This study explored the perspectives on place of eight people with severe mental illness living, for one year or longer, in an urban psychiatric hospital. The research questions were: how do people with severe mental illness view the psychiatric hospital as place?; and how do they make meaning of the experience of living in hospital. The research employed a phenomenological approach, as described by Giorgi (1985). Using purposive sampling, one time, semi-structured, individual interviews were conducted. The audio recorded interviews were transcribed and thematically coded using Giorgi’s (2005) method. The meanings of the participants’ experiences are captured by the meta-theme: this is not a home; it’s a hospital. Four additional major themes emerged; and each of the major themes also had sub-themes The findings of this study challenged commonly held assumptions on how people living long term in a psychiatric hospital view the hospital as place and on institutionalization.

This study explored the perspectives on place of eight people with severe mental illness living, for one year or longer, in an urban psychiatric hospital. The research questions were: how do people with severe mental illness view the psychiatric hospital as place?; and how do they make meaning of the experience of living in hospital. The research employed a phenomenological approach, as described by Giorgi (1985). Using purposive sampling, one time, semi-structured, individual interviews were conducted. The audio recorded interviews were transcribed and thematically coded using Giorgi’s (2005) method. The meanings of the participants’ experiences are captured by the meta-theme: this is not a home; it’s a hospital. Four additional major themes emerged; and each of the major themes also had sub-themes The findings of this study challenged commonly held assumptions on how people living long term in a psychiatric hospital view the hospital as place and on institutionalization.

Cardiac rehabilitation (CR) is recommended for those living with heart disease, however adherence is suboptimal. The home program (HP) model of care is as clinically effective as traditional programs (TP), however little information exists about the HP’s effect on adherence. The objectives of this thesis were to 1) compare adherence of patients in a HP and TP model of CR. 2) To characterize self-regulatory self-efficacy (SR-SE) in a CR HP and 3) to explore the reasons for non-completion of a HP. Study 1 showed adherence to be similar between the TP and HP. Study 2 showed that SR-SE was high throughout the HP for completers, but dropped in those who did not complete the program. The HP is a good alternative for those unable to attend a TP; however those with low SR-SE may require further interventions to help them complete their program.

Cardiac rehabilitation (CR) is recommended for those living with heart disease, however adherence is suboptimal. The home program (HP) model of care is as clinically effective as traditional programs (TP), however little information exists about the HP’s effect on adherence. The objectives of this thesis were to 1) compare adherence of patients in a HP and TP model of CR. 2) To characterize self-regulatory self-efficacy (SR-SE) in a CR HP and 3) to explore the reasons for non-completion of a HP. Study 1 showed adherence to be similar between the TP and HP. Study 2 showed that SR-SE was high throughout the HP for completers, but dropped in those who did not complete the program. The HP is a good alternative for those unable to attend a TP; however those with low SR-SE may require further interventions to help them complete their program.

There is compelling evidence that regular physical activity is likely to play a role in the secondary prevention of stroke and comorbid coronary artery disease. However, structured physical activity programs are not widely available for people following stroke. Cardiac rehabilitation programs (CRP) are well suited to provide exercise training following traditional stroke rehabilitation. However, people following stroke may be limited by a constellation of neurological deficits that may prevent them from effectively participating in and benefiting from an adapted CRP. Accordingly, the objectives of this work were to 1) examine the utility of cardiopulmonary exercise stress testing (CPET) for developing an exercise prescription in people ≥3 months post-stroke with mild/moderate motor impairments 2) determine ability to achieve minimal recommended exercise training levels reported to elicit health benefits during a single standard CR session following completion of a CRP 3) evaluate the physiological, and cognitive effects of a 24-week CRP of resistance and aerobic exercise and the effect of stroke-recovery-time. It was hypothesized that most patients (>50%) would reach a level of exertion on the CPET that would provide recommended exercise prescription target levels and that individuals would be able to systematically reach these target levels during a CR session. Moreover, the established exercise program would result in physiological and cognitive benefit independent of time-from-stroke. Study 1 demonstrated that most patients achieved a level of exertion during the CPET sufficient to inform an exercise prescription. In Study 2 patients with motor impairments were able to meet or exceed minimal recommended exercise target levels of intensity, duration and energy expenditure. In Study 3 a CRP yielded improvements over multiple domains of recovery (cardiovascular fitness, functional ambulation, sit-to-stand performance, and muscular strength). While those referred ≤1 year and >1 year post-stroke derived benefits from a CRP, those who started earlier (≤1 year) had greater improvements in ambulatory performance. In Study 4 combined aerobic and resistance exercise resulted in improvements in cognitive function. Change in cognition was positively associated with change in fat-free mass and change in anaerobic threshold. In summary people post-stroke are able to effectively participate in and benefit from an adapted CRP.

There is compelling evidence that regular physical activity is likely to play a role in the secondary prevention of stroke and comorbid coronary artery disease. However, structured physical activity programs are not widely available for people following stroke. Cardiac rehabilitation programs (CRP) are well suited to provide exercise training following traditional stroke rehabilitation. However, people following stroke may be limited by a constellation of neurological deficits that may prevent them from effectively participating in and benefiting from an adapted CRP. Accordingly, the objectives of this work were to 1) examine the utility of cardiopulmonary exercise stress testing (CPET) for developing an exercise prescription in people ≥3 months post-stroke with mild/moderate motor impairments 2) determine ability to achieve minimal recommended exercise training levels reported to elicit health benefits during a single standard CR session following completion of a CRP 3) evaluate the physiological, and cognitive effects of a 24-week CRP of resistance and aerobic exercise and the effect of stroke-recovery-time. It was hypothesized that most patients (>50%) would reach a level of exertion on the CPET that would provide recommended exercise prescription target levels and that individuals would be able to systematically reach these target levels during a CR session. Moreover, the established exercise program would result in physiological and cognitive benefit independent of time-from-stroke. Study 1 demonstrated that most patients achieved a level of exertion during the CPET sufficient to inform an exercise prescription. In Study 2 patients with motor impairments were able to meet or exceed minimal recommended exercise target levels of intensity, duration and energy expenditure. In Study 3 a CRP yielded improvements over multiple domains of recovery (cardiovascular fitness, functional ambulation, sit-to-stand performance, and muscular strength). While those referred ≤1 year and >1 year post-stroke derived benefits from a CRP, those who started earlier (≤1 year) had greater improvements in ambulatory performance. In Study 4 combined aerobic and resistance exercise resulted in improvements in cognitive function. Change in cognition was positively associated with change in fat-free mass and change in anaerobic threshold. In summary people post-stroke are able to effectively participate in and benefit from an adapted CRP.

This thesis examines hospitalizations for ambulatory care sensitive conditions among persons with an intellectual disability living in Manitoba from 1999 to 2003. Hospitalizations for ambulatory care sensitive conditions are considered an indicator of access to, and the quality of, primary care. Intellectual disability can be defined as a disability originating before age 18 characterized by significant limitations both in intellectual functioning and in adaptive behaviour as expressed in conceptual, social, and practical adaptive skills. Between 1 and 3% of the population has an intellectual disability. This thesis addressed three objectives: 1) To identify ambulatory care sensitive conditions that are applicable to persons with an intellectual disability; 2) To compare hospitalization rates for ambulatory care sensitive conditions between persons with and without an intellectual disability in Manitoba; 3) To identify factors associated with hospitalizations for ambulatory care sensitive conditions among adults with an intellectual disability living in Manitoba. An online survey of primary care providers with experience working with persons with an intellectual disability found consensus on fifteen ambulatory care sensitive conditions applicable to persons with an intellectual disability. Large discrepancies in hospitalization rates for these conditions were found between persons with and without an intellectual disability. Controlling for age, year, sex, and region, persons with an intellectual disability were 6 times more likely to be hospitalized for an ambulatory care sensitive condition. Future research should investigate reasons for the large discrepancy in rates between persons with and without an intellectual disability. Among adults with an intellectual disability, living in a rural area (odds ratio 1.3; 95% CI=1.0, 1.8), living in an area with a high proportion of First Nations people (odds ratio 2.3; 95% CI=1.3, 4.1), and experiencing higher levels of comorbidity (odds ratio 25.2; 95% CI=11.9, 53.0) were all associated with a higher likelihood of being hospitalized for an ambulatory care sensitive condition. Dwelling in higher income areas had a protective effect (odds ratio 0.56; CI=0.37, 0.85). The results suggest that addressing the socioeconomic problems of poorer areas and specifically areas densely populated by First Nations people would likely have an impact on hospitalizations for ACS conditions for persons with an intellectual disability.

In contrast to cardiac rehabilitation (CR) programs, traditional stroke rehabilitation aims to maximize functional independence and does not have a strong focus on exercise training and risk factor modification. Given the parallels between stroke and heart disease in cardiovascular etiology and risk factors, CR may be suited to supplement stroke rehabilitation by providing opportunities to enhance fitness and manage stroke risk factors. The aim of this work was to 1) examine the use of a non-adapted CR program of care with individuals with stroke and/or transient ischemic attack (TIA) through a retrospective database review, 2) using a prospective trial, determine the feasibility and effects of an adapted CR program for people with mild to moderate impairment from stroke, and 3) explore characteristics related to degree of program response in aerobic and functional capacity through secondary data analysis. The results from Study 1 demonstrated that traditional CR is an underutilized service for individuals with stroke or TIA, yet improvements in aerobic fitness were comparable to their non-stroke counterparts. In Study 2, adapted CR was feasible for individuals with a range of stroke-related disability and effective in increasing aerobic capacity. The anticipated carry over to improved walking capacity was not observed. There were no changes in health-related quality of life or stroke risk factors. Study 3 identified subgroups of participants who improved or declined in aerobic and ambulatory capacity after the adapted CR program. There were no differences in baseline characteristics, indices of time, intensity or volume of exercise performed across the response subgroups. In summary, given the parallels between stroke and heart disease, the needs of the stroke population and dearth of community-based exercise programming available for them, the CR model of care may be applied for individuals with stroke to provide opportunities for exercise training and risk factor modification.

This qualitative study investigated the experiences of family caregivers who cared for a stroke survivor throughout weekend passes from an in-patient rehabilitation facility. Following a Husserlian phenomenological perspective, I interviewed 15 family caregivers of stroke survivors on two separate occasions: within one week after their first scheduled weekend pass, and again two weeks after their final transition home. Interviews followed a semi-structured interview guide, and were audio recorded. Interviews were transcribed verbatim, and analyzed using the principles outlined by Giorgi (1997). Analysis of the caregivers’ descriptions of their experiences led to five themes: (i) Caregivers feel overwhelmed throughout the weekend pass, (ii) Access to supportive resources influences caregiving experiences, (iii) Caregivers adjust to the weekend pass throughout its subsequent use, (iv) Caregivers feel a responsibility and a need to be included by health professionals in the care of their family stroke survivor, and (v) Caregivers describe the weekend pass as a means towards recovery. This study has implications for future health services. By appropriately training and supporting caregivers throughout the weekend pass health care professionals can increase the positive experiences of caregivers, and optimize the opportunity to prepare caregivers and stroke survivors for the eventual transition home.

Occupational therapists assess and make recommendations for modifying home environments to facilitate caregiving of children in their homes. Children who are profoundly and permanently physically disabled remain dependent for their care throughout their lifespan. As they mature, the physical demands on family members to provide care become more challenging requiring major modifications to ease caregiving. Qualitative interview data of ten educationally influential occupational therapists (EIOTs) were collected to examine what information the EIOTs collect and how they prioritize and organize these data to make modification recommendations. The data were analyzed using grounded theory methodology. The findings detail myriad information required by the EIOT to make recommendations for modifications. Findings suggest a future oriented and highly contextualized information gathering process. The themes were integrated into a process model that suggests how therapists may be developing recommendations. The findings highlight important implications for research, education, clinical practice and service delivery policy.