are seen in the number of cases of children in long-term care protection as seen in Figure 64.

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Figure 64: Child, Youth and Family Services, Community Corrections, Number of Long Term Protection Cases, Average Per Month

The number of referrals for Child, Youth and Family Services has also decreased with 282 referrals made in 2005, down by about 9% for 2004. This is reflected in Figure 65. Figure 65: Child, Youth and Family Services, Community Corrections, Number of Referrals to Child, Youth and Family Services

The number of children with child welfare allowance arrangements in place (support and financial services are provided to a relative or significant other to provide care for a child when parents are

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unable to do so) has remained fairly constant in the past three years with eight or nine children having these arrangements in place. 7.9.3 Child, Youth and Family Services Conclusion In rural Newfoundland and Labrador, there tends to be a strong tradition of family and friends taking care of children in their home. While there are only two daycares on the peninsula, there are no waiting lists for those daycares. There is a gap between the numbers of foster families on the peninsula and the demand. Should a foster family not be available, a child/youth in care may have to be sent to foster care off the Burin Peninsula.

7.10 Palliative Care Palliative care attempts to improve the quality of life of patients and their families facing a lifethreatening illness. Palliative care provides the prevention and relief of suffering and treatment of pain and other problems, physical, psychosocial and spiritual.118 7.10.1 Perception of Palliative Care There were no concerns raised regarding institutional based palliative care services. There was some reference to the lack of home-based palliative care. Some needs assessment participants felt that home-based palliative care was preferable for the patient and family while noting that this option would save the health system money. They felt support offered in this area would be of great benefit. 7.10.2 Palliative Care: What is Available Currently, a palliative care bed is designated at the Burin Peninsula Health Care Centre and a palliative/respite care bed is designated at the U.S. Memorial Health Centre. Current palliative care bed numbers seem to match current demand. In the case of a person wishing to receive home-based palliative care, meetings occur with Eastern Health staff to determine appropriateness, particularly around issues of pain management. 7.10.3 Palliative Care Conclusion It is not clear if there is a gap in this service or not. The service may be available depending on a number of circumstances but the option of providing home-based palliative care needs to be further investigated.

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7.11 Accessibility and Waitlist 7.11.1 Perception of Accessibility and Wait List Focus group participants and key informants expressed confusion about the health services available to them. They are not aware of some services that are available on the peninsula and are unsure of contact information. Long distance costs are a barrier for some people and others expressed frustration at the complexity of forms that need to be completed and the lack of physical accessibility of medical clinics and other offices. Individuals saw these concerns not only with health services but with other social services offered. There were also general comments about wait lists. 7.11.2 Accessibility and Wait List Status When asked if they were able to obtain health services when needed in the Burin Peninsula telephone survey, 92.3% of respondents felt that they were able to obtain health services when needed always/most of the time (See Figure 66). Figure 66: Burin Peninsula Telephone Survey Respondents Able to Obtain Services When Needed Able to Obtain Services Always Most of the time Sometimes Rarely Never Total

n (%) 236 (48.6%) 213 (43.8%) 31 (6.4%) 5 (1.0%) 1 (0.2%) 486 (100.0%)

As seen in Figure 67, eighty-four per cent (84%) of respondents said there was nothing that prevented them or any family members from receiving health services or medical advice during the previous year. There was no significant difference in the response by area.

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Figure 67: Burin Peninsula Telephone Survey Prevented Service Prevented Service

n (%)

410 (84.4%)

Lack of health services

17 (3.5%)

Wait time

16 (3.3%)

Financial

7 (1.4%)

Travel Issues

6 (1.2%)

No answer

30 (6.2%)

When asked to comment on barriers or obstacles to obtaining health care services on the Burin Peninsula, the interviewers transcribed the respondentsâ&#x20AC;&#x2122; answers and coded them into six major themes. Some respondents gave more than one response. Figure 68 shows that over 36% of respondents noted a lack of health services and 31% reported lack of health professionals as the major barriers. Figure 68: Burin Peninsula Telephone Survey Barriers/Obstacles to Receiving Health Services Rating

Barrier

Lack of Health Services119 Lack of Health Professionals Wait Time Travel Retention and Recruitment of Professionals Cost

n (%) 176 (36.2%) 151 (31.1%) 84 (17.3%) 64 (13.2%) 38 (7.8%) 21 (4.3%)

A breakdown by area in Figure 69 shows that lack of health services and/or lack of health professionals on the peninsula were listed as the greatest barriers in all four areas of the peninsula, particularly for the Marystown/Burin respondents.

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Figure 69: Burin Peninsula Telephone Survey Respondentsâ&#x20AC;&#x2122; Biggest Barrier to Obtaining Health Services by Area

Area

Lack of Health Service

Lack of Health Professional

Retention and Recruitment

Wait Times

Travel

Cost

16 (19%)

34 (40%)

4 (5%)

11 (13%)

1 (1%)

92 (39%)

90 (38%)

16 (7%)

42 (18%)

27 (11%)

11 (5%)

30 (28%)

31 (29%)

10 (9%)

22 (20%)

21 (19%)

7 (6%)

13 (22%)

21 (36%)

7 (12%)

9 (16%)

5 (9%)

2 (3%)

Burin Peninsula North (85) Marystown/Burin Area (235) Grand Bank/Fortune Area (108) St. Lawrence Area (58)

The telephone survey revealed that 68% of those with a regular family doctor have been cared for by that doctor for more than four years (see Figure 70). When the length of time options were categorized into less than four years and greater than four years, significantly more respondents from Burin Peninsula North, Marystown/Burin and Grand Bank/Fortune areas reported being cared for by a regular family doctor for more than four years when compared to St. Lawrence Area. Figure 70: Burin Peninsula Telephone Survey Respondents by Area Who Have Regular Family Doctor by Length of Time Cared For Area Burin Peninsula North Marystown/Burin Area Grand Bank/Fortune Area St. Lawrence Area Total

Length of time cared for by family doctor 1 to 2 3 to 4 <1 year >4 years years years 2 12 7 60 (2.5%) (14.8%) (8.6%) (74.1%) 5 34 31 61 (2.2%) (14.7%) (13.4%) (69.7%) 3 13 14 58 (3.4%) (14.8%) (15.8%) (65.9%) 2 12 4 13 (6.5%) (38.7%) (12.9%) (41.9%) 12 71 56 292 (2.8%) (16.5%) (13.0%) (67.7%)

Total 81 (100.0%) 231 (100.0%) 88 (100.0%) 31 (100.0%) 431 (100.0%)

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A two-year review of family physicians in St. Lawrence indicates that there has been one four week vacancy of one general practitioner in 2005 and two vacancies in 2004 totalling 10 weeks. This means over a two-year period, there was a total of 14 weeks when the full complement of physicians was not available at the U.S. Memorial Health Centre. When people call the U.S. Memorial Health Centre for an appointment with a General Practitioner, they are provided with the next available appointment. This does not encourage people to have a family physician. Figure 71 provides the wait lists for secondary services. The wait list for general surgery has increased. Other than that, the longest wait times for speciality services at the Burin Peninsula Health Care Centre are in the area of the rehabilitation services. For comparison purposes, the wait times at the Dr. G.B. Cross Memorial Hospital, Clarenville, a comparable size facility serving a comparable population base, is also provided. The wait times are very similar with the exception of the rehabilitation group which has a much higher wait time at the Dr. G.B. Cross Memorial Hospital. Figure 71: Wait Lists in Weeks for Speciality Services at the Burin Peninsula Health Care Centre and the Dr. G.B. Cross Memorial Hospital, Clarenville Speciality General Surgery Gyn Surgery Internal Medicine OBS/GYN Pediatrics Psychiatry Physiotherapy (Routine) Occup. Therapy (Routine) Speech Pathology

BPHCC March 31, 2003

GBC March 31, 2003

BPHCC March 31, 2004

GBC March 31, 2004

BPHCC March 31, 2005

GBC March 31, 2005

15*

0/6 0 1

0/10 0 4

1 0 2

2 1 2

1 1 3

6 1 1

On Leave

40 child 160 adult

52 child

40 child 68 adult

52 child

36 child 36 adult

* One General surgery vacancy April â&#x20AC;&#x201C;Sept. 2005

The rehabilitative group has the longest wait lists. As of March 2006, the wait list for speech pathology services was 12 weeks; for occupational therapy services it was 12 weeks and for physiotherapy services it was 28 weeks.

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Figure 72 reviews the vacancy rate of specialists for the past two years. In 2004-05, there was a twoweek period without full specialist coverage and in 2004-05, there was a 12-week gap in service in surgery, 15-week in obstetrics/gynecology, and 6-week in anaesthesiology.

Figure 72: Vacancies/Locum Coverage

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Although many participants in the needs assessment process were focused on physician recruitment and retention, there are also difficulties recruiting other health providers such as pharmacists, speech language pathologists, occupational therapists and physio-therapists. 7.11.3 Accessibility and Wait List Conclusion In rural Newfoundland, recruitment and retention of health providers can be challenging. This is particularly the case with smaller centres. Recruitment and retention efforts continue and when physician vacancies occur, efforts are made to secure locum coverage.

7.12 Health Services Conclusion In general, participants in the needs assessment expressed the need to have intersectoral partnerships to address health issues in a holistic and seamless manner. There were many concerns about primary health services and the importance of health promotion, prevention and early intervention. People want a health system that provides collaborative care across the continuum to enhance accountability and accessibility.

“I raised 12 children and now I have to shovel my own driveway or pay someone to do it.” - Focus Group Participant

“At times we are enabling problems through our processes.” - Focus Group Participant

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Health Care Facilities Infrastructure Review An infrastructure assessment was undertaken on the following facilities on the Burin Peninsula: Burin Peninsula Health Care Centre, Burin U.S. Memorial Health Centre, St. Lawrence Blue Crest Nursing Home, Grand Bank Grand Bank Community Health Centre, Grand Bank The infrastructure assessment involved an evaluation of the architectural, mechanical and electrical systems to determine the buildingsâ&#x20AC;&#x2122; current condition and the priority needs and costs associated with correcting identified infrastructure deficiencies. This work was undertaken by VFA, a firm that specializes in such assessments. In addition to the four facilities on the Burin Peninsula, six additional facilities were assessed across the Eastern Health region for a total of ten facilities. That assessment covered a significant portion (over two-thirds) of the total space that Eastern Health operates. The Burin Peninsula Health Care Centre and U.S. Memorial Health Centre were found to be in the best condition of those ten facilities and would therefore be amongst the best of all facilities within Eastern Health. The other two facilities on the Burin Peninsulaâ&#x20AC;&#x201D;the Blue Crest Nursing Home and the Grand Bank Community Health Centreâ&#x20AC;&#x201D;were identified as having considerable deficiencies in their infrastructure that would require substantial capital investment to correct. On November 2, 2005, the provincial government announced $11 million to construct a new primary health clinic in Grand Bank and redevelop the Blue Crest Nursing Home. Health and community services spaces were not assessed by VFA given that they are mostly rented spaces.

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8. DETERMINANTS OF HEALTH SUMMARY OF THE BURIN PENINSULA A summary of the situation on the peninsula based on the determinants of health is as follows: Socio-Economic Environment - The socio-economic environment is comprised of several determinants of health: Income and Social Status; Employment and Working Conditions; Education; Social Support Networks; and Social Environment. There are many concerns expressed in the area of the socio-economic environment. Overwhelmingly, the lack of employment and out-migration dominate all aspects of the qualitative and quantitative research. The sustainability of many of their communities is dependent upon partnerships and networking opportunities in order to build community development and capacity. From an education perspective, there is frustration with the lack of emphasis on health in the education curriculum and the lack of focus on healthy living within the school system. There are activities happening with the school system and more are anticipated given the recent release of the provincial wellness plan. Physical Environment - The Burin Peninsula highway is the main issue that arose in terms of the physical environment. Most people saw it as an isolating factor although some people noted that the highway resulted in the peninsula getting more services than they would ordinarily have, given their population. Personal Health Practices and Coping Skills and Gender and Culture - There is a strong desire by a broad cross section of the community to focus on health promotion, prevention and early intervention within the community, particularly for youth and seniors, and as it relates to gender. Healthy Child Development - Parenting education is thought to be important for parents of children of all ages. Parenting education is offered on the peninsula and is a priority of the health promotion plan Healthy People, Healthy Communities, Healthier Future. Health Services - People want to see more intersectoral partnerships between government departments/agencies to address health issues in a more holistic and seamless manner. People want to see greater regional and provincial planning of the delivery of health and community services. There were many concerns expressed about primary health care, particularly inequitable access to primary health care services across the peninsula. The Burin Peninsula North area does not have access to the same level of services as other areas of the peninsula.

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People want the best level of service available, particularly within the community. They want a seamless health system that provides collaborative care across the continuum to enhance accountability and accessibility. Success Story: Placentia West Leadership Team At town hall forums held by the Strategic Social Plan – Eastern Region in 2002, the need to help communities to develop partnerships for resource sharing and capacity building was identified. The Strategic Social Plan initiated a “Facilitating Community Partnerships – Pilot Project” and requested proposals from communities to address that need. One of the two pilot projects selected was from the Placentia West area of the Burin Peninsula. The proposal was submitted by Christ the King School in Rushoon in partnership with the Regional Recreation Commission and the Placentia West Development Association. A Leadership Team was established and listed below are the goals and some of the outcomes: 1)

Increase literacy levels in the Placentia West area • • •

Increase the level of fitness and opportunities for social interaction in Placentia West • • •

Activities Formed a Placentia West 50s Plus Club with activities that included Club Activity night, lowimpact aerobics program and presentations Offered after-school outdoor activities program for primary and elementary school children Offered aerobics three times a week to women of all ages in the Placentia West area

Provide opportunities for life-long learning by developing employability skills among unemployed youth • • •

Activities Provided library cards for adult users with access provided to the school library after hours. Received funding from various sources and enabled opening the school computer lab and hiring a literacy coordinator Held parent and preschool literacy events

Activities Offered career planning sessions Developed “Our School as Heart of our Community” project which involved designing space on the walls of a school corridor to display the accomplishments of past students and to encourage current students Developed proposal and obtained funding to enhance the craft industry

Promote healthy living and develop self-care skills • • • •

Activities Conducted a needs assessment Increased awareness of health resources available in Placentia West by public forum Developed and presented to government a summary of the health services available in the Placentia West area Initiated the Placentia West Health Service Committee

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9. THE CHALLENGES OF SETTING PRIORITIES AND MAKING DECISIONS Eastern Healthâ&#x20AC;&#x2122;s Strategic Plan has been developed by the Board of Trustees. It provides a vision for the organization and identifies strategic priority areas. These foundational statements provide guidance for decision-making throughout the organization. Even with this guidance, many of the decisions that are made in the health care system are challenging and are affected by competing interests. The delivery of health and community services is a topic of great attention. Health care is an extremely important social and community concern for Newfoundlanders and Labradorians and because of this, there are many expectations of the health sector. Consumers of these services seek the most effective care or services that can be delivered. Citizens of a community also see other important roles for health services, such as being a major employer and the role that institutions fulfill in helping to create community identify. Perspectives and expectations of the health system are directly influenced by the context in which it is viewed. It is in this milieu of heightened expectations that trustees, staff and physicians must make critical policy and funding allocation decisions. When an organization delivers a social service to a community, there is naturally a degree of tension that exists between the organization and the community it serves. The community typically wants the best services available. The organization, in this case, Eastern Health, must serve almost 300,000 people in 246 communities with available resources. Although this natural tension exists, it can result in a community and an organization working together, each one accountable to the other, to ensure the best available service. There are any number of challenges that may impact decision making. Decisions must be made within structural limitations of the system including government legislation, available funding, professional roles, unionized workforces, and incomplete information. Within the system, there is a constant need to balance priorities. For example, how much priority should be given to treating illness versus investing in health promotion? This challenge is particularly an issue for Eastern Health which offers the full continuum of care (i.e., illness prevention and health promotion, not just disease treatment) (priorities challenge). Another example would be, to what extent should the interests of those who are strong advocates be balanced against those who do not have a strong voice? For instance, the interests of those with mental health needs versus those with specialist cancer or specialized surgical needs (advocacy challenge). To what degree should political priorities and interests influence planning and policies (political challenge)? 120

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All of these factors contribute to the difficulties of making tough decisions in the face of changing public expectations. The Board of Trustees and the staff of Eastern Health acknowledge the complexities of decision-making and work very hard at ensuring decisions are evidenced-based.

10. ISSUES, RECOMMENDATIONS AND ACTIONS On February 23, 2006, the Board of Trustees of Eastern Health adopted its strategic plan. Included in this plan are four lines of business. These are sets of programs and services that represent what the organization delivers to its external clients. The Board of Trustees of Eastern Health has outlined four primary lines of business. They are to: 1) promote health and well-being; 2) provide supportive care; 3) treat illness and injury; 4) advance knowledge. The issues that arose from this needs assessment will be considered in relation to these lines of business. In addition, there are also a number of organizational/administrative issues that will be examined in a separate category. Figure 73 visually demonstrates Eastern Health’s overlapping lines of business with the organization’s vision of Healthy People, Healthy Communities in the centre. Encircling the lines of business are the administrative structures and policies that provide direction to the staff as they go about their day-to-day business. Figure 73: Eastern Health’s Vision Statement and Lines of Business

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The following section includes a listing of the issues arising from the needs assessment, the sources from which the issues were heard, and a listing of the recommendations. The topics listed in the issues by source grid were heard from a number of sources. If an issue was referenced by a number of different sources, it is more likely to be an issue for many or all stakeholders. For example, one of the issues that will be discussed in the section Promote Health and Well-Being is the following: There is a strong desire by a broad cross section of the community to focus on health education, prevention and promotion. Concerns were expressed about lifestyle choices and personal health practices, particularly as they relate to the prevalence of heart disease, cancer and diabetes. This issue was referenced in many of the 20 focus group sessions, discussed in many of the 24 key informant interviews and referenced in the telephone survey results. There is also a substantial amount of secondary information that stresses the need for health education, prevention and promotion. Because this theme was repeated in our primary and secondary research, there is a sense of validity that the issue is an important one for stakeholders and was therefore identified as a priority.

10.1 Organizational/Administrative Issues Each organization has organizational policies that provide parameters and guidance for employees. In many ways, the core values of an organization offer principles and a guiding framework for all employees. The core values for Eastern Health, as outlined in the organizationâ&#x20AC;&#x2122;s Strategic Plan, are as follows: Collaboration

Each person consults, cooperates, works and advocates with partners to improve services and the health of people and communities.

Confidentiality

Each person ensures individual privacy within policy and legal frameworks.

Excellence

Each person strives for leadership through sound judgment, decision-making and competency, adhering to the principle of life-long learning.

Growth

Each person helps individuals and communities achieve their potential.

Integrity

Each person conducts himself or herself in an honest, just, fair and accountable manner.

Respect

Each person treats others with compassion and understanding manifested in their attitudes and actions.

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The need to improve communications was expressed as a concern from a number of perspectives. (i) The public does not feel knowledgeable about services available to them in their area and they do not always have access to contact information. (ii) Participants referenced long-distance charges and the lack of user-friendly forms as barriers to accessing services. There were complaints about policies being made but no explanation given as to their purpose or intent.

√

People want to see greater regional and provincial planning of the delivery of health and community services.

√

People want to see more intersectoral partnerships between government departments/agencies to address health issues in a more holistic and seamless manner.

√

People identified the need to move toward more consistent policies within Eastern Health.

√

Secondary Information

Written Submissions

Telephone Survey

Focus Groups

Organizational/Administrative Issues

Key Informants

Figure 74: Organizational/Administrative Issues by Source Grid

√

The needs assessment process revealed the need for Eastern Health to improve the reliability and validity of data.

Recommendations and actions regarding organizational/administrative issues are as follows: 1. Ensure that the results of this community health needs assessment are broadly communicated to the public, participants in the focus groups, key informants, staff, and physicians. 2. Provide the Board of Trustees with a semi-annual written report on the status of the recommendations in this report.

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3. Provide a public report two years from the release of this needs assessment on the progress made in implementing the recommendations of the report. 4. Enhance communications and actions that lead to increased public knowledge of why decisions are made. Eastern Health must continue to challenge itself to be accountable and transparent to the public. 5. Improve linkages between health providers to enhance client accessibility to available services. •

•

The management team of Eastern Health, Peninsulas Region, will investigate new innovative uses of telemedicine on the Burin Peninsula to reduce the necessity of travel by patients/clients.

•

6. Increase the user-friendliness of access to Eastern Health’s programs and services. •

•

The Corporate Communications Department will provide guidelines to Eastern Health staff on the development of user-friendly forms.

7. Develop a Regional Health Services Plan along an integrated continuum within Eastern Health’s regional and provincial mandates and available resources. •

8. Strengthen partnerships between Eastern Health and the Departments of Health and Community Services and Human Resources, Labour and Employment. •

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level of care to clients and to foster awareness of each departmental policies and their impact on each other. 9. Partner with other regional integrated health authorities and provincial government departments to ensure awareness of the impact each of the departments has on developing healthy communities. 10. Review Eastern Healthâ&#x20AC;&#x2122;s internal administrative and clinical policies to ensure consistency in the provision of programs and services throughout the region. 11. Eastern Health will finalize, in conjunction with the Department of Works, Services and Transportation and the Department of Health and Community Services, the plans for the redevelopment of the Blue Crest Nursing Home and the construction of the Grand Bank Community Health Centre. 12. Improve the integrity of data collected in the delivery of programs and services and work to integrate community and institutional data and apply it to a population health model.

10.2 Promote Health and Well-Being One of the lines of business for Eastern Health is to promote health and well-being. Eastern Health implements measures that promote and protect population health and help prevent disease or injury. The main categories of programs in this line of business are: Health Protection â&#x20AC;&#x201C; Disease Prevention, Health Promotion and Child Protection.121 Health Protection â&#x20AC;&#x201C; Disease Prevention - This program is directed towards decreasing the probability of individuals, families, and communities experiencing health problems, assisting with the changes in physical and social environments needed to improve health, and implementing legislation/regulations to support improvements. Health Promotion - Health promotion is a comprehensive range of population health and community development programs aimed at enabling and fostering individuals, families and communities to take control of and improve their health. This is accomplished through information sharing, community mobilization and capacity building, group facilitation, advocacy, the provision of resource materials and the improvement of health status in our communities.122 Child Protection - This program focuses on promoting the safety, well-being and protection of children.

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Written Submissions

Secondary Information

√

Participants want investments in people and communities to support sustainable communities. This is achieved by building and supporting partnerships and networking opportunities to build community development and capacity.

√

The declining economic base of communities affects their ability to sustain town infrastructure, impacting their influence upon ensuring healthy communities.

√

People feel there is a lack of intervention and coping mechanisms available to ensure good mental health well-being, particularly in the face of unemployment and outmigration levels.

√

Public and health providers expressed concern regarding the need to improve dental care services.

√

People are concerned about youth and ensuring that they have good health practices and coping skills.

√

There is concern about the aging population and its implications on health services delivery, particularly health promotion and wellness.

√

Focus Groups

There is a strong desire by a broad cross section of the community to focus on health education, prevention and promotion. Concerns were expressed about lifestyle choices and personal health practices, particularly as they relate to the prevalence of heart disease, cancer and diabetes.

Health Promotion and Well-Being

Key Informants

Telephone Survey

Figure 75: Promote Health and Well-Being Issues by Source Grid

√

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From an education perspective, there is frustration with the lack of emphasis on health in the education curriculum and the lack of focus on healthy living within the school system.

√

Parenting education is important for parents of children of all ages.

√

Some concern was expressed about the lack of daycare services on the peninsula, particularly in the smaller towns.

√

Recommendations and actions regarding health promotion and well-being issues are: 1. Strengthen the commitment to health promotion, prevention and early intervention. •

•

Enhance the awareness of Eastern Health staff of the principles of health promotion and the Healthy People, Healthy Communities, Healthier Future and Health Promotion in Action documents.

•

Increase membership of community groups and agencies on the Burin Peninsula on the Eastern Regional Wellness Coalition.

•

Explore opportunities to enhance parenting education and support within available resources.

•

Increase the uptake of cervical screening on the Burin Peninsula through implementation of the rural Eastern Cervical Screening Program.

•

Ensure regional input into the Department of Health and Community Services’ plan for Healthy Aging.

•

Develop regional strategies for the Burin Peninsula that reflect the provincial government’s overarching strategic plan.

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2. Partner with community groups to promote and enhance community development and capacity. •

•

Eastern Health will promote the concept of establishing a Celebrating Rural Health Week with key partners to highlight and celebrate the innovations occurring in rural areas.

3. Strengthen and create more formal linkages with the Rural Secretariat, Burin Peninsula. •

4. Request an annual meeting between the Trustees of the Eastern School District and the Board of Trustees of Eastern Health to identify opportunities for information sharing, collaborative initiatives and policy development. 5. Examine and strengthen linkages at the senior management level with external partners such as school boards and post-secondary institutions to strengthen strategic planning and policy development.

10.3 Provide Supportive Care The second line of business outlined in Eastern Health’s Strategic Plan is to provide supportive care. Eastern Health provides community-based support and continuing care, residential care options and home support and nursing home care for individuals with assessed needs. These services are provided in select locations and are means-tested and criteria-based. In many cases, there is a relationship with other government agencies such as Human Resources and Employment for subsidized funding to supplement program funding. The supportive care line of business consists of three broad categories: Individual, Family and Community Supportive Services - These programs provide financial and supportive services and case management for individuals of all ages with assessed need. The

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program focuses on supporting individuals, families and caregivers and promoting independence, community inclusion, safety and well-being. Services are limited and provision is based upon financial assessment and the individual’s ability to pay. Short-term adult residential care - These programs provide short respite and/or transitional stays for individuals. The services are offered in selected locations. Long-term adult residential care - These programs are responsible for residential nursing home care that is provided to individuals who require on-going support due to their frailty, disability or chronic illness. Access to services is through the single entry system where an individual’s needs are assessed and matched with appropriate available placements.

People expressed concern about services to seniors, particularly the number and location of long-term care beds.

√

People worry about the lack of funding to hire home support workers and lack of workers available for hire.

√

People want to see more intersectoral partnerships between government departments/agencies to address health issues in a more holistic and seamless manner.

√

There were a few references to concerns about the lack of foster parents on the peninsula, lack of alternative family care homes and a few references to wanting homebased palliative care.

√

Secondary Information

Written Submissions

Telephone Survey

Focus Groups

Provide Supportive Care

Key Informants

Figure 76: Provide Supportive Care Issues by Source Grid

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Recommendations and actions regarding supportive care are: 1. Continue to ensure appropriate level of long-term care service by monitoring long-term care bed occupancy rates and wait lists. 2. Develop a marketing plan to increase the number of foster families and alternate family care homes on the Burin Peninsula. 3. Investigate the feasibility of providing home-based palliative care services in line with the regional plan. 4. Provide education opportunities for staff to increase knowledge about complex disabilities in order to provide a supportive role to families and caregivers providing home support. 5. Work with provincial educational institutions to determine the feasibility of providing a personal care home worker/support worker course/program.

10.4 Treat Illness and Injury The third line of business for Eastern Health is to treat illness and injury. Eastern Health investigates, treats, rehabilitates and cares for individuals with illness or injury. The clinical intent of these services is to treat illness and injuries, relieve symptoms, reduce the severity of an illness or injury, and educate patients. In addition, Eastern Health provides care at the beginning of life (new born care) and at the end of life (palliative care). These services are offered in a variety of locations throughout the region. The location of specific services is dependent upon multiple factors including the level of care (primary, secondary and tertiary), access to health professionals and access to appropriate facilities. For certain services people can self-refer while other services require a referral from a specific health professional. 123

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Figure 77: Treat Illness and Injury Issues Grid Key Informants √

Focus Groups √

Telephone Survey √

Written Submission √

There was concern with the turnover of health care providers, particularly physicians.

√

There were many concerns expressed about primary health care, particularly inequitable access to primary health care services across the peninsula.

√

There is a lot of community support for nurse practitioner services and community health nurses and concerns about their lack of use or change in focus from home-based services to office-based services. People expressed support for services to be offered in the community.

√

People wonder why more speciality clinics are not offered, particularly in the area of ophthalmology.

√

There are concerns about ambulance services ranging from a lack of timely response to questions about proper ambulance maintenance.

√

Treat Illness and Injury The provision of a dialysis unit has overwhelming support from the general public.

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Secondary Information

Burin Peninsula Community Health Needs Assessment

People are interested in ensuring the Burin Peninsula Health Care Centre has the best medical equipment possible.

√

The conversion of patient rooms to offices at the Burin Peninsula Health Care Centre makes people wonder if the facility is being used appropriately.

√

Wait lists for health services in general are a concern for people. People expressed frustration with family physicians for accepting one complaint only per visit.

√

In addition to general mental health well-being concerns, there were references to mental illness and the difficulties people can have in accessing services such as beds and community supports.

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√

Recommendations and actions regarding treat illness and injury issues are: 1. Install and test CT Scanner at the Burin Peninsula Health Care Centre by August 2006. 2. Establish a Working Group to oversee the development of dialysis services on the Burin Peninsula. 3. Establish an integrated model for the delivery of primary health services on the Burin Peninsula. As part of the development of the model, primary health services currently delivered throughout the peninsula will be reviewed.

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4. Establish a single community liaison committee to provide input for the entire peninsula into the community development and community capacity building components of the primary health model. 5. Develop an operational plan for submission to the Department of Health and Community Services to deliver primary health services through a centralized health centre in the Burin Peninsula North area. This would include community, medical and nurse practitioner services. Such services will help to improve the continuity and accessibility of care to patients/clients. 6. Partner with local stakeholders to establish a Working Group to redesign ambulance services. This should address gaps in the ambulance system particularly in the areas of implementation of provincial policies/standards, advances in scope of practice, medical control, quality control and utilization of ambulance services. 7. Validate the appropriate allocation of inpatient beds using a clinical efficiency model. 8. Communicate to the Department of Health and Community Services and the Newfoundland and Labrador Medical Association the concerns about the one-complaint-per-visit practice. 9. Share outcomes of this needs assessment with community stakeholders to help identify strategies to attract another community-based dentist for the peninsula. 10. Prioritize the needs for capital and equipment resources of the Burin Peninsula as part of Eastern Healthâ&#x20AC;&#x2122;s strategic priorities. 11. Monitor speciality visiting clinics to ensure scheduled programs are consistently offered. 12. Continue to recruit an ophthalmologist to provide visiting clinics on the Burin Peninsula. 13. Implement the approved regional mental health plan within available resources.

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11. CONCLUSION Health is a social concern that affects us all. Everyone would like to have the best state of health for themselves and their families. The factors that impact our health are many and they are each interrelated. The tendency when thinking about health services is to focus on hospitals and beds. We do not often tend to think of the impact that housing, employment and incomes can have on our health. But in order to get an overall picture of the health of a community, it is necessary to consider what is happening in all of the determinants of health and how they impact the health of a population. The underlying premise of the determinants of health is that communities have the knowledge and ability to impact these determinants and thus impact their health. This document is a comprehensive look at the Burin Peninsula as a whole. It is a document that can be used by individuals, communities and organizations to decide how to work on enhancing the health of the communities, not just next year or in five years from now, but in the generations to come.

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12. APPENDICES 12.1 Appendix A - Terms of Reference – Steering Committee 1.0 Purpose The Committee will oversee the community health needs assessment on the Burin Peninsula. 2.0 Duties The duties of the Committee are to: 2.1 Oversee the development of a community health needs assessment plan for the Burin Peninsula 2.2 Seek advice from the Community Health Needs Advisory Committee 2.3 Review the primary and secondary research that comprises the community health needs assessment 2.4 Approve the community health needs assessment results 2.5 Evaluate the health needs assessment process 3.0 Membership The Committee will be chaired by Wayne Miller, Senior Director, Corporate Strategy and Research. The Chair will report to the CEO on the activities of the Committee. The Committee will include the following people: Wayne Miller, Senior Director, Corporate Strategy and Research Pat Coish-Snow, Chief Operating Officer (COO), Peninsulas Keith Bowden, Director of Infrastructure Support Beth Mayo, Director of Integrated Health Services, Burin Peninsula Mona Romaine-Elliot, Director of Integrated Health Services – Community Health, Peninsulas Susan Bonnell, Director, Corporate Communications Lisa Browne, Planning Specialist Jane Macdonald, Planning Specialist Nadine Whelan 4.0 Meeting The Committee shall meet every six weeks until the completion of the assessment or at the call of the chair. 5.0 Quorum A majority (50% plus 1) of all members shall constitute a quorum.

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12.2 Appendix B - Terms of Reference – Advisory Committee 1.0 Purpose The purpose of the Community Health Needs Assessment Advisory Committee is to provide advice and feedback on the Burin Peninsula Needs Assessment to the Health Needs Assessment Steering Committee of Eastern Health. 2.0 Duties The duties of the Community Health Needs Assessment Advisory Committee are to: 2.1 Act as a resource to the Health Needs Assessment Steering Committee on the Burin Peninsula Health Needs Assessment 2.2 Serve as a mechanism to exchange ideas related to the Burin Peninsula Community Health Needs Assessment 2.3 Respond to questions from the Community Health Needs Assessment Steering Committee 3.0 Membership The committee shall consist of individuals representing organizations that shape the health of individuals and communities (Health Canada’s determinants of health). The committee will be facilitated by Wayne Miller or Lisa Browne who will be responsible for calling the meetings. The facilitator will report to the Health Needs Assessment Steering Committee. Membership shall include, but not be limited to, representatives from the following areas: Employment & Working Conditions Education Social Support Networks Income and Social Status Physical Environment Healthy Child Development Seniors Youth and Teens 4.0 Meetings The committee shall meet a maximum of five times during the course of the completion of the needs assessment on the Burin Peninsula. The initial meeting will be to update the committee on the needs assessment plan. Subsequent meetings will be called for the Community Health Needs Assessment Steering Committee to exchange ideas about the progress of the needs assessment. A concluding meeting will present the results of the needs assessment.

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12.3 Appendix C â&#x20AC;&#x201C; Representatives/Organizations Invited to Attend Focus Group Sessions

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12.4 Appendix D - Listing of Key Informants Greg Domineaux, Regional Partnership Planner, Rural Secretariat – Burin Peninsula Staff Sgt. Tom Power, RCMP – Burin Peninsula Dr. Michael Graham, Administrator, College of the North Atlantic Honourable Clyde Jackman, MHA, District of Burin-Placentia West Judy Foote, MHA, Grand Bank District Calvin Payne, Pharmacist, Bay L’Argent Colleen Walsh, Chair, Grace Sparkes House Cyril Dodge, Burin Peninsula Health Care Foundation Chair Dr. Mendoza, Family Physician, Terrenceville Percy Barrett, MHA, District of Bellevue Freeman Green, District Manager, Department of Human Resources, Labour and Employment Clint Grandy, T.J. MacDonald Achievement House Dr. Acharya, Physician, Bay L’Argent Evelyn Tilley, Director of Addictions Services (former HCS-E) Natalie Moody, Director of Health Promotion Beth Mayo, Director of Integrated Health Services, Burin Peninsula Mona Romaine-Elliot, Director of Integrated Services, Community Health, Peninsulas Pat Coish-Snow, Chief Operating Officer, Peninsulas Dr. J. Arthur, Medical Director and Chief of Staff Chris Mullett, Director, Child Welfare and Community Corrections (former HCS-E) Dr. Catherine Donovan, Medical Officer of Health (former HCS-E) Cathie Barker-Pinsent, Director, Child Youth and Family Services and Regional Director Adoptions Dr. Kevin Beamont, VP, Medical Services, former Peninsulas Health Care Corporation Dr. S. Beckley, Senior Medical Officer of Health, Grand Bank

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12.5 Appendix E â&#x20AC;&#x201C; Burin Peninsula Health and Community Needs Assessment Telephone Survey Results Fall 2005

Burin Health and Community Needs Assessment Telephone Survey Results Fall 2005

Health Research Unit Division of Community Health and Humanities Faculty of Medicine Memorial University of Newfoundland

2 Health Research Unit Project Team: Veeresh Gadag, PhD, Professor of Biostatistics, HRU Director, Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland T. Montgomery Keough, BSc (Hons), Research Assistant, Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland E. Ann Ryan, MSc, Manager HRU, Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland Interviewers: Judy Maddigan, Mary Hynes, Bernice Stokes Acknowledgements: The Health Research Unit would like to thank: Lisa Browne, Planning Specialist, Eastern Regional Integrated Health Authority and Wayne Miller, Senior Director, Corporate Strategy and Research, Eastern Regional Integrated Health Authority, for their input into the survey questionnaire design, the regional breakdowns and their support throughout the telephone interview period. Linda Longerich, retired Manager of the HRU, for her input into the initial stages of the survey design and coordination of the study. And especially the people of the Burin peninsula, who generously gave us their time and their comments for the study.

Table of Contents Introduction……………………………………………………………………..

Methods……………………………………..…………………………………... Survey Instrument……………………………………………………… Sampling Methodology………………………………………………… Response Rates…………………………………………………………. Data Analysis……………………………………………………………

4 4 5 6 6

Results…………………………………………………….…………………….. Sample Description Age Distribution…………………………………………………. Respondent Age and Gender…………………………………….. Income…………………………………………………………… Health Services Utilization Health Services: Family Doctor...………………………………. Health Services: Other………......………………………………. Health Services: Off the Burin Peninsula ………………..……... Satisfaction with Health Services………………... ……………... Community Health and Community Problems……………….………………. Personal Health & Wellness Low Income Cut-off..…………………………………………… Personal Health..………………………………… ……………... Factors Affecting Health………………………………………..

7 8 8 9 11 17 20 23 30 34 34 35

Conclusions…….………………..……………………………………………… 40 Overall…………………………………………………………………… 41 Region…………………………………………………………………… 42 References……………………………………………………………………….

Appendices………………………………………………………………………

Introduction The Eastern Regional Health Authority is the largest integrated health network in Newfoundland and Labrador, serving a regional population of more than 290,000 and offering unique provincial programs and services. Eastern Health was formed in 2005 from the merger of seven health care organizations. The new health region extends west to Port Blanford and includes all communities on the Avalon, Burin and Bonavista Peninsulas. There are more than 80 hospitals, health care centres, long-term care facilities and community care sites. The creation of Eastern Health provides the opportunity to complete a needs assessment based on the full continuum of health and community services. The Board of Trustees has identified the completion of needs assessments as one of its strategic priorities. The needs assessment is overseen by a Steering Committee and has an Advisory Committee comprised of individuals from the Burin Peninsula to provide advice and feedback to the Steering Committee. As one component of the community needs assessment, Mr. Wayne Miller, Senior Director, Corporate Strategy and Research, Eastern Regional Integrated Health Authority, approached the Health Research Unit to complete a telephone survey of the Burin Peninsula. The telephone survey uses a population health approach in determining the community and health needs of the population of the Burin. That is, it focuses on some of the broader determinants of health such as Health Services, Health and Community Problems, Personal Health and Wellness, Income, and Demographics. It should be noted that during the first week of the telephone interviews the provincial government announced its plan for the construction of a new primary health clinic in Grand Bank and the redevelopment of the Blue Crest Interfaith Home to improve the health care services in the region. This may have had some influence on the satisfaction ratings with health services offered on the Burin Peninsula. However, the small number of surveys completed before the announcement was made did not allow for a useful comparison of the health services satisfaction ratings with those completed after the announcement.

Methods Survey Instrument The questionnaire used in the telephone survey was developed by the HRU with input from Ms. Lisa Browne, Planning Specialist, Eastern Regional Integrated Health Authority, and Mr. Wayne Miller. It was based upon a previous Health Research Unit survey instruments for the Community Needs Assessment for the Grenfell Regional Health Services1 and also the General Practice Assessment Survey (GPAS).2 Some of the questions were only applicable to the respondent while others related to the entire household represented by the respondent. After the Steering Committee approved the instrument, a pilot of 9 surveys was conducted. Results from the pilot indicated no major changes to the survey were required.

5 Sampling Methodology The Burin peninsula area to be surveyed was divided into four regions for sampling purposes (regional division was done by the Eastern Health). These were:

Region A: North of Spanish Room – population 4,130 • Jean De Baie, Red Hbr, Rushoon, Baine Hbr, Parker’s Cove, Petite Forte, Southeast Bight, Brookside, Boat Hbr, Monkstown, Grand LaPieree, Terrenceville, English Hbr East, Hbr Mille, Little Hbr, Little Bay, Bay’ L’Argent, St. Bernard’s – Jacques Fontaine Region B: Burin/Marystown – population 11,520 • Frenchman’s Cove, Garnish, Winterland, Lewin’s Cove, Epworth-Great Salmonier, Burin, Port an Bras, Fox Cove-Mortier, Beau Bois, Marystown, Spanish Room Region C: Grand Bank/Fortune area – population 5,280 • Fortune, Grand Bank, Point May, Lamaline, Point Au Gaul, Grand Beach Region D: St. Lawrence area – population 2,775 • Lord’s Cove, Lawn, St. Lawrence, Little St. Lawrence Residential telephone numbers were obtained from a computer database within these sampling areas. Numbers were randomized to produce the working telephone contact list. In the absence of information on the potential response rate to the survey, we used a conservative rate of 50%. For this response, to allow for a 5% dropout halfway through the completion of the survey, for a population of about 24,000 on the Burin peninsula, 486 questionnaires were completed. This

6 sample size, distributed proportional to the regional population size, will allow for cross comparison among the four regions at the stated level of significance. A 5% significance when applied to statistical tests will mean that the stated conclusions are true 19 times out of 20. Trained telephone interviewers solicited interviews from this phone list until the required proportional sample from each region was completed. The total sampled from each area was: Region A: 85; Region B: 235; Region C: 108; Region D: 58. These numbers are proportionally representative of the regional populations. A maximum of seven attempts at contact were made for each telephone number, at different times of the day and days of the week. During the survey period the interviewers met weekly with the research team to discuss survey problems and ensure consistency in survey presentation. Verbal consent was obtained from eligible household residents, those 19 years or older and knowledgeable about the health care utilization and issues of the household. Response rates Of the 595 residents contacted and eligible, 486 consented to be interviewed, for an 82% response rate. The 486 surveys represent a total of 1239 household members. Data analysis Completed surveys were entered into SPSS and analyzed. Open ended questions and comments were coded before data entry. Where appropriate, categories were collapsed to increase the power of statistical cross tabulations. Health services utilization is based on the respondentâ&#x20AC;&#x2122;s recall of events in the year previous to the interview (November 2004 â&#x20AC;&#x201C; November 2005). All health and lifestyle responses are self reported. The telephone survey was designed to collect mainly quantitative responses. Some open ended questions were coded as to major theme or area of concern. Solicited specific comments and also spontaneous comments were recorded by the interviewer where respondents offered. Because these recorded statements provide more in depth information, examples are included in the report. However, they should not be taken as direct quotes. Statistics Canadaâ&#x20AC;&#x2122;s Low Income Cut-offs (LICO)3 convey the income level at which a family may be in strained circumstances because it has to spend a greater proportion of its income on necessities than the average family of similar size. Specifically, the threshold is defined as the income below which a family is likely to spend 20 percentage points more of its income on food, shelter and clothing than the average family. For this study, the values calculated by Statistics Canada for a population size of under 30,000 were used. See Appendix 2, Low Income Cut -Off Income Calculations.

Sample Description

Age Distribution of Household Members The 486 households surveyed represented a total of 1239 household members (one household did not provide enough information to determine their respective household members).

Under the age of 19 19 years and older Total

Table 1: Population Age Distribution Newfoundland & Burin Sample Labrador4 262 128* (21.2%) (25.0%) 977 384* (78.9%) (75.0%) 1239 512* (100.0%) (100.0%)

Canada4 785* (24.6%) 2407* (75.4%) 3192* (100.0%)

*NL and Canada number x 103.

Table 1 shows our Burin Peninsula sample compared to age group percentages from 2001 census data for the province and Canada. Seventy-nine (79%) percent of the household members in our sample were 19 years of age and older. The percentage of population 20 years of age and older for the province4 and Canada4 is 75.0% and 75.4%, respectively. Since the Burin data is for those 19 years of age and older, and the provincial and national data is for those 20 years of age and older, statistical tests to compare the populations are not possible. However, there is some similarity with respect to the data.

Age and Gender Distribution of Respondents Of the 486 respondents (persons who completed the survey for the household), 370 (76.1%) were females while 115 (23.7%) were males (one respondent would not provide this information). Table 2 shows the distribution of age and gender for the respondents. Although the total number of female respondents is greater than male, there is similar age distribution for the two genders. Gender Male Female Total

Table 2: Age Group and Gender of Survey Respondents Age 20 to 34 Age 35 to 64 Age 65 & older 10 86 19 (9%) (75%) (17%) 46 260 63 (13%) (70%) (17%) 56 346 82 (11.6%) (71.5%) (16.9%)

Total 115 (100%) 369 (100%) 484* (100.0%)

*Two respondents did not either indicate age or how many lived in household.

There were significantly more people between the ages of 35 and 64 in the Burin sample when compared to provincial4 and national data4. There were also more females than males in the Burin sample; however, this finding is not uncommon as men tend to participate in surveys less frequently than women5.

Income Respondents were asked their household income. Ninety percent (438/486) of respondents provided detailed household income information. All income brackets were represented in the sample population (see Table 3). Table 3: Yearly Household Income Distribution Ć&#x2019; Income Level (%) 1 Less than 4,000 (0.2%) 14 5,000 to 9,999 (3.2%) 51 10,000 to 14,999 (11.6%) 34 15,000 to 19,999 (7.8%) 67 20,000 to 29,999 (15.3%) 94 30,000 to 39,999 (21.5%) 92 40,000 to 59,999 (21.0%) 48 60,000 to 79,999 (11.0%) 37 80,000 or more (8.4%) 438 Total (100.0%)

Health Services Utilization

Health Services: Family Doctor Eighty-nine percent (431/486) of respondents indicated that they have a regular family doctor (see Table 4). This compares with a recent provincial report indicating 85% of Newfoundlanders and Labradorians have a regular family doctor6. A regional breakdown indicates that significantly fewer respondents from Regions D reported having a regular family doctor (χ2 = 102.68, ρ < 0.05, df = 3). Table 4: Respondents Who Have a Regular Family Doctor by Region Have a Regular Family Doctor Total Yes No 81 4 85 A (95.3%) (4.7%) (100.0%) 231 4 235 B (98.3%) (1.7%) (100.0%) Region 88 20 108 C (81.5%) (18.5%) (100.0%) 31 27 58 D (53.4%) (46.6%) (100.0%) 431 55 486 Total (88.7%) (11.3%) (100.0%)

The 55 respondents who indicated they did not have a regular family were asked why they did not have a regular family doctor and where they went for general practitioner services. The answers provided by the respondents were transcribed and coded. Fifty-three percent (29/55) indicated retention & recruitment was the main reason why they did not have a regular family doctor (see Table 5a). When asked where they went for general practitioner services, 71% (39/55) indicated they went to a clinic/hospital (see Table 5b). Table 5a: Why Respondent Does Not Have a Regular Family Doctor ƒ (%) 29 Retention & Recruitment of (52.7%) Professionals 10 See Whoever is Available (18.2%) 6 Cannot get one – not specified (10.9%) 3 No Doctor Available (5.5%) 7 Other (12.7%) 55 Total (100.0%)

“…doctors always changing…” “…get whoever you can…” “…can’t get one…” “…no doctor in community…” “…haven’t been to a GP in 4 years…”

Table5b: Where Respondent Indicated He/She Goes to Receive General Practitioner Services ƒ (%) 39 Clinic/Hospital (70.9%) 4 Other (7.3%) 12 Not Specified (21.2%) 55 Total (100.0%)

“…Grand Bank Hospital…” “…go to clinic…” “…nurse practitioner…”

12 Overall, 68% (292/431) of those with a regular family doctor had been cared for by the doctor for more than four years (see Table 6). When the length of time options were categorized into less than 4 years and greater than 4 years, significantly more respondents from Region A, B, and C reported being cared for by a regular family doctor for more than 4 years when compared to Region D (χ2 = 11.48, ρ < 0.05, df = 3). Table 6: Respondents Who Have Regular Family Doctor by Time Cared For by Region Length of time cared for by family doctor Total <1 year 1 to 2 years 3 to 4 years >4 years 2 12 7 60 81 A (2.5%) (14.8%) (8.6%) (74.1%) (100.0%) 5 34 31 61 231 B (2.2%) (14.7%) (13.4%) (69.7%) (100.0%) Region 3 13 14 58 88 C (3.4%) (14.8%) (15.8%) (65.9%) (100.0%) 2 12 4 13 31 D (6.5%) (38.7%) (12.9%) (41.9%) (100.0%) 12 71 56 292 431 Total (2.8%) (16.5%) (13.0%) (67.7%) (100.0%)

Respondents with a regular family doctor were asked the time needed to drive from their home to their doctor’s office. Looking at the different regions, a greater percentage of respondents from Regions A, B, and D indicated a driving time of 10 – 30 minutes; however, a greater percentage of respondents from Region C indicated a driving time of less than 10 minutes (see Table 7). Table 7: Driving Time for Home to the Doctor’s Office by Region Drive Time Total 10 – 30 <10 Minutes >30 Minutes Minutes 14 46 21 81 A (17.3%) (56.8%) (25.9%) (100.0%) 85 143 2 230 B (37.0%) (62.2%) (0.9%) (100.0%) Region 35 26 27 88 C (39.8%) (29.5%) (30.7%) (100.0%) 5 14 12 31 D (16.1%) (45.2%) (38.7%) (100.0%) 139 229 62 430 Total (32.3%) (43.3%) (14.4%) (100.0%)

The range provided was from 1 minute to 240 minutes. When the entire range is considered, the mean driving time is 19.04 minutes. To obtain a more representative mean driving time the 5 highest scores were removed from the calculations. This yielded an average driving time of 17.56 minutes (CI = 16.03, 19.09). When the difference in driving time between the regions was examined, respondents from Region B reported a significantly shorter drive time when compared to Regions A, C, and D (F = 32.688, ρ < 0.05, df = 3).

13 When asked to rate the length of time to drive to the doctor’s office, 51% (218/430) rated the drive as good and 31% (134/430) reported the drive time as excellent (see Table 8). Table 8: Length of Time to Drive to Doctor’s Office by Rating Rating Poor Fair Good Excellent 1 1 64 73 <10 (0.7%) (0.7%) (46.0%) (52.5%) Minutes Time to drive to 8 34 131 56 10-30 doctor’s (3.5%) (14.8%) (57.2%) (24.5%) Minutes office 11 23 23 5 >30 (17.7%) (37.1%) (37.1%) (8.0%) Minutes 20 58 218 134 Total (4.7%) (13.5%) (50.7%) (31.2%)

Total 139 (100.0%) 229 (100.0%) 62 (100.0%) 430* (100.0%)

*1 respondent who indicated had a regular family doctor did not provide this information.

When respondents with a family doctor were asked how often they were able to see their own family doctor and not some other doctor in the same clinic, 91% (394/431) indicated that they were able to see their regular family doctor always/most of the time. Ninety-four percent (386/412) of respondents rated the ability to see there doctor as good/excellent. A regional breakdown indicates that most respondents were able to see their own family doctor always/most of the time (see Table 9). Table 9: Able to See Regular Family Doctor by Region Able to see regular family doctor Total Always/Most of Sometimes/ the Time Rarely 65 7 72 A (90.2%) (9.8%) (17.5%) 224 4 228 B (98.2%) (1.8%) (55.3%) Region 77 6 83 C (92.8%) (7.2%) (20.1%) 28 1 29 D (96.6%) (3.4%) (7.1%) 394 18 412 Total (100.0%) (100.0%) (100.0%)

14 When asked how quickly they were able to get an appointment with a particular family doctor, 29% (119/421) of respondents with a regular family doctor indicated they were able to get an appointment within a day; 46% (195/421) within the week; and 25% (107/421) within 2 weeks or more (see Table 10). Fifty-nine percent (249/419) rated the time needed to schedule an appointment as good/excellent. When the length of time options were categorized into less than 2 weeks and 2 weeks or longer, significantly more respondents from Region C indicated it took two weeks or more to schedule an appointment with a particular family doctor (χ2 = 73.09, ρ < 0.05, df = 3). Table 10: Time Needed to Schedule an Appointment with a “Particular Family Doctor” by Region Time Needed

A B Region C D Total

Same day/Next day 53 (69.7%) 46 (20.1%) 10 (11.4%) 10 (35.7%) 119 (28.3%)

Within the Week 15 (19.7%) 142 (62.0%) 25 (28.4%) 13 (46.3%) 195 (46.3%)

Two weeks or more 8 (10.5%) 41 (17.9%) 53 (60.2%) 5 (17.9%) 107 (25.4%)

Total 76 (100.0%) 229 (100.0%) 88 (100.0%) 28 (100.0%) 421 (100.0%)

15 Respondents, regardless of having a regular family doctor or not, were asked how quickly they were able to obtain an appointment with any family doctor. Overall, 62% (117/189) of respondents indicated they were able to obtain an appointment within a day while 26% (49/189) were able to schedule an appointment within the week. Twelve percent (23/189) indicated it took 2 weeks or more to obtain an appointment. Fifty-seven percent (104/182) of respondents rated the time needed to schedule an appointment with any family doctor as good/excellent. Respondents from all 4 areas more frequently reported they were able to get an appointment within a day (see Figure 1). Figure 1: Time Needed to Schedule an Appointment with "Any Family Doctor" by Region

100%

2.2%

9.2% 90%

19.0%

21.7% 12.3%

33.3%

80% 70%

23.8% 36.2%

60% 50% 40% 30%

78.5% 64.4%

57.1% 43.1%

20% 10% 0% Region A

Region B

Within a day

Region C

Within the week

Region D

2 weeks or more

There were 293 (61%) respondents who specified that this question did not apply to them. Reasons provided include, but not limited to: Always able to see my own doctor Never had to yet Havenâ&#x20AC;&#x2122;t seen any other doctor No other doctor there Would wait to see [my] own doctor Go to emergency

16 When asked if they needed an urgent appointment to see a family doctor or general practitioner, 58% (282/486) of respondents indicated there were able to obtain an appointment on the same day (note: no other time limits were asked). For all regions, significantly fewer respondents from Region C reported being able to schedule an urgent appointment the same day (χ2 = 15.82, ρ < 0.05, df = 3) (see Table 11). Table 11: Able to Schedule an Urgent Appointment on the Same Day by Region Able to Schedule an Urgent Appointment on the Same Day Total Yes No 62 8 70 A (88.6%) (11.4%) (100.0%) 139 43 182 B (76.4%) (23.6%) (100.0%) Region 44 29 73 C (60.3%) (39.7%) (100.0%) 37 15 52 D (71.2%) (28.8%) (100.0%) 282 95 377 Total (74.8%) (25.2%) (100.0%)

Twenty-two percent (106/486) of respondents indicated this question did not apply to them. Reasons include, but not limited to: Go to the hospital Visits emergency if doctor is not visiting the local clinic [go to] emergency Never have to When asked about wait time in the doctor’s waiting room, overall 32% (153/485) and 18% (89/485) of the respondents indicated a wait time of up to 30 minutes and up to 15 minutes, respectively. Thirty-six percent (175/485) of respondents indicated a wait time in excess of 45 minutes (see Table 12). Fifty-one percent (243/479) of respondents rated the wait time in the doctor’s waiting room as good/excellent. When the length of time options were categorized into less than 30 minutes and 30 minutes or more, significantly more respondents from Region C indicated wait times of 30 minutes or more (χ2 = 24.08, ρ < 0.05, df = 3).

A B Region C D Total

Table 12: Wait Time in Doctor’s Waiting Room by Region Wait Time in Doctor’s Waiting Room Up to 15 Up to 30 Up to 45 More than No time Minutes Minutes Minutes 45 Minutes 2 20 30 10 23 (2.3%) (23.5%) (35.3%) (11.8%) (27.1%) 11 45 77 29 72 4.7(%) (19.2%) (32.9%) (12.4%) (30.8%) 2 13 21 7 65 (1.9%) (12.0%) (19.4%) (6.5%) (60.2%) 2 11 25 5 15 (6.4%) (18.9%) (43.1%) (8.6%) (25.9%) 17 89 153 51 175 (3.5%) (18.4%) (31.5%) (10.5%) (36.1%)

Total 85 (100.0%) 234 (100.0%) 108 (100.0%) 58 (100.0%) 485 (100.0%)

Health Services: Other As stated previously, some of the questions were only applicable to the respondent while others related to the entire household represented by the respondent. The utilization questions were applicable to the entire household. Therefore, utilization rates were calculated based on a total of 1239 household members. Physician Visits Overall Our sample of 1239 household members utilized the services of a general practitioner an estimated 6095 times during the previous year. This represents an average utilization rate for a general practitioner of approximately 5 visits/person/year. This compares with recent HRU reports that found utilization rates of 4 visits/person/year in the Downtown Area of St. John’s12 and for Bell Island8. When asked how many times in the previous year the respondent or members of the household visited with a specialist physician there were a reported 1140 visits during the previous year. This represents an average utilization rate for specialist physician of approximately 1 visit/person/year∗. Regionally There was a significant difference between the regions regarding general practitioner visits (χ2 = 24.73, ρ < 0.05, df = 3). Region A had the highest general practitioner utilization rate. There was also a significant difference between the regions regarding specialist visits (χ2 = 10.41, ρ < 0.05, df = 3). In contrast to general practitioner visits, Region A had the lowest specialist utilization rate (see Figure 2). Figure 2: General and Specialist Visits/Person/Year by Region 7 6

6.2 4.9

4.3

4.2

4 3 2 1 0

0.74 Region A

0.99

0.76

Region B

Region C

General Practitioner

∗

1.2

Region D

Specialist

There was no comparison utilization rate for specialist as the questions presented in the aforementioned reports were different from those in the present study.

18 Public Health Nurse/Community Health Nurse/Nurse Practitioner There were a reported total of 685 visits to a public health nurse, community health nurse, or nurse practitioner representing an estimated less than 1 visit/person/year. Emergency Department A total of 1001 visits were made to an emergency department yielding a utilization of the emergency department of less than one visit/person/year. Overnight Stays/Admissions at a Hospital One hundred and fifty three overnight stays/admissions were reported. This translates into a utilization rate of 0.12 admissions/person/year.

19 In Table 13 the “Households Using” column indicates the number of households using the services listed, while the “Total Visits per Year” column indicates the number of visits to that service by all household members and is indicative of multiple visits. Rate/person/year (the number in brackets is the “Total Visits per Year” column) was calculated by dividing the total number of visits by the total number of household members (ex. blood test = 2426/1239). Blood tests were the most utilized service (432/486, 88.9%) followed by x-ray/ultrasound (333/486, 68.5%). Table 13: Utilization of Other Health Services Rating

Households Using ƒ (%)

Total Visits per Year ƒ (rate/person/year)

Blood Tests

432 (88.9%)

2426 (1.96)

X-rays/ultrasound

333 (68.5%)

1393 (1.12)

Dentist

249 (51.2%)

1001 (0.81)

Physiotherapy

80 (16.5%)

827 (0.67)

Dietician

74 (15.2%)

418 (0.34)

Diabetic Educator

40 (8.2%)

101 (0.08)

Social Worker

31 (6.4%)

112 (0.09)

Psychiatrist

34 (7.0%)

258 (0.21)

Respiratory Therapist

29 (6.0%)

59 (0.05)

Chiropractor

20 (4.1%)

295 (0.24)

Other*

27 (5.6%)

1225 (0.99)

Speech Language Therapist

14 (2.9%)

140 (0.11)

Occupational Therapist

10 (2.1%)

76 (0.06)

Mental Health Professional

9 (1.9%)

191 (0.15)

Child Mgmt. Specialist

3 (0.6%)

61 (0.05)

Addictions Counsellor

1 (0.2%)

3 (0.002)

Behaviour Mgmt. Specialist

2 (0.4%)

3 (0.002)

Service

*Other: Services for substance abuse, nutritional support, etc

Health Services: Off the Burin Peninsula Figure 3: Travelled off the Burin Peninsula

350 300 250 200 150 100 50 0

309 63.6% 177 36.4%

Yes

When asked if any member of the household had travelled off the Burin Peninsula for any health service, test, treatment, or medical advice 309 (63.3%) of the 486 respondents indicated that at least one household member had travelled outside the Burin Peninsula in the past year (see Figure 3).

When each region is considered, Region D reported the highest percentage of respondents indicating some member of their household leaving the Burin Peninsula for health services (see Table 14). There was no significant difference between the regions (Ď&#x2021;2 = 7.21, Ď > 0.05, df = 3). Table 14: Households Who Needed to Travel Outside Burin Peninsula for any Health Service by Region Travelled Outside the Burin Peninsula for any Health Service Yes No 51 34 A (60.0%) (40.0%) 151 84 B (64.3%) (35.7%) Region 62 46 C (57.4%) (42.6%) 45 13 D (77.6%) (22.4%)

21 The 309 respondents who indicated they had travelled off the Burin Peninsula for service were then questioned concerning: 1) where it was received; 2) the type of service received; and 3) why they travelled off the Burin Peninsula. In some cases, respondents reported that they made multiple trips off the Burin Peninsula for services. Table 15 summarizes the results as the question was presented to the respondents. Table 15: The ‘Where’, ‘What, and ‘Why’ for Respondents Who Indicated They Had Travelled Off the Burin Peninsula for Service. Where? Health Care Service? Why? 448 - St. John’s 377 – service not available 428 – Specialist service (ie. physician, optometrist, etc). 56 - Clarenville 88 – referred 10 - Gander 12 – wait lists too long 90 – Services (ie. CT scan, MRI, dialysis, etc). 4 - Arnold’s Cove 13 – other (ie. personal preference, in St. John’s, etc) *one respondent indicated other (unable to specify “other” location for confidentiality reasons)

A regional breakdown of why respondents travelled off the Burin Peninsula is presented in Figure 4. Regionally, the main reason for having travelled off the Burin Peninsula was because the service was not available. A higher percentage of trips off the peninsula due to referrals were reported from Region B* (see Figure 4).

Figure 4: Reason for Travelling off the Burin Peninsula by Region 90.0%

84.9%

84.1%

80.0%

75.2%

73.6% 70.0% 60.0% 50.0% 40.0% 30.0%

22.4%

20.0% 10.0% 0.0%

15.8% 10.9% 3.7% 1.2% Region A

2.4% 1.6% Region B

Service Not Available *Statistical analysis not applicable.

Referred

11.3%

5.9% 2.9% Region C Wait Lists Too Long

1.9% 1.9% Region D Other

22 Overall, the majority of respondents (410/486, 84.4%) indicated that nothing prevented them or family members from receiving health services or medical advice during the previous year. However, 17 (3.5%) and 16 (3.3%) respondents reported that lack of health services or wait time, respectively, prevented them from receiving health services or medical advice (see Table 16). Table 16: Prevented Service ƒ (%) No

410 (84.4%)

Lack of health services

17 (3.5%)

Wait time

16 (3.3%)

Financial

7 (1.4%)

Travel Issues

6 (1.2%)

No answer

30 (6.2%)

There was no significant difference in the response to this question by region (χ2 = 0.68, ρ > 0.05, df = 3). See Figure 5.

Firgure 5: Regional Breakdown of Respondents who Indicated Nothing Prevented Being Able to Receive Health Care or Medical Advice 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

89.3%

90.9%

Region A

Region B

89.8%

Region C

87.3%

Region D

Satisfaction with Health Services Table 17 provides the number and percent levels of satisfaction with the health services available on the Burin Peninsula. Of those who rated the service, Table 17 indicates that the services with the highest satisfaction rating (ie. >75.0%) were lab/x-ray, ambulance, community health/public health nurse, hospital inpatient, and allied health professionals (ie. the greatest percentage choosing ‘very satisfied’). Those with the highest percentages for ‘not at all satisfied’ were addictions, mental health, dental, home care/support, and emergency. Please note: results for addictions, mental health, and home care/support must be interpreted with caution due to small number of responses. Table 17: Satisfaction with Community Services Satisfaction Level Rating Not at all Somewhat Very Satisfied Satisfied Satisfied ƒ ƒ ƒ Service (%) (%) (%) Community Health 4 46 265 n = 315 (1.3%) (14.6%) (84.1%) Home Care/ Support 18 30 66 n = 114 (15.8%) (26.3%) (57.9%) Emergency (hospital) 49 143 219 n = 411 (11.9%) (34.8%) (53.3%) Ambulance 8 28 200 n = 236 (3.4%) (11.9%) (84.7%) Long-term Care 12 35 77 n = 124 (9.7%) (28.2%) (62.1%) Hospital inpatient 15 68 259 n = 342 (4.4%) (19.9%) (75.7%) Mental Health 16 10 38 n = 64 (25.0%) (15.6%) (59.4%) Addictions 6 2 15 n = 23 (26.1%) (8.7%) (65.2 %) 84 95 159 Dental n = 338 (24.9%) (28.1%) (47.0%) Allied Health 15 47 189 n = 251 (5.9%) (18.7%) (75.3%) 4 9 33 C, Y, & F Services n = 46 (8.7%) (19.6%) (71.7%) Lab/X-ray 6 54 412 n = 472 (1.3%) (11.4%) (87.3%)

Don’t know ƒ (%) 171 372 74 248 358 144 421 460 139 230 428 14

If a respondent indicated that they were not at all satisfied with a particular service, the interviewer was instructed to further question why the respondent was not satisfied. The following are a selection of these comments: Couldn’t get appointment, had to go to Clarenville Very poor…have to travel too far for therapy Lists are a mile long, hard to get appointment Is expensive unless insurance Clients - poor service, insufficient staff Work load - too much for one person

24 A regional breakdown of satisfaction ratings was completed for the services that had the highest number of responses. Over 70% of those rating the services were ‘very satisfied’ with community health/public health nurse, ambulance, hospital in-patient, and allied health (see Tables 17a, b, c, and d, respectively). There was no significant difference between the regions. Table 17a: Satisfaction with Community Health/Public Health Nurse by Region Satisfaction Level Not at all Somewhat Very Total A Region

B C D

Total

Satisfied ƒ (%)

Satisfied ƒ(%)

2 (3.1%) 2 (1.4%) 0 (0.0%) 0 (0.0%) 4 (1.3%)

13 (20.3%) 16 (11.3%) 12 (18.8%) 5 (11.1%) 46 (14.6%)

49 (76.6%) 124 (87.3%) 52 (81.3%) 40 (88.9%) 265 (84.1%)

Table 17b: Satisfaction with Ambulance Services by Region Satisfaction Level Not at all Somewhat Very Total

64 (100.0%) 142 (100.0%) 64 (100.0%) 45 (100.0%) 315 (100.0%)

A Region

C D Total

Table 17c: Satisfaction with Hospital Inpatient Services by Region Satisfaction Level Not at all Somewhat Very Total A Region

B C D

Total

Satisfied ƒ (%)

1 (1.7%) 11 (6.5%) 2 (2.9%) 1 (2.2%) 15 (4.4%)

13 (22.0%) 32 (18.9%) 15 (21.7%) 8 (17.8%) 68 (19.9%)

45 (76.3%) 126 (74.6%) 52 (75.4%) 36 (80.0%) 259 (75.7%)

Satisfied ƒ (%)

1 (2.0%) 4 (4.0%) 3 (6.4%) 0 (0.0%) 8 (3.4%)

5 (10.0%) 13 (13.1%) 6 (12.8%) 4 (10.0%) 28 (11.9%)

44 (88.0%) 82 (82.8%) 38 (80.9%) 36 (90.0%) 200 (84.7%)

50 (100.0%) 99 (100.0%) 47 (100.0%) 40 (100.0%) 236 (100.0%)

Table 17d: Satisfaction with Allied Health Services by Region Satisfaction Level Not at all Somewhat Very Total

59 (100.0%) 169 (100.0%) 69 (100.0%) 45 (100.0%) 342 (100.0%)

Over 50% of those rating emergency services were ‘very satisfied’. Of those respondents who rated emergency services ‘not at all satisfied’, Region B had the highest percentage at 16% (see Table 17e).

Satisfied ƒ (%)

A Region

B C D

Total

Satisfied ƒ (%)

Satisfied ƒ(%)

4 (9.5%) 8 (6.3%) 1 (2.1%) 2 (5.9%) 15 (6.0%)

5 (11.9%) 22 (17.2%) 13 (27.7%) 7 (20.6%) 47 (18.7%)

33 (78.6%) 98 (76.6%) 33 (70.2%) 25 (73.5%) 189 (75.3%)

Table 17e: Satisfaction with Emergency Services by Region Satisfaction Level Not at all Somewhat Very Total A Region

B C D

Total

Satisfied ƒ (%)

6 (8.0%) 33 (15.8%) 5 (6.6%) 5 (9.8%) 49 (11.9%)

30 (40.0%) 71 (34.0%) 26 (34.2%) 16 (31.4%) 143 (34.8%)

39 (52.0%) 105 (50.2%) 45 (59.2%) 30 (58.8%) 219 (53.3%)

75 (100.0%) 209 (100.0%) 76 (100.0%) 51 (100.0%) 411 (100.0%)

42 (100.0%) 128 (100.0%) 47 (100.0%) 34 (100.0%) 251 (100.0%)

25 There was a significant difference between the regions for the dental services and lab/x-ray services (see Tables 17f and 17g, respectively). Significantly more respondents from Region D chose the rating ‘not at all satisfied’ for dental services (χ2 = 20.14, ρ < 0.05, df = 6). Table 17f: Satisfaction with Dental Services by Region Satisfaction Level

A Region

B C D

Total

Not at all Satisfied ƒ (%)

Somewhat Satisfied ƒ (%)

Very Satisfied ƒ (%)

10 (19.6%) 43 (25.7%) 9 (12.3%) 22 (46.8%) 84 (24.9%)

16 (31.4%) 46 (27.5%) 26 (35.6%) 7 (14.9%) 95 (28.1%)

25 (49.0%) 78 (46.7%) 38 (52.1%) 18 (38.3%) 159 (47.0%)

Total

51 (100.0%) 167 (100.0%) 73 (100.0%) 47 (100.0%) 338 (100.0%)

For lab-x-ray services, significantly more respondents from Region C chose the rating ‘somewhat satisfied’ for this service (χ2 = 22.10, ρ < 0.05, df = 3). Table 17g: Satisfaction with Lab/X-ray Services by Region Satisfaction Level

A Region

B C D

Total

Not at all Satisfied ƒ (%)

Somewhat Satisfied ƒ (%)

Very Satisfied ƒ (%)

0 (0.0%) 3 (1.3%) 3 (2.9%) 0 (0.0%) 6 (1.3%)

7 (8.2%) 20 (8.8%) 24 (23.1%) 3 (5.5%) 54 (11.4%)

78 (91.8%) 205 (89.9%) 77 (74.0%) 52 (94.5%) 412 (87.3%)

Total

85 (100.0%) 228 (100.0%) 104 (100.0%) 55 (100.0%) 472 (100.0%)

26 In general, respondents felt that they were able to obtain health services when needed always/most of the time (449/486, 92.4%) (see Table 18). Table 18: Able to Obtain Services When Needed ƒ (%) 236 Always (48.6%) 213 Most of the time (43.8%) 31 Sometimes (6.4%) 5 Rarely (1.0%) 1 Never (0.2%) 486 Total (100.0%)

Broken down by region, Regions B and C had the lowest percent of those responding ‘always’ (see Table 19). There was no significant difference between the regions (χ2 = 1.67, ρ > 0.05, df = 3).

A B Region C D Total

Table 19: Ability to Obtain Services When Needed by Region Able to Obtain Services When Needed Most of the Always Sometimes Rarely Never time 42 34 8 1 0 (49.4%) (40.0%) (9.4%) (1.2%) (0.0%) 111 105 16 2 1 (47.2%) (44.7%) (6.8%) (0.9%) (0.4%) 51 50 6 1 0 (47.2%) (46.3%) (5.6%) (0.9%) (0.0%) 32 24 1 1 0 (55.2%) (41.4%) (1.7%) (1.7%) (0.0%) 236 213 31 5 1 (48.6%) (43.7%) (6.4%) (1.0%) (0.2%)

Total 85 (100.0%) 235 (100.0%) 108 (100.0%) 58 (100.0%) 486 (100.0%)

27 When asked to comment on barriers or obstacles to getting health care services on the Burin Peninsula, the interviewers transcribed the respondents’ answers. The answers were then coded into six major themes. Some respondents gave more than one response. Table 20 shows that over 36% (176/486) of respondents noted lack of health services and 31% (151/486) reported lack of health professionals as the major barriers to receiving health services on the Burin Peninsula. Lack of health professionals and retention & recruitment were coded separately because the lack of a health professional (doctors, specialists, technicians) may reflect a decision from the health authority not to offer the doctor/specialist/technician whereas retention & recruitment speaks directly to the difficulty in obtaining and retaining physicians to the Burin Peninsula (eg. lack of a dermatologist vs. salaries are too low, etc). Table 20: Barriers/obstacles to Receiving Health Services Rating ƒ Barrier (%) 176 Lack of Health Services (36.2%) 151 Lack of Health Professionals* (31.1%) 84 Wait Time (17.3%) 64 Travel (13.2%) Retention & Recruitment of 38 Professionals§ (7.8%) 21 Cost (4.3%)

Availability of health care personnel and not enough diagnostic equipment and machinery for CT scans, ultrasounds *Not enough doctors, they are overworked *Lack of specialists *Not enough health care providers - doctors, specialists, technicians Waiting for appointments, weeks sometimes Travelling to St. John’s in winter to see specialist is difficult, if you have to cancel appointment could be months before it could be booked again §Hard to get medical doctors and personnel to come to peninsula §Isolation; no incentive for professional health workers to come here Financial - cost of travel by ambulance and own vehicle

28 Table 21 gives the six most often cited barriers by region. Lack of the health service and/or lack of health professional on the peninsula were listed as the greatest barrier(s) in all four regions, particularly for Region B. Travel was reported as a barrier by a greater percentage in Region C. Table 21: Biggest Barrier to getting health services, by Region Lack of Health Service

Lack of Health Professional

Retention and Recruitment

Wait Times

Travel

Cost

Region A (85)

16 (19%)

34 (40%)

4 (5%)

11 (13%)

1 (1%)

Region B (235)

92 (39%)

90 (38%)

16 (7%)

42 (18%)

27 (11%)

11 (5%)

Region C (108)

30 (28%)

31 (29%)

10 (9%)

22 (20%)

21 (19%)

7 (6%)

Region D (58)

13 (22%)

21 (36%)

7 (12%)

9 (16%)

5 (9%)

2 (3%)

Community

Health and Community Problems Telephone respondents were read a list of common community issues and asked to rate them as not a problem, somewhat of a problem, or a major problem for their community. Table 22 lists these community problems and respondents’ ratings.

Community Problem

Table 22: Community Problems Not a Minor Major problem problem problem ƒ ƒ ƒ (%) (%) (%)

Availability of recreational facilities

129 (26.5%)

152 (31.3%)

Marital difficulties/violence in the home

157 (32.3%)

Water/sewer services

Rating

Don’t know ƒ (%)

No response* ƒ (%)

164 (33.7%)

33 (6.8%)

8 (1.6%)

99 (20.4%)

19 (3.9%)

202 (41.6%)

9 (1.9%)

315 (64.8%)

70 (14.4%)

88 (18.1%)

5 (1.0%)

8 (1.6%)

Chronic illnesses (heart disease, diabetes, etc)

34 (7.0%)

188 (38.7%)

217 (44.7%)

39 (8.0%)

8 (1.6%)

Cancer

48 (9.9%)

120 (24.7%)

292 (60.1%)

17 (3.5%)

9 (1.9%)

Out migration

25 (5.1%)

62 (12.8%)

386 (79.4%)

4 (0.8%)

9 (1.9%)

Obesity/overweight

88 (18.1%)

226 (46.5%)

139 (28.6%)

23 (4.7%)

10 (2.1%)

Wheelchair access

321 (66.0%)

106 (21.8%)

30 (6.2%)

20 (4.1%)

9 (1.9%)

Smoking

129 (26.5%)

181 (37.2%)

134 (27.6%)

32 (6.6%)

10 (2.1%)

Unemployment

22 (4.5%)

113 (23.3%)

332 (68.3%)

10 (2.1%)

9 (1.9%)

Alcohol abuse

138 (28.4%)

157 (32.3%)

54 (11.1%)

127 (26.1%)

10 (2.1%)

Gambling

88 (18.1%)

176 (36.2%)

117 (24.1%)

95 (19.5%)

10 (2.1%)

Air or water pollution

373 (76.7%)

62 (12.8%)

25 (5.1%)

16 (3.3%)

10 (2.1%)

Transportation

343 (70.6%)

93 (19.1%)

32 (6.6%)

9 (1.9%)

Teenage pregnancy

225 (46.3%)

132 (27.2%)

24 (4.9%)

95 (19.5%)

10 (2.1%)

Loneliness

100 (20.6%)

202 (41.6%)

103 (21.2%)

72 (14.8%)

9 (1.9%)

Poverty

233 (47.9%)

186 (38.3%)

30 (6.2%)

27 (5.6%)

10 (2.1%)

31 Rating

Not a problem ƒ (%)

Minor problem ƒ (%)

Major problem ƒ (%)

ƒ (%)

No response ƒ (%)

Crime

280 (57.6%)

171 (35.2%)

15(3.1%)

10 (2.1%)

Availability of support for elderly

220 (45.3%)

160 (32.9%)

59 (12.1%)

38 (7.8%)

9 (1.9%)

Maintaining healthy diet

294 (60.5%)

137 (28.2%)

40 (8.2%)

6 (1.2%)

9 (1.9%)

Vehicle accidents

354 (72.8%)

104 (21.4%)

5 (1.0%)

14 (2.9%)

9 (1.9%)

Sexually transmitted diseases

196 (40.3%)

15 (3.1%)

2 (0.4%)

263 (54.1%)

10 (2.1%)

Housing conditions

398 (81.9%)

51 (10.5%)

9 (1.9%)

16 (3.3%)

12 (2.5%)

Depression/other mental health conditions

161 (33.1%)

150 (30.9%)

44 (9.1%)

122 (25.1%)

9 (1.9%)

Illegal drug use

106 (21.8%)

179 (36.8%)

62 (12.8%)

130 (26.7%)

9 (1.9%)

Prescription drug abuse

164 (33.7%)

84 (17.3%)

23 (4.7%)

206 (42.4%)

9 (1.9%)

Financial services (banking)

308 (63.4%)

82 (16.9%)

83 (17.1%)

4 (0.8%)

9 (1.9%)

Availability of support groups

258 (53.1%)

92 (18.9%)

60 (12.3%)

67 (13.8%)

9 (1.9%)

Literacy

257 (52.9%)

165 (34.0%)

6 (1.2%)

48 (9.9%)

10 (2.1%)

Community Problem

Don’t know

*No response: question not asked, respondent did not provide an answer, answer was not recorded, etc.

32 Respondents were then asked to choose the single most important problem in their community. The interviewers transcribed the respondents’ answers and the answers were then coded. Over 38% (185/486) listed unemployment as the main problem for their community. Unemployment was also the main community problem within each region (see Table 23).

A B Region C D Total

Table 23: Top Five Community Problems by Region Community Problem Lack of Availability Out Unemployment Health of Rec. Migration Services Facilities 32 23 7 8 (37.6%) (27.1%) (8.2%) (9.4%) 81 41 24 19 (34.5%) (17.4%) (10.2%) (8.1%) 53 18 8 3 (49.1%) (16.7%) (7.4%) (2.8%) 19 5 7 5 (32.8%) (8.6%) (12.1%) (8.6%) 185 87 46 35 (38.1%) (17.9%) (9.5%) (7.2%)

Cancer 2 (2.4%) 20 (8.5%) 9 (8.3%) 5 (5.2%) 34 (7.0%)

Total

85 235 108 58 486

Unemployment; out migration; nothing left to [community name], everyone gone - hardly enough left Unemployment - everyone gone who can work, no job opportunities here Health care…travelling very inconvenient for seniors who may have to see heart specialist or whatever...lack of technology…only one dentist. Unemployment; availability of recreation facility (should have YMCA in Burin) Cancer - doctors are shocked by how many [cases]

Personal Health and Wellness

Low Income Cut-off Useable household income levels for the calculation of Statistics Canada Low Income Cut-Off (LICO) values were reported by 438 respondents (see Appendix 3). The incidence of households which fall below the LICO on the Burin Peninsula is 24% (106/438). Region D has the highest incidence of low income with 34% (19/56) (see Table 24). There was no significant difference between the regions (χ2 = 4.62, ρ > 0.05, df = 3). The incidence of low income in economic families is 16.3% for the province as a whole3.

Table 24: LICO by Region LICO

A B Region C D Total

Total

Below

Above

19 (25.3%) 44 (20.6%) 24 (25.8%) 19 (33.9%) 106 (24.2%)

56 (74.7%) 170 (79.4%) 69 (74.2%) 37 (66.1%) 332 (75.8%)

75 (100.0%) 214 (100.0%) 93 (100.0%) 56 (100.0%) 438 (100.0%)

Personal Health Self-Reported Health In this section respondents 19 years and older were asked about their own personal health and wellness. Respondents were asked to rate their own health as poor, fair, good, very good, or excellent (see Figure 6). Regionally, there was no significant difference in self reported health status (χ2 = 2.23, ρ > 0.05, df = 6) (ratings were grouped into poor/fair, good, and very good/excellent). Figure 6: Self-Reported Health Rating by LICO

A comparison between calculated LICO values and self-reported health status is presented in Figure 6. When selfreported health status was grouped into poor/fair, good, and very good/excellent, there was no significant difference between calculated LICO values and self reported health status (χ2 = 4.318, ρ > 0.05, df = 2).

140 124 37.3%

120 100

98 29.5%

80 60

61 18.4%

40 20

39 36.8%

26 24.5%

12 7 3.6% 6.6%

37 11.1% 28 26.4%

6 5.7%

0 Poor

Fair

Good

Above LICO

Very Good

Below LICO

Excellent

Factors Affecting Health Smoking Twenty four percent (114/486) reported that they smoked cigarettes daily. This is consistent with values of daily smoking rates for all age groups in Statistics Canada 2001 Community Health Survey7 for NL and Canada (25% and 22%), respectively but is lower than rates from a recent HRU Bell Island8 report where incidence of daily smoking was 32%. Gambling∗ Twenty three percent (111/486) of respondents reported taking part in gambling or gaming activities for money on average once a week or more. This compares with a recent HRU report of Bell Island8 where respondents report a gambling incidence of 46%. Drinking∗ Few respondents (45/486; 9%) reported drinking on average more than 7 drinks per week. This is consistent with a recent HRU report of Bell Island8 (9%). Physical Activity∗ Sixty-six percent (323/486) reported participating in regular physical or recreational activity such as walking, jogging, bicycling, sports, aerobics, etc., at least 2-3 times per week for twenty minutes or more. This is in comparison to an activity rate reported in the Bell Island8 report of 59%. LICO and Lifestyle Factors While there were percentage differences between the calculated LICO value and respective lifestyle factor, there were no significant differences (see Figure 7). Figure 7: Respondents Who Indicated Smoked, Consumed Alcoholic Beverages, and/or Gambled by LICO 80.00% 76.2%

70.00% 66.0%

60.00% 50.00% 40.00% 30.00% 20.00%

29.2%

10.00% 0.00%

6.6%

10.8%

Below LICO

Above LICO

Smoking

∗

25.3%

22.6%

18.1%

Drinking

Gambling

Physical Activity

There was no national and provincial data for gambling. The questions used to collect the national and provincial data for alcohol consumption and for physical activity were different from those in the present study.

36 Incidence of Chronic Disease There were 376 respondents (77.4%) who reported a health professionalâ&#x20AC;&#x2122;s diagnosis of diabetes, high blood pressure, or high cholesterol. Overall, 15% had diabetes, 33% had high blood pressure, and 29% had high cholesterol. Region A had the lowest self-reported incidence (12%) of diabetes while Region D had the highest self-reported incidence (24%) of diabetes. Incidence of high blood cholesterol was highest in Region C (35%) and Region A (34%) and lowest in Region B (27%). The incidence of high blood pressure ranged between 30% and 36% in the four regions (see Figure 8). Figure 8: Incidence of Chronic Dis eas e by Region 40% 35% 30%

35% 35%

35% 34%

30% 27%

25% 20% 15%

14%

12%

36%

24% 17%

21%

10% 5% 0%

Region A Diabetes

Region B High Blood Pres s ure

Region C

Region D

High Blood Choles terol

There was no significant difference between the regions with respect to diabetes, to high blood pressure, or to high cholesterol.

37 Diet and Body Mass Index (BMI) Seventy-six percent (369/486) of respondents believe they eat a healthy diet; 23% (116/486) did not think they were eating a healthy diet. When asked what prevented them from eating a health diet, personal choice (78/116, 67.2%) and cost (18/116, 15.5%) were the main reasons provided. We collected self reported height and weight from 477 of 486 respondents which allowed us to calculate a value for Body Mass Index (BMI). Underweight and normal categories were combined because only one respondent had a BMI in the underweight category (see Table 25). Table 25: Body Mass Index by Gender BMI

Males

Females

All

Underweight/Normal < 24.9 Overweight 25.0 - 29.9 Obese >30.0

20 (17.4%) 68 (59.6%) 26 (22.8%)

134 (36.9%) 130 (35.8%) 99 (27.2%)

154 (32.3%) 198 (41.5%) 125 (26.2%)

Totals

114

363

477*

*9 respondents did not provide adequate data

Just over 41% of respondents had a BMI in the ‘overweight’ and 26% were in the ‘obese’ category. This compares with recent Bell Island8 reported values of 39% and 24% and Canadian7 data of 34% and 15%, respectively, for these categories. A greater percentage of males than females were calculated to be in the overweight category. As mentioned previously, the calculated LICO values were grouped into ‘above’ or ‘below’ categories. A comparison using these LICO categories with the calculated BMI values shows that a higher percentage of respondents had a BMI in the ‘overweight’ category (see Table 26). There was no significant difference between calculated LICO values and calculated BMI values (χ2 = 3.47, ρ> 0.05, df = 2). Table 26: Low Income Cut-off by Body Mass Index LICO Below LICO Above LICO 35 111 Underweight/Normal (33.0%) (33.9%) 38 142 Overweight (35.8%) (43.4%) 33 74 Obese (31.1%) (22.6%) 106 327 Total (100.0%) (100.0%)

Total 146 (33.7%) 180 (41.6%) 107 (24.7%) 433 (100.0%)

38 When comparing the self-rated health level, a greater percentage of respondents who rated their health as good, very good, or excellent fell within the normal BMI range while a greater percentage of respondents who rated their health as fair fell within the overweight BMI range. Of the respondents who rated their health as poor, a greater percentage fell within the overweight and obese BMI range (see Table 27).

BMI

Table 27: Health Rating by Body Mass Index (BMI) Health Rating Very Poor Fair Good Good 4 22 61 46 Underweight/Normal (18.2%) (23.2%) (33.9%) (34.1%) <24.9 9 39 75 55 Overweight (40.9%) (41.1%) (41.7%) (40.7%) 25.0 – 29.9 9 34 44 34 Obese (40.9%) (35.8%) (24.4%) (25.2%) >30.0 22

Total

180

Excellent 21 (47.7%) 20 (45.6%) 3 (6.8%)

135

Total 154 198 124 476*

*10 respondents did not provide adequate data

When the health ratings were collapsed into poor/fair and good/very good/excellent, significantly more respondents with a calculated BMI of normal self-reported their health as good, very good, or excellent (χ2 = 11.75, ρ< 0.05, df = 2). Prevention Practices Almost all respondents (472/486, 97%) reported having their blood pressure checked within the last 2 years from the date of the interview. Eighty-three percent (402/486) reported having their cholesterol checked within the last two years. This compares with the recent Bell Island report of 92% and 75%, respectively. There is some similarity with respect to provincial and national percentages when looking at the gender-specific preventative practices of breast exam, mammogram, PAP test, and PSA test (see Table 28). Table 28: Preventative Tests – Gender Specific Test in last 2 years (Females = 370)

ƒ (%)

NL7

Canada7

Breast Exam

248 (67%)

63%

Mammogram

184 (50%)

49%*

PAP test

242 (65%)

70%*

68%*

50 (43%)

37%

38%

*Test in the last 3 years

PSA test in last 2 years (Males = 115)

39 More specifically, while 65% of female respondents indicated they had a PAP test within the last 2 years, 6% (23/371) reported a PAP test done within the last 3 years, and 22% (82/371) reported a PAP test done more than 3 years ago (see Table 29).

n = 370 PAP Test

Less than a year ago 165 (44.6%)

Table 29: When was the last time you had a PAP test done? More Within 2 Within 3 Donâ&#x20AC;&#x2122;t than 3 Never years years Know years ago 77 23 82 13 8 (20.8%) (6.2%) (22.2%) (3.5%) (2.2%)

Other

Total

2 (0.5%)

370 (100.0%)

Age and Prevention Practices Based on information from the Canadian Cancer Society regarding clinical breast examinations and mammograms9 as well as The National Cancer Institute, the American Cancer Society, and the American College of Radiology recommendations for annual mammograms10, the ages provided by respondents were divided into three groups - less than 40, between 40 and 64, and 65 or older - and applied to all prevention practices. For the female preventative practices (ie. breast exam, mammogram, and PAP test) there was a significant difference between the three age groups. Women older than 65 were less likely to have had a breast exam or a PAP test. Conversely, women under the age of 40 were less likely to have had a mammogram. For the male preventative practices (ie. PSA test) there was a significant difference among the age groups. Men under the age of 40 were less likely to have had a PSA test done.

Conclusions

Conclusions: Overall Family Doctor • For respondents who indicated they had a regular family doctor o Most indicated had a family doctor most for more than 4 years o Most indicated they were able to see their regular family doctor always/most of the time • For those respondents who did not have a regular family doctor o Retention and recruitment of professionals was the main reason why they did not have a regular family doctor o Indicated they went to the hospital or clinic for the services of a general practitioner • On average, it took 10-30 minutes to travel to doctor’s clinic • 53% of respondents indicated wait times in the doctor’s waiting room of less than 30 minutes • Physician utilization rates o General practitioner: 5 visits/person/year. This compares to 4 vists/person/year for the Downtown Area of St. John’s12 and for Bell Island8. o Specialist physician: approximately 1 visit/person/year. Health Services Utilization • 65% traveled off the Burin Peninsula for some sort of health service o St. John’s was the most common location o Visits with a specialist were the most common reason • 93% felt able to obtain a health service either always or most of the time • Most commonly reported barriers to receiving health services were lack of health services and/or lack of health service professionals Community Issues • For all regions unemployment was the most commonly reported problem Personal Health & Wellness • 24% of households fell below the LICO compared with 16.3% to the province as a whole • Rates of diabetes and high blood pressure for the peninsula were higher compared to NL • Calculated ‘overweight’ and ‘obese’ BMI’s for the Burin Peninsula were comparable with results from a recent HRU report8 but higher than the national data7. However, in self-report surveys height has a tendency to be overestimated while weight has a tendency to be underestimated11. Therefore, the results are a conservative approximation.

Conclusions: Region Family Doctor • Significantly fewer respondents from Region D reported having a regular family doctor o Of those with a regular family doctor, significantly fewer respondents from Region D reported being under the care of that family doctor for more than 4 years • More respondents from Region C indicated it took two weeks or more to schedule an appointment with a particular family doctor • More respondents from Region C indicated they were unable to schedule an urgent appointment the same day • Region C had the longest wait time in the doctor’s waiting room • Respondents from Region C had to wait the longest to obtain an appointment • Region C had the lowest general practitioner utilization rate, and the second lowest specialist utilization rate Health Services Utilization • Region C had the lowest number of households who reported travel off the Burin Peninsula for some sort of health service and the highest percentage of respondents who indicated “travel” as a major barrier to receiving health services o Of the reasons provided for “why traveled off the peninsula”, Region C had the highest reports of wait lists being too long and the second highest for being referred off the peninsula for service o Region D had the highest percent traveling off the peninsula Community Issues • “Out migration” was the second most commonly reported community problem for Regions A, B, and C while “lack of health services” was the second most common community problem for Region D o Region D also had the highest percentage indicating “lack of health services” as a community problem Personal Health & Wellness • Region C and Region D both had the highest percentage of respondents rating their health status as good/very good/excellent • Region D had the highest percent of low-income households • Region D had the highest percentage of self-reported diabetes

References

44 1. Health Research Unit, Community Needs Assessment for the Grenfell Regional Health Services. St. John’s: Memorial University of Newfoundland, 1999 2. General Practice Assessment Survey (GPAS), Modified by the Patient Research Centre, Memorial University of Newfoundland. Safran/The Health Institute and National Primary Care Research and Development Centre. 3. Low Income Rate (2000 income), by household status, Canada, provinces, territories, health regions and peer groups, 2001. http://www.statcan.ca/English/freepu/82-221XIE/00604/tables/html/226_01.htm 4. Accounts 2001 census data (website: www.communityaccounts.ca). 5. Prairie Research Associates, Inc. Comparing Two Respondent Selection Methods in Telephone Surveys. http://www.pra.ca/resources/birthday.pdf 6. Department of Health & Community Services, Health Scopes: Reporting to Newfoundlanders and Labradorians on Comparable Health and Health System Indicators. St. John’s: Newfoundland & Labrador Centre for Health Information, 2002. 7. Canadian Community Health Survey (2003). Statistics Canada. http://www.statcan.ca 8. Health Research Unit, Findings from the Bell Island Telephone Survey: Fall 2004. St. John’s, Memorial University of Newfoundland, 2005. 9. Early detection and screening for breast cancer (2006). Canadian Cancer Society. Retrieved February 2006 from http://www.cancer.ca/ccs/internet/standard/0,3182,3172_10175_74544430_langIden,00.html 10. Blanchard, K., Colbert, J.A., Puri, D., Weissman, J., Moy, B., Kopans, D.B., Kaine, E.M., Moore, R.H., Halpern, E.F., Hughes, K.S., Tanabe, K.K., Smith, B.L., & Michaelson, J.S. Mammographic Screening: Patterns of Use and Estimated Impact on Breast Carcinoma Survival. Cancer. 2004 101(3): 495-507. 11. Gunnell, D., Berney, L., Holland, P., Maynard, M., Blane, D., Frankel, S., & Smith, G.D. How accurately are height, weight and leg length reported by the elderly, and how closely are they related to measurements recorded in childhood? International Journal of Epidemiology. 2000 29: 456-464. 12. Health Research Unit, Findings Assessment of the Primary Health Care Needs in the Downtown Area of St. John’s. St. John’s, Memorial University of Newfoundland, 2005.

Appendix 1 SURVEY INSTRUMENT

46 Informed Consent Form Telephone Survey for Burin Peninsula Needs Assessment Hello, my name is ________________. I am calling for the Eastern Health Board that provides the health and community services on the Burin Peninsula. I am calling about a health survey for residents of the Burin Peninsula. I would really appreciate some of your time this morning/afternoon/evening. I would like to speak to someone 19 years of age or older. Would this apply to you? If speaker is eligible then go to # 2. If not, request they bring eligible person to phone. Before proceeding any further, I would like to read the following consent statement to you to make sure that you understand our study. Eastern Health wants to determine the health and community services needs of residents of the Burin Peninsula. We are asking the general public for their ideas on some health issues in a brief telephone questionnaire. Your participation is very important to us. The questions will only take about 20 to 30 minutes to complete. Your comments will be held in strictest confidence and no names will be used. Of course, you may refuse to answer any questions. Your participation will help us better understand the need for health and social programs and services in your community. Would you mind answering these questions now? Make appointment if necessary.

Burin Peninsula Needs Assessment: Telephone Survey Health Services: Family Doctor

ID #_________

Code___

I am going to start by asking you some questions about your family doctor or your regular general practitioner. 1 First of all…Do you have a regular family doctor or a regular GP? Yes

No (If No) Could you tell me why not? _____________________________________ (If No) Where do you go for GP services? _______________________________ If NO go now to Q6

How long have you been cared for by this doctor? Would it be…. < 1 year 1 to 2 years 3 to 4 years More than 4 years

a) On average, how long does it take you to travel from your home to your regular doctor’s office? ______hours ______minutes b) How would you rate the convenience of the location of your doctor’s office? Poor Fair Good Excellent

In general, how often do you see your usual family doctor and not another doctor in the same clinic? a) always most of the time b) How do you rate this? Poor

sometimes rarely does not apply Fair Good Excellent

Thinking of times when you wanted to see a particular family doctor or GP… a) How quickly do you usually get an appointment? same day next day within the week b) How do you rate this? Poor Fair

2-3 weeks 4 weeks or more Good Excellent

doesn’t apply

Thinking of the times when you were willing to see any GP or family doctor… a) How quickly do you usually get an appointment? same day next day within the week b) How do you rate this? Poor Fair

2-3 weeks 4 weeks or more Good Excellent

doesn’t apply

If you need an urgent appointment to see a family doctor or GP, can you normally get one on the same day? Yes No Doesn’t apply /never needed

a) How long do you usually have to wait in the doctor’s waiting room before you get in to see the doctor? (GP not specialist) No time, get in right away up to 15 minutes up to 30 minutes up to 45 minutes more than 45 minutes b) How do you rate this? Poor Fair Good

Excellent

a) About how many times in the last year have you seen any family doctor or GP? (any general practitioner not a specialist) #__________ b) About how many times have any other members of your household seen a GP? #____

B. Health Services: Other

The next questions are about health services other than those of a family doctor or GP. I will ask about services used by you or members of your household (family). 10 About how many times in the last year have you or members of your household seen a specialist physician (cardiologist, endocrinologist, surgeon etc )? #__________ Could you please tell me what kind of specialist was seen? (record all that apply) a ________________________________ c ________________________________

b __________________________ d __________________________

11 About how many times have you or members of your household seen a public health nurse, community health nurse or nurse practitioner in the last year? #__________ 12 About how many times in the last year have you or members of your household gone to the emergency department of a hospital? # __________ 13 About how many times in the last year have you or members of your household stayed overnight at a hospital? Count number of admissions, not number of nights in hospital. # ______ 14 I am going to read you a list of some other health services. Stop me if I come to a service that any member of your household has used in the last year. If used ask - About how many times in the last year has this service been used? Complete for all that apply: #__ physiotherapist #__dietician #__ psychiatrist #__respiratory technologist # __diabetic educator #__addictions counsellor #__occupational therapist #__ dentist #__ behaviour management specialist #__speech language therapist #__social worker #__child management specialist #__blood tests #__X-rays/ultrasound #__mental health professional #__ Other Specify ___________________________________

15 In the past year, did any member of your household travel outside the Burin Peninsula for any health service, test, treatment or medical advice? Yes No 16 If YES, (for each of these health care visits) could you please tell me where the service was located, what service was received there and why the person in your household travelled off the Burin Peninsula for this service? Code laterâ&#x20AC;Ś.. Location? (SJ, CL) Health Care Service? Why off the Burin? a ___________________ _____________________ ______________________________ b ___________________ _____________________ ______________________________ c ___________________ _____________________ ______________________________ d ___________________ _____________________ ______________________________ 17 In the last year, has anything prevented you or family members from receiving health care or medical advice? Code laterâ&#x20AC;Ś

C. Satisfaction with Health Services

The next questions will be about your satisfaction with the health services on the Burin Peninsula. Eastern Health provides a number of health care services to the Burin Peninsula. I am going to read them to you individually. 18 Please rate these as I read the list as either: not at all satisfied, somewhat satisfied or very satisfied with the services available on the Burin Peninsula

Community Health/Public Health nurses

not at all 1

some what 2

very sat 3

If dissatisfied, why? DK ___________________

or Nurse Practitioners (child health, pre/post natal, school programs, vaccinations, home visits) Home Care/Home support

DK ___________________

Emergency Services (hospital)

DK ___________________

Ambulance Services

DK ___________________

Long-term care (Nursing homes)

DK ___________________

Hospital in-patient Services (admission)

DK ___________________

Mental Health Services

DK ___________________

Addictions Services

DK ___________________

Dental Services

DK ___________________

Allied Health Services

DK ___________________

(physiotherapy, occupational therapy, speech therapy, dietician, respiratory, recreation) Child, youth and family Services

DK ___________________

Lab and x-ray Services

DK ___________________

19 Have you been able to obtain health services when you needed them? (all services that relate to your health including in the hospital, in the community or in your home) Always Most of the time Sometimes Rarely Never 20 What do you think is the biggest barrier or obstacle to getting health care services on the Burin Peninsula? Code laterâ&#x20AC;Ś..

D. Health and Community Problems 21 Now I am going to read you a list of common problems which may affect the health and well being of a community. I’d like you to rate to what extent you think they are a problem in your community. We are concerned here with all of the things that make and keep people healthy. Please rate the following items I will read as: Not a problem, somewhat of a problem, or a major problem.

Availability of recreational facilities Marital difficulties/violence in home Water/sewer services........................ Chronic illnesses (heart disease, diabetes, arthritis, blood pressure) Cancer............................................... Out migration - people/families leaving the community...................... Obesity/Overweight.......................... Wheelchair access.............................. Smoking............................................ Unemployment.................................. Alcohol abuse.................................... Gambling………………………….. Air or water pollution........................ Transportation................................... Teenage pregnancy........................... Loneliness......................................... Poverty.............................................. Crime................................................. Availability of support for the elderly housing, home care, meals, activities Maintaining healthy diet (fresh fruits and vegetables)......................... Vehicle accidents - cars, snowmobiles, ATVs, motocross Sexually transmitted diseases AIDS, Chlamydia, herpes, hepatitis B Housing conditions............................ Depression or other mental health conditions.................... Illegal drug abuse............................... Prescription drug abuse ..................... (pain pills, tranquilizers) Financial services (banking)............ Availability of support groups (cancer, bereavement, etc.) Literacy 22

Not a problem 1 1 1

Somewhat of a problem 2 2 2

Major problem 3 DK 3 DK 3 DK

1 1

2 2

3 3

DK DK

1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3

DK DK DK DK DK DK DK DK DK DK DK DK DK

1 1

2 2

3 3

DK DK

1 1 1

2 2 2

3 3 3

DK DK DK

1 1

2 2

3 3

DK DK

Record if volunteered Comments?

Out of all of these or any others that you can think of, what do you think is the number one problem in your community? __________________________________________

E. Personal Health and Wellness The next few questions are about your own personal health and wellness.

23 How would you rate your own health in general? Would you say it is… poor

fair

good

very good

excellent

24 a) In general do you think that you eat a healthy diet? Yes No Don’t know b) If no, what prevents you from having a healthy diet?

25 Have you ever been told by a health professional that you have diabetes? Yes No Don’t know 26 Have you ever been told by a health professional that you have high blood pressure? Yes No Don’t know 27 Have you ever been told by a health professional that you have high cholesterol? Yes No Don’t know 28 Do you currently smoke cigarettes daily? Yes No 29 Do you take part in gambling or gaming for money on average once a week or more? (Scratch ‘n win, lottery, break open tickets, video lottery terminals, card games, bingo) Yes No Refused 30 Do you drink alcoholic beverages on average more than 7 drinks/week? (a drink would be a beer, glass of wine or shot of liquor) Yes No Refused 31 Do you participate in regular physical or recreational activities like walking, jogging, bicycling, sports, aerobics at least 2-3 times/week? (activity of 20 minutes or more) Yes No 32 When was the last time you had your blood pressure checked? less than a year ago > 3 years

within 2 years Never

within last 3 years Don’t know

33 When was the last time you had your cholesterol checked? less than a year ago > 3 years

within 2 years Never

34 Could you tell me your height? 35 Could you tell me your weight?

within last 3 years Don’t know

_____ feet _____ inches ______ pounds

or _____ cm or _______ kg

FOR WOMEN

36 When was the last time you had a breast exam by a doctor or nurse? less than a year ago > 3 years

within 2 years within last 3 years Never Don’t know

37 When was the last time you had a mammogram? less than a year ago > 3 years

within 2 years within last 3 years Never Don’t know

38 When was the last time you had a PAP test (cervical cancer screening)? less than a year ago > 3 years

within 2 years within last 3 years Never Don’t know

FOR MEN

39 Have you ever had a blood test for prostate cancer called a PSA test? Yes No Don’t know 40 If YES, when did you last have this test? less than a year ago > 3 years

within 2 years within last 3 years Never Don’t know

F. Demographics Now, I just have a few more questions about you and your household.

41 Record if knownotherwise ask

Male

Female

42 Could you tell me what year you were born? 19 __ __ 43 Could you tell me how many people there are in your household (that is people who live with you and share income and expenses) under the age of 19 # _______ 19 or over #______ 44 Considering all of the members of your household, about what would you estimate the total yearly income to be? Would the total household income be….. refused Don’t know less than $5000 $5000 or more less than $20,000

less than $10,000 $10,000 or more less than $30,000

less than $15,000 $15,000 or more less than $40,000

$20,000 or more less than $60,000

$30,000 or more $60,000 to $79,999

$40,000 or more $80,000 or more

45. Do you have any other comments you would like to make regarding health care services on the Burin Peninsula? This completes our survey. On behalf of the Eastern Health Board I would like to thank you very much for your time and comments!

Appendix 2 INCOME CALCULATIONS

54 Mean Income An estimate of mean income was calculated based on the most detailed level of income information in Question 44 (the last column). Data was collected in nine ranges. An absolute value was assigned to each range as follows: <$5000 calculated as $4000 $5000-$10,000 calculated as $7500 $10,000-$15,000 calculated as $12,500 $15,000-$20,000 calculated as $17,500 $20,000-$30,000 calculated as $25,000 $30,000-$40,000 calculated as $35,000 $40,000-$60,000 calculated as $50,000 $60,000-$79,999 calculated as $70,000 $80,000 or more calculated as $90,000 Low Income Cut-offs Low income cut-offs (LICOs) were calculated based on income question #37 and using the 2003 LICOs table shown below. Burin Peninsula LICOs were calculated using the ARural@ values. The most detailed value for income question #44 (column three) was used where available. When this value was not available, column two was used to obtain an estimate if possible. For some households, the LICO table cut-off values fell within the reported income range. In this case, median values for the income range in column three were used (as above). Before Tax Low Income Cut-Offs (LICOs), 2003 Population of Community of Residence Family Size

500,000+

100,000499,999

30,00099,999

Less than 30,000

Rural

$19,795

$16,979

$16,862

$15,690

$13,680

$24,745

$21,224

$21,077

$19,612

$17,100

$30,774

$26,396

$26,213

$24,390

$21,268

$37,253

$31,952

$31,731

$29,526

$25,744

$41,642

$35,718

$35,469

$33,004

$28,778

$46,031

$39,483

$39,208

$36,482

$31,813

$50,421

$43,249

$42,947

$39,960

$34,847

Source: Prepared by the Canadian Council on Social Development using Statistics Canadaâ&#x20AC;&#x2122;s Low Income Cut-Offs, from low income cut-offs from 1994-2003 and low income measures from 1992-2001 Catalogue # 75F0002MIE N. 002 March 2004. Website: http://www.ccsd.ca/factsheets/fs_lico03_bt.htm

Appendix 3 BODY MASS INDEX

56 Body mass index (BMI) was calculated as follows: BMI = weight in lbs/ (height in inches)2 x 703 BMI categories were indexed as follows: < 18.5 underweight 18.5-24.9 normal 25.0-29.9 overweight 30 or greater obese Source: Canada Statistics, Canadian Community Health Survey 2003.

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12.6 Appendix F - Written Submissions Request Community Health Needs Assessment Eastern Health is conducting a community health needs assessment on the Burin Peninsula. A needs assessment gathers information about the health needs and resources of a community to determine what issues are most important and to develop a plan to address those priorities. A health needs assessment looks at what determines the health of a community, from income and education to physical and social environments. Written submissions are invited from individuals, community partners and service organizations about the health needs of the Burin Peninsula. Written submissions should be received by Dec. 5 to: Lisa Browne Planning Specialist, Eastern Health 35 Tilley's Road Clarenville, NL A5A 1Z4 709 466-5863 (p) 709 466-1623 (f) lbrowne@peninsulas.ca

Burin Peninsula Community Health Needs Assessment

12.7 Appendix G - Written Submissions Received Topic Kidney Dialysis Role of the Nurse Practitioner North of Marystown Obesity Kidney Dialysis Kidney Dialysis, 911 Network, prevention, dental services, ambulance, diagnostic equipment, unused beds at USM* Physician services Pap smears; lack of physician services Kidney Dialysis Grace Sparkes House; Importance of Itinerant Teachers; Positive Aspects of Family Physicians working at ER; Wastage of supplies* Kidney Dialysis Allied Health * Submissions received following key informant interview or focus group session.

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Burin Peninsula Community Health Needs Assessment

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12.8 Appendix H - Secondary Sources Annette Johns, Gail Lush, Karene Tweedie and Kathy Watkins, 2004. Adolescent Sexual DecisionMaking in Newfoundland and Labrador. Burin Peninsula Brighter Futures Project with ACCA-Atlantic Consulting and Counselling Associates, 2005. Evaluation of the Burin Peninsula Brighter Futures Project, Final Report. C. James Frankish, Elan Paluck, Deanna Williamson, and C. Dawne Milligan, 1999. Linking Health Research and Decision Making: The Use of Population Health and Health Promotion Research by Regional Health Authorities. Canadian Population Health Initiative, 2004. Improving the Health of Canadians. Centre for Health Information Newfoundland and Labrador, 2006. Fast Facts, Tobacco Use. Chinook Health Region, 1998. Developing Healthy Communities, A Determinants of Health Workbook. Chinook Health Region. The Determinants of Health. Christiane Poulin, Debbie Sue Martin and Michael Murray, 2005. Newfoundland and Labrador (Island Portion Only) Student Drug Use Survey 2003, Summary Report. Committee on Public Health Capacity, 2004. Investing in Health, A Report on Public Health Capacity in Newfoundland and Labrador. Community Accounts Web Site, 2006. Government of Newfoundland and Labrador. Website: www.communityaccounts.ca. Community Capacity Building Subcommittee, 2006. Learning from Experience, Building Sustainable Regions Through Community Partnerships. Craig Mitton, San Patten, Cam Daonaldson, and Howard Waldner, 2005. Priority-Setting in Health Authorities: Moving Beyond the Barriers, The Calgary Experience. Department of Health and Community Services, 2005. Newfoundland and Labrador Gambling Prevalence Study. Department of Health and Community Services, 2005. Wellness Highlights.

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Department of Human Resources, Labour and Employment, Government of Newfoundland and Labrador. Understanding the Labour Market Landscape in Newfoundland and Labrador: A Baseline Report, A Framework for Labour Market Development Background Report #1. Diane-Gabrielle Trembley, 2002. Employment Security as a Determinant of Health. Dietitians of Newfoundland and Labrador, Newfoundland and Labrador Public Health Association and Newfoundland and Labrador Association of Social Workers, 2004. The Cost of Eating in Newfoundland and Labrador â&#x20AC;&#x201C; 2003. Doreen Westera, Lorna Bennett and Doreen Dawe, 2004. Project Teen Newfoundland and Labrador: A Comprehensive Survey. Eastern Health and Community Services Board, 2001. 2001 Annual Report. Eastern Health and Community Services Board, 2001. Evaluation of the Model for the Delivery of School-Based Services, Phase I â&#x20AC;&#x201C; Year 1 (2001-02). Eastern Health and Community Services Board, 2003. Strategic Plan. Eastern Health and Community Services Board, 2004. Annual Report 2003-04. Eastern Health and Community Services Board, 2005. Health Promotion in Action 2004-2007, Healthy People, Healthy Communities, Healthier Future. Eastern Health and Community Services Board, 2003. Health in Our Schools: The Issue of Making Condoms Available to Youth. Eastern Mental Health Strategy Report of Stakeholder Consultations, 2004. A Collaborative Project: Networking to Build the Future in Mental Health for Eastern Newfoundland. Eastern Newfoundland Health and Community Services Region and Local Public Health Infrastructure Development (LoPHID) Project, 2000. Examining Prenatal Services. Eastern Newfoundland Health and Community Services Region and Local Public Health Infrastructure Development (LoPHID) Project, 2001. Dialogue on Heart Health. Eastern Newfoundland Health and Community Services Region and Local Public Health Infrastructure Development (LoPHID) Project, 2000. Dialogue with Youth about Risk and Resilience. Eastern Regional Health Authority, 2006. Strategic Plan.

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Goss Gilroy Inc., 2001. Report on the Evaluation of Basic Literacy/ABE Level I Programs in Newfoundland and Labrador. Government of Newfoundland and Labrador, Department of Education, 2000. Words to Live By, A Strategic Literacy Plan for Newfoundland and Labrador 2000. Gregor Coster, 2000. Health Needs Assessment for New Zealand, Background Paper and Literature Review. Health and Community Services Eastern, 2002. Health in Our Community, A Profile of the Eastern Region. Health Research Unit, Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, 2005. Burin Health and Community Needs Assessment Telephone Survey Results, Fall 2005. Housing Policy Working Group of the St. John’s Status of Women, 2005. A Housing Strategy for Newfoundland and Labrador. Interlake Regional Health Authority, 2004. Interlake Community Health Assessment 2004. Katherine Scott, 2002. Income Inequality as a Determinant of Health. Lisa Follett, 2003. Grace Sparkes House Administrator’s Annual Report, April 2002 - March 2003. Lisa Follett, 2004. Grace Sparkes House Administrator’s Annual Report, April 2003 - March 2004. Lisa Follett, 2005. Grace Sparkes House Administrator’s Annual Report, April 2004 - March 2005. Lise Gauvin, 2003. Social Disparities and Involvement in Physical Activity: Shaping the Policy Agenda in Healthy Living to Successfully Influence Population Health. Market Quest Research Group Inc. 11, 2005. 2005 Newfoundland and Labrador Gambling Prevalence Study. Market Quest Research Group Inc. 13, 2005. 2005 Newfoundland and Labrador Gambling Prevalence Study. Peggy R. Baikie, 2003. Child Care Services Needs Assessment, Newfoundland and Labrador, Final Report. Peninsulas Health Care Corporation, 2004. Strategic Plan. Peninsulas Health Care Corporation, 2001. PHCC Health Needs Assessment 2001.

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Peninsulas Health Care Corporation, 2003. Corporate Report Card, Annual Report, April 1, 2002 – March 31, 2003. Peninsulas Health Care Corporation, 2004. Corporate Report Card, Annual Report, April 1, 2003 – March 31, 2004. Peninsulas Health Care Corporation, 2005. Corporate Report Card, Annual Report, April 1, 2004 – March 31, 2005. Policy Research Associations, 2005. School Organization Plan, Eastern School District, 2006/07 to 2010/11. Reducing Poverty in Newfoundland and Labrador: Working Towards a Solution. Plain Language Summary. Rick Singleton (in consultation with Lisa Browne, Louise Jones and Daryl Pullman), 2006. Ethics Lens on Priority Setting within Eastern Health, Draft 3. Satya Brink, 2005. IALSS 2003 Key Policy Research Findings. Schooner Regional Development Corporation Board of Directors, 2004. Charting Our Course for the Future, 3 Year Business Plan. Sharon Canning, Eastern Health and Community Services Board, 2002. Profile of Young Offenders, Eastern Region. St. John’s Status of Women Council, 2003. “Something’s Got to Change” Research Report: GenderInclusive Analysis and Housing Policy Development in Newfoundland and Labrador. St. John’s Status of Women Council/Women’s Centre, 2002. Hammer and Nail Project: Women and Housing Issues, Action Research Report. Strategic Policy Directorate of the Population and Public Health Branch and with the help of Treena A. Chomik, 2001. The Population Health Template: Key Elements and Actions That Define a Population Health Approach. Strategic Social Plan Newfoundland and Labrador, 2002. Town Hall Forums Report. Strategic Social Plan Newfoundland and Labrador. Facilitating Community Partnerships Pilot Project, Synopsis of Proposal Submissions. Sue Cavanagh and Keith Chadwick, 2005. Health Development Agency, Health Needs Assessment.

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Tanya Noseworthy, 2003. Current Supply and Gaps in Service Issues For Physiotherapy, Occupational Therapy and Speech Language Pathology Professionals in Newfoundland and Labrador. The Institute for the Advancement of Public Policy, Inc., 2003. Evaluation of the Literacy Development Council of Newfoundland and Labrador. Welsh Health Impact Assessment Support Unit, 2004. Improving Health and Reducing Inequalities, A Practical Guide to Health Impact Assessment. World Health Organization, 2002. Technical Briefing, Health Impact Assessment.

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12.9 Appendix I - Listing of Eastern Health Staff Consulted on Issues Arising from the Community Health Needs Assessment Kim Green, Director of Patient/Resident Care Jeannette Lundrigan, Social Work Program Co-ordinator Natalie Moody, Director of Health Promotion Chris Mullett, Director of Child Welfare/Community Corrections Judy O’Keefe, Director of Integrated Health Services – Long-Term Care & Supportive Care (Trinity/Conception/Placentia) Betty Reid-White, Director of Integrated Health Services – Community Health (Trinity/Conception/Placentia) Evelyn Tilley, Director of Addictions Services Nadine Whelan, Human Resources Specialist, Organizational Effectiveness

Burin Peninsula Community Health Needs Assessment

12.10 Appendix J â&#x20AC;&#x201C; Newsletters

Page 155 of 164

December 2005

Advisory Committee Meets The Burin Peninsula needs assessment is overseen by a Steering Committee comprised of management at Eastern Health. That committee will rely on an Advisory Committee to act as a resource; serve as a mechanism to exchange ideas related to the needs assessment; and respond to questions from the Steering Committee. The Needs Assessment Advisory Committee met on November 14. At that meeting, the committee reviewed their terms of reference, discussed the plan for the needs assessment and viewed a video Healthy People Make Healthy Communities about the determinants of health. Individuals on the committee represent the determinants of health. Advisory Committee members are pictured above: (sitting L to R) Lisa Follett, Vivian Hollett, Ellen Picco; (standing L to R) Charles Penwell, Andy Moriarity, Alphonsus Ward and Eastern Health's Senior Director, Corporate Strategy and Research, Wayne Miller. Missing from the photo are Stella Hollett, Lisa Browne, Planning Specialist with Eastern Health and Donna Brenton.

BURIN PENINSULA Needs Assessment

December 2005

Focus Groups and Key Informant Interviews The week of Nov. 14 was a busy one on the Burin Peninsula! Thirteen focus groups were held throughout the peninsula. Focus groups are a good way to identify the perceptions, concerns and priorities for key stakeholder groups. Sessions were held with mayors, health providers, partner groups, business and community leaders. Focus group participants indicated that they were pleased to have the opportunity to provide their input. In addition to the focus group sessions, interviews were held with a number of individuals within Eastern Health and external to Eastern Health to get their perspectives on the health needs of the area.

Frank Murphy and Sheila Cox participated in one of the focus groups sessions held with communities north of Marystown.

Telephone Survey The Health Research Unit at Memorial University recently completed 400 telephone surveys on the peninsula. This survey asked a number of questions about health services, level of satisfaction with health services, health and community problems, personal health and wellness and demographic information. The surveyors' report excellent co-operation from respondents and are currently in the process of compiling the data.

Next Steps All of the information gathered from the people of the Burin Peninsula will help to provide a picture of the health needs of the area. Other information, such as existing research reports, demographic information, utilization and wait list information will further provide a picture of the health needs of the area. Action items and an implementation plan will then be developed with a report expected late February 2006.

December 2005

BURIN PENINSULA Needs Assessment

The Determinants of Health When considering health, we often think of things like hospital beds, x-rays and blood tests. Health is much more than physical health. It is an overall state of well-being, including physical, social, mental and spiritual health. Health is determined by a number of different factors that all act together. Some of these factors are part of you and others are part of your surroundings. You can control some of these factors but others cannot be controlled by you. Together, these factors are called the determinants of health. Health Canada lists the determinants as: • Income and social status • Social support networks • Education • Employment and working conditions • Physical environment • Personal health practices and coping skills • Healthy child development • Culture • Health Services • Gender • Biology and Genetic Environment

Employment and Working Conditions One of the determinants of health that has been mentioned a lot at interviews and focus groups is employment. Employment is one of the biggest stressors in our lives. People who are unemployed, underemployed or who work in stressful jobs often have poorer health. Think about employment and working conditions and ask yourself: • How is my job (or lack of job) affecting my health? • What can I do to reduce stress from my job? • What can I do to create a healthier workplace? • As a community, what can we do to promote safer and healthier workplaces? • How can we support people in our community who are unemployed or underemployed?

BURIN PENINSULA Needs Assessment

December 2005

Healthy Child Development Health Child Development is another determinant of health. Healthy, happy babies have the best chance of growing up to be healthy adults. Before a child is born is the time to begin focusing on child development. Low birth weight and premature babies, for example, are more likely to have health problems than normal weight, fullterm babies. Smoking, drinking alcohol, using drugs or eating a poor diet during pregnancy can lead to low birth weight. The first five years of life is a time when children learn personal health practices. Healthy eating habits and active lifestyles are learned in childhood. Think about healthy child development and ask yourself: • How can I give my children the best possible start in life? • What practices-good or bad-am I passing on to my children? • What can my community do to help our children get a good start in life?

Burin Peninsula Fast Facts • The number of seniors on the Burin Peninsulas is growing. There is a 65% projected increase of the number of seniors living on the Burin Peninsula: 2,534 in 1991 to 4,186 in 2019. • The rate of smoking (current daily smokers) on the Burin Peninsula in 2001 was 23%. The provincial rate was 25%. • The median age of people in communities on the Burin Peninsula ranges from 31 in Creston North to 46 in Harbour Mille (based on 2001 Census). The median age for the province is 38. • In 2001, 86% of homes on the Burin Peninsula were owned versus rented. This is compared to 78% for the province and 66% for Canada. • The 2003 income for every man, woman, and child (personal income per capita) on the Burin Peninsula was $17,300. For the province, it was $19,800. Fast facts information compiled from Community Accounts www.communityaccounts.ca

This newsletter will provide information about the Burin Peninsula community health needs assessment on an ongoing basis. To be added to the distribution list or to comment on the newsletter, please contact Lisa Browne, Planning Specialist, Eastern Health, at 709 466-5863 or lbrowne@peninsulas.ca.

January 2006

Advisory Committee Update The Advisory Committee, which is made up of people representing the determinants of health, met on December 13, 2005 for a focus group session. Facilitator Nadine Whelan led the group through a discussion about community issues, health concerns, current capacity, perceived service gaps and opportunities for improvement. This focus group session was one of 16 held on the peninsula. On January 4, 2006, the Advisory Committee was invited by the Burin Peninsula Kidney Dialysis Committee to attend a meeting about the need for dialysis services on the peninsula. Those in attendance spoke about the impact on families and communities when services are not available on the peninsula. The committee will meet again in February to discuss the qualitative results of the needs assessment.

Needs Assessment Timeline While it had been hoped that the needs assessment telephone survey would be completed before Christmas, it has been necessary for the Health Research Unit at Memorial University to continue on with the surveys in January to ensure that each area of the peninsula has sufficient numbers of surveys completed to provide valid results. This has meant that the telephone survey report will not be ready until early February. Once the telephone survey report is received, the needs assessment report will be written and a preliminary draft presented to the Eastern Health Board meeting at the end of March. The Board plans on releasing the report at its meeting on the Burin peninsula in May.

BURIN PENINSULA Needs Assessment

January 2006

The Determinants of Health In the December 2005 edition of this newsletter, we looked at two of the determinants of health: employment and working conditions and healthy child development. Another determinant of health is personal health practices and coping skills. These are things that people can do to directly affect their health. Some lifestyle choices such as eating a healthy diet, exercising regularly or wearing a helmet are positive. Other choices, such as smoking or abusing drugs/alcohol can have a negative impact on our health. Good decision making, self-awareness, access to information and support from family and friends can help us to make healthy choices. It is also important to use good coping skills to deal with the challenges of life. How we cope with stress has an impact on our health. Think about personal health practices and coping skills and ask yourself: â&#x20AC;˘ â&#x20AC;˘ â&#x20AC;˘

Are there things you can do to improve your health? How do you cope with challenges? How can you support people in your community to make healthier choices?

Success Stories: Learning From Each Other While conducting focus group sessions and key informant interviews, a number of examples of innovation and partnerships have been told. We would like to hear about them! Do you belong to a community group that is working together for a healthier community? Perhaps your town has an activity to promote healthy living or you belong to a group that has made a difference to the health of your area. Contact Lisa Browne at the contact information below or leave a message toll-free at 1-866-563-7422 and your call will be returned. Let's learn from each other!

The Burin peninsula offers many beautiful hiking areas and walking trails. In addition to being an excellent personal health practice, walking and hiking are excellent ways to cope with the challenges of everyday life.

This newsletter will provide information about the Burin peninsula community health needs assessment on an ongoing basis. To be added to the distribution list or to comment on the newsletter, please contact Lisa Browne, Planning Specialist, Eastern Health, at 466-5863 (p), 466-1623 (f ) or lbrowne@peninsulas.ca

February 2006

Telephone Survey Draft Report Received In consultation with Eastern Health representatives, the Health Research Unit at Memorial University of Newfoundland developed a telephone survey tool for the Burin peninsula needs assessment. The survey was based upon a previous Health Research Unit survey instrument used for other health organizations. Residential telephone numbers were obtained from a computer database within four areas of the Burin peninsula: Burin Peninsula North; Marystown/Burin area; St. Lawrence area and Grand Bank/Fortune area. Numbers were randomized to produce the working telephone contact list. During the survey period the interviewers met weekly with the research team to discuss survey problems and ensure consistency in survey presentation. Trained telephone interviewers solicited interviews from this phone list until the required proportional sample from each area of the region was completed. Of the 595 residents contacted and eligible, 486 consented to be interviewed, for a response rate of 82%. This is an excellent response rate. The 486 surveys represent a total of 1239 household members. The results of the survey will provide information about health services, health and community issues, personal health and wellness and demographics.

Advisory Committee Update The Advisory Committee met on February 10, 2006 to review the findings from the key informant interviews, the focus group sessions and the telephone survey. The committee will meet again in March to discuss the issues that have arisen from the needs assessment results.

BURIN PENINSULA Needs Assessment

February 2006

The Determinants of Health In the December 2005 and January 2006 editions of this newsletter, we looked at the following determinants of health: employment and working conditions; healthy child development; and personal health practices and coping skills. For this edition, we will consider education as a determinant of health. Health status improves with level of education. People who are more educated usually have more job opportunities, greater job security, higher job satisfaction and higher incomes. In addition, education gives people more control over their lives. This allows people to evaluate options, make choices and take action to improve health (Public Health Agency of Canada). Low literacy plays a role in a person's ability to understand their health care needs and those of their loved ones. The educational profile of the residents of the Burin peninsula, as provided by the provincial government's Community Accounts, is noted in the graph below and indicates that 52% of residents have a high school education or more and 48% do not have a high school education.

During key informant interviews and focus group sessions, participants commented on the primary and secondary school system on the Burin peninsula in a very positive light. They felt that their children were receiving a good education. A number of concerns were expressed with the perceived lack of emphasis on health education and healthy living in the school system. From a post-secondary perspective, a number of respondents thought highly of the role that the campus of the College of the North Atlantic plays on the peninsula. Think about education and ask yourself: • What knowledge or skills do you need to accomplish a goal in your life? • How can you learn those skills? Do you need formal or informal education? • Are there things your community could be doing to make educational opportunities more accessible? (From the Determinants of Health, Chinook Health Region)

March 2006

Assessment Update In February 2006, the Advisory Committee and Steering Committee reviewed the findings of the primary research completed for the needs assessment: key informant interviews, focus groups, telephone interviews. On March 14, 2006, the Planning Committee of the Board of Trustees of Eastern Health was presented with the findings. The next step will be to review the findings and draft broad recommendations. In early April, the Advisory Committee will meet to discuss these findings and recommendations. A plan will be developed to communicate the results of the report which will be released in May. Throughout the needs assessment process, the people of the Burin peninsula have been enthusiastic and supportive participants. It is their openness and willingness to participate that provided insight into the needs of the community.

BURIN PENINSULA Needs Assessment

March 2006

The Determinants of Health

In the past three editions of this newsletter, the following determinants of health have been examined: employment and working conditions; healthy child development; personal health practices and coping skills; and education. For this edition, we will consider social support networks as a determinant of health. Support from family, friends and communities is associated with better health. Such support can help you solve problems and help you have a sense of control over life circumstances. In fact, people who have supportive family and friends actually get sick less often and live longer that people who don't have strong networks. Communities where jobs are secure and few people leave are more likely to have good social support networks. Stable communities offer opportunities for people to get together through community projects, social events and sports teams. During the needs assessment process, the people and the sense of community on the peninsula was one of the key strengths consistently mentioned. A number of people indicated that it is the ability to work together that allows the peninsula to lobby to have their needs met. This strength, however, is being challenged by unemployment and resulting out migration. For the period 1991-1996, the Burin peninsula had an out migration rate of -7.6% compared with the provincial rate of -5.1%.

Volunteering in your community helps you to build social support networks. Here, Chief Operating Officer Pat Coish-Snow thanks volunteers Erica Prior and Jessica Prior.

This out migration is having a number of effects. The traditional rural Newfoundland family with a core nuclear unit and extended family supports is changing as a result of either whole families moving off the peninsula or one member of a family moving away for periods of a time. In some cases, older members of families are in their home communities without extended family members around. There is also a sense that parent and caregiver stress increase when one member of a family moves away for a period of time. Think about social support networks and ask yourself: â&#x20AC;˘ As a community, what can you do to create a more supportive or caring environment? â&#x20AC;˘ What can you do to build or strengthen social support networks in your community (i.e. volunteer, get involved in community activities, etc.)? â&#x20AC;˘ Do you have supportive family and friends who will provide help or encouragement when you need it? (The Determinants of Health, Chinook Health Region)

Burin Peninsula Community Health Needs Assessment

12.11

Page 156 of 164

Appendix K - Community Accounts

The Community Accounts breaks down the Burin Peninsula into eight sub-regions. Probing determinant of health issues by these sub-regions can further enhance the understanding of the Burin Peninsula. These areas and their populations are as follows: Sub-Region Bay Lâ&#x20AC;&#x2122;Argent

Towns Included

Bay L'Argent, Harbour Mille, Little Bay East, Little Harbour East and St. Bernard's-Jacques Fontaine Burin Burin, Epworth, Fox Cove-Mortier, Lewin's Cove, Port au Bras and Salmonier Fortune-Grand Bank Fortune, Frenchman's Cove, Garnish, Grand Bank, Grand Beach and L'Anse au Loup Lamaline Lamaline, Lawn, Lord's Cove, Point May, Point au Gaul and Taylor's Bay Mortier Bay Beau Bois, Jean de Baie, Marystown, Rock Harbour, Spanish Room and Winterland Placentia Bay West Centre Baine Harbour, Boat Harbour, Brookside, Monkstown, Parker's Cove, Petit Forte, Red Harbour, Rushoon and South East Bight St. Lawrence Little St. Lawrence and St. Lawrence Terrenceville English Harbour East, Grand le Pierre and Terrenceville

Population of Area % of Population of Peninsula 1,310 5.5%

3,900

16.4%

5,425

22.9%

1,785

7.5%

6,760

28.5%

1,675

7.0%

1,705

7.2%

1,145

4.8%

Burin Peninsula Community Health Needs Assessment

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13. Endnotes

Sue Cavanagh and Keith Chadwick, Summary: Health Needs Assessments at a Glance (Health Development Agency, 2005) 6-9. 2

Sue Cavanagh and Keith Chadwick 6-9.

Sue Cavanagh and Keith Chadwick 20-22.

“WHO Definition of Health.” World Health Organization. Retrieved February 2006. <http://www.who.int/about/definition/en/>. 5

“Determinants of Health.” About Population Health. Canadian Institute for Health Information. Retrieved February 2006. <http://www.secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=cphi_aboutph_e>. 6

“Determinants of Health.” Retrieved February 2006.

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“The Focus Group Interview and Other Kinds of Group Activities.” University of Illinois at Urbana-Champaign. Retrieved March 2006 <http://www.aces.uiuc.edu/~PPA/pdf_files/Focus.pdf >.

“Using Key Informants Interviews.” University of Illinois at Urbana-Champaign. Retrieved March 2006 <http://www.aces.uiuc.edu/~PPA/pdf_files/Informant1.PDF>. 12

Community Needs Assessment for the Grenfell Regional Health Services. St. John’s: Memorial University of Newfoundland, 1999 and General Practice Assessment Survey (GPAS), Modified by the Patient Research Centre, Memorial University of Newfoundland. Safran/The Health Institute and National Primary Care Research and Development Centre. 13

Division of Community Health and Humanities, Memorial University of Newfoundland. Burin Health and Community Needs Assessment Telephone Survey Results (Memorial University of Newfoundland, 2005) 8.

Burin Health and Community Needs Assessment Telephone Survey Results 8.

“Comparing Two Respondent Selection Methods in Telephone Surveys.” Prairie Research Associates, Inc.. Retrieved March 2006.<http://www.pra.ca/resources./birthday.pdf>.

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“Coastal Flooding.” Newfoundland and Labrador Heritage. Retrieved January 2006 <http://www.heritage.nf.ca/environment/c_flooding.html>.

“The Sinking of the USS Truxton and Pollux,” Town of St. Lawrence. Retrieved January 2006 <http://www.discoverstlawrence.com/truxton_pollux.htm>.

“Mining.” Newfoundland and Labrador Heritage. Retrieved January 2006 <http://www.heritage.nf.ca/society/mining.html>.

“Industrial Disease and St. Lawrence.” Newfoundland and Labrador Heritage. Retrieved January 2006 <http:// www.heritage.nf.ca/society/industrial_disease.html>.

“The History of Shipbuilding in Marystown” Marystown Heritage Museum Corporation, Virtual Museum of Canada. Retrieved February 2006 <http://www.virtualmuseum.ca/pm.php?id=story_line&lg=English&fl=&ex=00000165&sl=2938&pos=1>.

“Burin Peninsula Rural Secretariat Demographic Accounts.” Community Accounts, Government of Newfoundland and Labrador. Retrieved January 2006 <http://www.communityaccounts.ca>.

“Population Projections – Total Province By Economic Zone - Medium Scenario.” Economic Research and Analysis, Government of Newfoundland and Labrador. Retrieved March 2006. <http://www.economics.gov.nf.ca/population/byzone.asp>.

“Burin Peninsula Rural Secretariat Education Accounts.” Community Accounts, Government of Newfoundland and Labrador. Retrieved February 2006. <http://www.communityaccounts.ca>.

“Burin Peninsula Rural Secretariat Demographic Accounts.” Community Accounts, Government of Newfoundland and Labrador. Retrieved January 2006 <http://www.communityaccounts.ca>.

“Charting Our Course for the Future.” Board of Directors, Schooner Regional Development Corporation (Schooner Regional Development Corporation, 2004) 9-20.

The Economic Planning Group of Canada, A Special Place A Special People: The Future of Newfoundland and Labrador Tourism,

Department of Environment and Conservation, Fortune Health Ecological Reserve. Retrieved January 2006. <http:// www.env.gov.nl.ca/parks/wer/r_fhe/>.

“Charting Our Course for the Future.” Board of Directors, Schooner Regional Development Corporation (Schooner Regional Development Corporation, 2004) 3-8.

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“Charting Our Course for the Future.” Board of Directors, Schooner Regional Development Corporation (Schooner Regional Development Corporation, 2004) 3-8.

“Summary Infrastructure Map for Burin Peninsula.” Community Accounts, Government of Newfoundland and Labrador. Retrieved February 2006. <http://www.communityaccounts.ca/CommunityAccounts/maps/Burin_all.pdf>. 37

“Determinants of Health.” About Population Health. Canadian Institute for Health Information. Retrieved February 2006. <http://www.secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=cphi_aboutph_e>.

“Key Determinants.” What Determines Health. Public Health Agency of Canada. Retrieved February 2006. <http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/index.html#key_determinants>.

Canadian Institute for Health Information. “Improving the Health of Canadians.” (Canadian Institute for Health Information, 2004) 24.

“Burin Peninsula Rural Secretariat Region Profile.” Community Accounts, Government of Newfoundland and Labrador. Retrieved February 2006. <http://www.communityaccounts.ca>.

“Burin Peninsula Rural Secretariat Region Profile.” Community Accounts, Government of Newfoundland and Labrador. Retrieved February 2006. <http://communityaccounts.ca>.

“Burin Peninsula Rural Secretariat Region Profile.” Community Accounts, Government of Newfoundland and Labrador. Retrieved February 2006. <http://www.communityaccounts.ca>.

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“Poverty – What is Poverty?” The United Nations Office of the High Commissioner for Human Rights, <http://www.unhchr.ch/development/poverty-02.html>.

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D-G Tremblay and D. Rolland, 1998. Modèles de gestion de main-d'oeuvre; typologies et comparaisons internationales.

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“Burin Peninsula Rural Secretariat Labour Market Accounts.” Community Accounts, Government of Newfoundland and Labrador. Retrieved January 2006 <http://www.communityaccounts.ca>.

“Labour Force Characteristics, St. John's Census Metropolitan Area (CMA) and Labour Force Economic Regions, 3 Month Moving Averages Unadjusted February 2006.” Newfoundland and Labrador Statistics Agency. Retrieved April 2006. <http://www.nfstats.gov.nf.ca/statistics/Labour/LFC_Regional.asp >.

“Labour Force Survey Revision January 2006.” Statistics Canada. Retrieved April 2006. <http://www.nfstats.gov.nf.ca/statistics/Labour/LFC_Annual.asp>.

Community Accounts, 2006 Government of Newfoundland and Labrador, <http://www.communityaccounts.ca>.

“Key Determinants.” What Determines Health. Public Health Agency of Canada. Retrieved February 2006 <http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/index.html#key_determinants>.

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Housing Policy Working Group. “Housing Strategy for Newfoundland and Labrador.” (St. John’s Status of Women 2005) 8.

Strategic Social Plan, Eastern Region. Town Hall Forum Report. (Strategic Social Plan, Eastern Region, 2002) 26-30. 61

“Key Determinants.” What Determines Health. Public Health Agency of Canada. Retrieved February 2006. <http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/index.html#key_determinants>.

Department of Education. Government of Newfoundland and Labrador. Words to Live By: A Strategic Literacy Plan for Newfoundland and Labrador. Retrieved March 2006. <http://www.ed.gov.nl.ca/edu/literacy/litplan.pdf>. 63

“International Adult Literacy and Skills Survey 2003.” Statistics Canada. Retrieved Febuary 2006. <http://www.statcan.ca/Daily/English/051109/d051109a.htm>. 64

Department of Health and Community Services, “Achieving Health and Wellness Provincial Wellness Plan for Newfoundland and Labrador.” (Government of Newfoundland and Labrador, 2006) 30-33.

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“Burin Peninsula Rural Secretariat Education Accounts.” Community Accounts, Government of Newfoundland and Labrador. Retrieved January 2006 <http://www.communityaccounts.ca>.

Satya Brink, Ph.D. “Internal Adult Literacy and Skills Survey 2003: Key Policy Research Findings.” Presentation. November 9, 2005.

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Strategic Social Plan, Eastern Region. Town Hall Forum Report. (Strategic Social Plan, Eastern Region, 2002) p. 43-52. 71

“Key Determinants.” What Determines Health. Public Health Agency of Canada. Retrieved February 2006 <http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/index.html#key_determinants>.

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Personal interview, Luke Edwards, Superintendent, Department of Transportation, Works and Services. February 8, 2006.

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Peninsulas Health Care Corporation, PHCC Needs Assessment.(Peninsulas Health Care Corporation, 2001) 5.

Eastern Newfoundland Health and Community Services Region, Dialogue with Youth About Risk and Resilience (Health and Community Services Eastern Region and CIET Canada, 2000) 14-15. 81

Health and Community Services Eastern Board, “Healthy People, Healthy Communities, Healthier Future.” (Eastern Health and Community Services Board, 2004) 16.

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Department of Health and Community Services, “Achieving Health and Wellness Provincial Wellness Plan for Newfoundland and Labrador.” (Government of Newfoundland and Labrador, 2006) 31-32.

Eastern Newfoundland Health and Community Services Region, Dialogue with Youth About Risk and Resilience (Health and Community Services Eastern Region and CIET Canada, 2000) 16. 84

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Eastern Newfoundland Health and Community Services Region, Dialogue on Heart Health (Health and Community Services Eastern Region and CIET Canada, 2001) 8-10. 86

Peninsulas Health Care Corporation, PHCC Needs Assessment.(Peninsulas Health Care Corporation, 2001) 6.

Department of Health and Community Services. “Achieving Health and Wellness Provincial Wellness Plan for Newfoundland and Labrador.” (Government of Newfoundland and Labrador, 2006) 25-28.

Dietitians of Newfoundland and Labrador, Newfoundland and Labrador Public Health Association, Newfoundland and Labrador Association of Social Workers. The Cost of Eating Healthy in Newfoundland and Labrador. (2003) 2-4. 89

Dietitians of Newfoundland and Labrador, Newfoundland and Labrador Public Health Association, Newfoundland and Labrador Association of Social Workers. “The Cost of Eating Healthy in Newfoundland and Labrador.” (2003) 5-6.

Department of Health and Community Services, “Achieving Health and Wellness Provincial Wellness Plan for Newfoundland and Labrador.” (Government of Newfoundland and Labrador, 2006) 16.

Eastern Newfoundland Health and Community Services Region, Dialogue on Heart Health (Health and Community Services Eastern Region and CIET Canada, 2001) 13. 92

Eastern Newfoundland Health and Community Services Region, Dialogue with Youth About Risk and Resilience (Health and Community Services Eastern Region and CIET Canada, 2000) 17-22. 93

Planned Parenthood Newfoundland and Labrador and Women’s Health Network, Newfoundland and Labrador, Principal Investigators: Annette Johns, and Gail Lush; Report prepared by Annette Johns, Gail Lush, Karen Tweedie and Kathy Watkins. Adolescent Sexual Decision-Making in Newfoundland and Labrador.

Department of Health and Community Services, “Achieving Health and Wellness Provincial Wellness Plan for Newfoundland and Labrador.” (Government of Newfoundland and Labrador, 2006) 16-17.

“Key Determinants.” What Determines Health. Public Health Agency of Canada. Retrieved February 2006 <http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/index.html#key_determinants>.

Canadian Institute for Health Information. “Improving the Health of Canadians.” (Canadian Institute for Health Information, 2004) 52.

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Dodge, D. Human Capital, “Early Childhood Development and Economic Growth: An Economist’s Perspective” <http:// www.sparrowlake.org/news/SparronLakeAlliance-speech-2May03-smallprint.pdf>.

“Key Determinants.” What Determines Health. Public Health Agency of Canada. Retrieved February 2006 <http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/index.html#key_determinants>.

This section written after an interview with Jane Green, B.Sc., M.Sc. British Columbia, Ph.D. Memorial, C.F.M.G., Memorial University of Newfoundland, March 13, 2006. Her assistance in writing this section is acknowledged with thanks.

100

“Key Determinants.” What Determines Health. Public Health Agency of Canada. Retrieved February 2006 <http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/index.html#key_determinants>. 101

Canadian Community Health Survey (Statistics Canada, 2003). <http://www.statcan.ca>.

102

Incidence rate of insitu and invasive cervical cancer in Newfoundland and Labrador, 1998-2003. Presentation by Joann Rose, Cervical Screening Initiatives Program, 2005. 103

Early detection and screening for breast cancer (2006). Canadian Cancer Society. Retrieved February 2006. <http://www.cancer.ca/ccs/internet/standard/0.3182.3172_10175_74544430_langId-en.00.html>. 104

Lisa Follett, Administrator’s Annual Report (Grace Sparkes House, 2002-03, 2003-04, 2004-05).

105

“What Determines Health.” Population Health. Public Health Agency of Canada. Retrieved April 2006 <http:// www.phac-aspc.gc.ca/ph-sp/phdd/determinants/index.html>. 106

Eastern Regional Health Authority. Strategic Plan (2006) 12-14.

107

Department of Health and Community Services, “Achieving Health and Wellness Provincial Wellness Plan for Newfoundland and Labrador.” (Government of Newfoundland and Labrador, 2006) 16.

108

Determinants of Health, Chinook Health Region.

109

Romanow Receives Prestigious Award In Washington, September 23, 2003. Roy J. Romanow's Pan-American Health Organization (PAHO) Speech.

110

Department of Health and Community Services, “Moving Forward: Mobilizing Primary Health Care.” (Government of Newfoundland and Labrador, 2003). 111

“About Primary Health Care” Health Care System. Health Canada. Retrieved March 2006. <http://www.hcsc.gc.ca/hcs-sss/prim/about-apropos/index_e.html>. 112

Canadian Institute of Health Information. <http://www.cihi.ca>. Excludes residents and physicians who are not licensed to provide clinical practice and have requested to the Business Information Group that their data not be published. 113

Health Research Unit, Findings Assessment of the Primary Health Care Needs in the Downtown Area of St. John’s. St. John’s, Memorial University of Newfoundland, 2005 and Health Research Unit, Findings from the Bell Island Telephone Survey: Fall 2004. St. John’s, Memorial University of Newfoundland, 2005.

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114

Department of Health and Community Services, Health Scopes: Reporting to Newfoundlanders and Labradorians on Comparable Health and Health System Indicators. (St. John’s: Newfoundland and Labrador Centre for Health Information, 2002) 115

“Health Personnel Trends in Canada” Canadian Institute for Health Information, 1993-2002.

116

“Road Distance Database.” Newfoundland and Labrador Statistics Agency. Retrieved April 2006 <http://www.stats.gov.nl.ca/DataTools/RoadDB/Distances/Default.asp>. 117

Excludes residents and physicians who are not licensed to provide clinical practice and have requested to the Business Information Group that their data not be published. Includes physicians in clinical and/or non-clinical practice.

118

Palliative Care, World Health Organization Retrieved April 2006 <http://www.who.int/hiv/topics/palliative/care/en/>. 119

Lack of health professionals and retention and recruitment were coded separately because the lack of a health professional (doctors, specialists, technicians) may reflect a decision from the health authority not to offer the doctor/specialist/technician whereas retention and recruitment speaks directly to the difficulty in obtaining and retaining physicians to the Burin Peninsula (eg. lack of a dermatologist vs. salaries are too low, etc). 120

Rick Singleton. Ethics Lens on Priority Setting within Eastern Health. (2006) 6-10.

121

Eastern Regional Health Authority. Strategic Plan, (2006) 12.

122

Eastern Regional Health. Strategic Plan, (2006) 90.

123

Eastern Health. Strategic Plan, (2006) 15.