In recent years, research related to older adults and long-term care has been growing. Although much research in the past was focused on biomedical issues, more recent research has examined psychosocial issues faced by older adults within the long-term care setting. Despite the increase in literature and research on aging, long-term care, and dementia, there are still many gaps in our understanding of these phenomena. The concepts of body, self-identity, and place have received some attention over the last decade or so, but little systematic attempt has linked these concepts together, especially with relation to older adults and long-term care. In addition, the adjustment process of older adults into the long-term care facility has been examined, but the socialization processes have not been systematically examined. The purpose of this phenomenological study was to examine the process of socialization for new residents into the long-term care culture and environment, specifically focussing on how identities, bodies, and place are constructed and reconstructed by residents. Three residents were recruited for this study from a home for the aged in northwestern Ontario. Participant observation and three interviews over a six-month period with these residents focussed on concepts of place, self, and the body, as well as adjustment. Fifteen staff were also interviewed initially to gain an understanding of the long-term care environment and culture. Thirteen staff and two family members were interviewed at the end of the six-month period to gain an understanding of their perceptions of the resident’s transition into the long-term care facility. The findings indicate that a dismantling of the self occurs prior to coming into long-term care. Life in long-term care was described as living an altered life. Once admitted to the home for the aged, two types of socialization processes occurred—institutional and (inter)personal. Institutional socialization processes consisted of placing the body, defining the body, focussing on the body, managing the body, and relating to the body. Placing the body refers to the placement within the physical and social environment, residents’ adjustment to a new place, and how space within the facility was used. Defining the body refers to the assessments that were used just after admission which were focussed on the body as dysfunctional and limited. Focussing on the body occurred through the institution’s focus on body care, as well as the residents’ focus on their aging and unpredictable bodies, with a greater awareness of mortality and the immanence of death. Managing the body occurred through routines, risk management, and waiting. Finally, relating to the body referred to the boundaries of relationships that were defined, both resident relationships and staff relationships. The (inter)personal socialization processes capture the ways that residents internalized the institutional socialization processes. Internalizing the body refers to being a number and being a burden. Accommodating the body suggests ways in which residents complied to the institutional socialization processes. Accepting-resisting the body refers to the struggle residents had in accepting and fighting becoming a body, body limitations, and life in the institution. Re-creating the body illustrates ways in which residents reclaimed the body and alternative identities. All of these processes came together to create institutional bodies. These findings lead to a greater understanding of the ways in which body, self and identity, and place are intertwined. The institution served as a container for life, defining each of the lifeworld existentials. Lived space became institutional space, as personal space was redefined by the institution. Lived time also became structured by the institution, as temporal dimensions were defined by institutional time. The lived other became the institutional other, as staff became institutional brokers, attempting to balance the needs of the residents while adhering to the rules and regulations of the institution. The lived body also became the institutional body. The care encounter brought these dimensions together, and was the site for the production of institutional bodies. The findings of this study invite a rethinking of conceptions of the body and old age, particularly within the context of institutionalization, with bodies viewed as repositories of memories and containing both youth and age, rather than age as a ‘mask’. Residents exist within paradoxical rhythms of life, and thus, old age and institutionalization are not easily defined or theorized, but rather, reflect the complexity of lived experience.

Negative interpersonal workplace behaviours are an important but relatively infrequently studied occupational-stressor. The present research investigated the connection between these behaviours and employee well-being. This work had two main goals. The first goal was to provide greater insight into when and why social interactions at work can be harmful to employee well-being. Consistent with this goal, theory and research were reviewed, and results from two field studies were presented suggesting that (1) disrespect is an important characteristic of interpersonal workplace events that can explain detriments to employee well-being, and (2) both individual and contextual moderators are relevant in this process. In a first study, disrespectful leader behaviours were shown to negatively relate to employee well-being independent of demanding, production-focused leader behaviours. In a second study, perceived disrespectfulness mediated the relationship between exposure to negative interpersonal behaviour and well-being; workplace norms, social support, control-related self-beliefs, and negative affectivity moderated associations within the mediation sequence. Given the importance placed on objective measurement methods in the occupational stress literature, the inherent difficulties in measuring social stressors objectively, and the widespread use of self-report instruments in the literature, the second main goal of this work was to approach greater objectivity in the measurements of self-reported negative interpersonal workplace interactions. A number of approaches were used toward this end, including the development of a more objective self-report measure of interpersonal workplace behaviours, as well as the use of aggregate variables and the investigation of moderated relations within multilevel frameworks. Implications of this work and directions for further research are discussed.

Research exploring identity in the dementia context reveals that some aspects of personal and social identity persist in dementia while others evolve as persons living with dementia find ways to live with the changes in their lives. Leisure can be a space for developing and expressing identity and a space to resist stereotypical images and social expectations. Leisure may also play an important role in providing meaningful activity and engagement in life. Nonetheless, the meaning and experience of leisure in the context of dementia have received very little attention in the literature. Guided by the personhood movement, this phenomenological study aims to understand the subjective experience of dementia and the meaning and experience of leisure in the lives of persons living with early stage dementia. It explores leisure’s role in identity maintenance and/or development and leisure as a space for slowing down the process of dementia and resisting stigma associated with dementia and identity loss that could occur in dementia. Four persons living with early stage memory loss were recruited through local agencies to participate in this study. Each participant engaged in four conversational interviews following McCracken’s (1988) long interview format. Interviews were recorded and transcribed verbatim. Data were also collected through participant observation. The participants and I engaged in at least one of their favourite leisure activities together. Detailed field notes were recorded following each participant observation session. Using the method of photovoice, participants were given disposable cameras and asked to take photos of objects, places, and subjects that were meaningful for their leisure. These photos were discussed in Interview 2. Data were analysed in a manner consistent with phenomenology. Findings revealed that the participants experienced their journeys of memory loss within a paradox of challenge and hope. Participants juxtaposed the negative aspects of living with memory loss with the positive aspects of their lives. Essences of the experience include struggling with change, in which participants experience a wide variety of challenges as a result of being diagnosed with memory loss, including muddled thinking, fluctuating abilities, draining energy, frightening awareness, and disquieting emotions. However, participants counter these changes with the variety of ways in which they tackle life with dementia, including reconciling life as it is, battling through the changes by being proactive, living through relationships, being optimistic, and prolonging engagement in meaningful activity. Participants also experience threatening assaults on identities. Identity is threatened in terms of disappearing roles, losing independence, struggling with demeaning images and expectations, and losing confidence. However, participants juxtapose these threatening assaults by upholding identities. They do this by emphasizing abilities through leisure, changing perspectives, and engaging in life through leisure. This study deepens our current understandings of the subjective experience of dementia and leisure’s role within that experience. It helps us to understand the experience of leisure within the context of memory loss in terms of four lifeworld existentials: lived time, lived space, lived body, and lived other. The findings also contribute to our understandings of how persons living with dementia use leisure to resist a master status of dementia. Participants in this study used leisure as a space for resisting both the stigma of memory loss and the progression of memory loss. They overcome challenges in their leisure to demonstrate to themselves and others that they have many remaining abilities and are able to maintain valued aspects of their identities. The findings suggest that service providers, family members, and persons living with dementia should carefully consider the meaning of leisure and find ways to facilitate involvement in leisure that is meaningful for persons living with memory loss. In terms of future research, leisure in the context of relationships, including the importance of advocacy work for persons with dementia, should be examined. Although this study provides insight into the possibilities of alternative methods for understanding the experience of memory loss, further exploration is needed in this area.

Background: An essential component of managing the health care system effectively as the population ages is to provide care to seniors in the care setting that can best meet their needs. The majority of seniors wish to remain at home, to maintain their independence. Informal caregivers (family, friends and neighbours) provide as much as 80% of care to seniors who reside at home. The absence of or loss of an informal caregiver and/or a decline in a senior’s health may necessitate a change in care setting. Supportive Housing (SH) is a rapidly emerging alternative care setting for seniors who can no longer have their needs met at home. Objective: The objectives of this dissertation were: to provide a comprehensive description of the profile of SH clients in Ontario; to determining the role of SH in the continuum of care; to develop an algorithm to support care placement decisions; and to explore the longitudinal outcomes of SH clients including quality of life, and long-term care placement. The following four research questions were addressed: What are the socio-demographic and clinical characteristics of persons currently residing in SH units in Ontario? How do the profiles of current SH clients differ from the profiles of persons residing in other care settings? What changes occur in the appropriateness of SH to meet care needs over time? What factors are associated with discharge from SH to a long-term-care facility (LTC)? Methodology: The research questions were answered primarily using two Ontario interRAI data sets: A pilot sample of 1,720 SH clients collected using the interRAI Community Health Assessment and a sample of 29,790 Community Care Access Centre (CCAC) clients collected as part of normal clinical practice from clients residing in residential care setting, including SH. Data from LTC (N=832) and complex continuing care (CCC; N=425) clients in the Mississauga-Halton (MH) LHIN were also used. Data on care placement decisions were collected using a Staff Rating Form (N=332 in SH). Results: SH clients are a relatively light-care population who require support with instrumental activities of daily living (IADLs) and tend to lack an informal caregiver. SH clients who receive care from a CCAC are in the minority but represent a much more clinically complex sub-population. According to staff members, the majority (80%) of SH clients are appropriately placed; of the remaining 20%, 17% were prematurely admitted to SH and would be best cared for at home, a further 3% require LTC placement. Moreover, about 10% of seniors who receive care in the MH LHIN, have been inappropriately placed and would be best cared for in a SH unit. A Decisions Support Algorithm for SH (DASH) was developed to inform care placement decisions in Ontario. The algorithm was based on both resource availability and client care needs. Level of impairment in: IADLs, cognition, continence and score on the MAPLe algorithm (an interRAI prioritization algorithm; see Figure 11), were found to be significant predictors of care placement. Poor QoL was relatively rare (~5%) among SH clients and regression analysis was used to determine the variables associated with a decline in QoL. Finally, survival analysis determined that 20% of SH clients are discharged to LTC within one year. Age, dependence on others to perform IADLs, bladder incontinence, cognitive impairment, and higher MAPLe scores were associated with this discharge. Conclusions: Analyses in this dissertation have clearly indicated the need for a standardized assessment instrument in this sector. Arbitrary decisions around eligibility and discharge criteria for supportive housing have led to inappropriate placement of clients and confusion over the role supportive housing is to play in the continuum of care. Evidence-informed care placement decisions should consider client care needs as well as both the availability of formal and informal support. An integrated health information system, such as the interRAI instruments, facilitates a culture of evidence and improves communication across the care continuum. SH is a rapidly emerging alternative care setting for seniors. If managed carefully, SH has the potential to help address many health system level concerns as the population ages. It is hoped that this dissertation has answered some key questions and also inspired further research into an important and growing field.

Performing emotional labour in health care has been widely studied. However, there is a gap in the literature regarding mental health care. Therefore, the aim of this study was to identify (1) the method of emotional labour (i.e. hiding, faking, deep acting) adopted by mental health workers when interacting with patients; (2) the consequences associated with performing emotional labour- burnout, job satisfaction, and stress; and (3) which of these variables mentioned above predict the health and well-being of mental health workers. Findings revealed greater use of hiding emotions, than deep acting or faking emotions with patients. Several consequences, both positive and negative were identified. Among the negative consequences found, performing emotional labour through hiding and faking emotions was associated with burnout, job dissatisfaction, and stress. Conversely, through deep acting, increased personal accomplishment and job satisfaction was confirmed. No association between emotional labour and psychological distress, and physical symptoms were found.

Population aging in Canada is associated with a rising burden of heart failure (HF), a condition associated with substantial morbidity, mortality and health service use. HF management involves pharmacotherapy, exercise, dietary restrictions and symptom monitoring. First-line combination pharmacotherapy for HF consists of an angiotensin converting enzyme inhibitor (ACE inhibitor) or angiotensin receptor blocker (ARB) in conjunction with a β-adrenergic receptor blocker (β-blocker). This combination therapy can reduce mortality, improve symptoms and reduce health service use. However, evidence about the benefits of these therapies has been derived from randomized controlled trials in younger patients from acute care and specialty clinic settings. Little work has explored outcomes among older individuals and those in the community setting. In purposely studying an older cohort of individuals with HF, the goals of this research were three-fold: to comprehensively describe their sociodemographic, clinical and service use characteristics; to describe rates of usage of first-line HF pharmacotherapy and correlates of non-use; and to examine the outcomes of mortality, long-term care (LTC) admission, long-stay hospitalization, admission, new cognitive decline and new functional decline as well as predictors of these outcomes. To achieve these aims, this work made use of the extensive data available through the Resident Assessment Instrument – Home Care (RAI-HC) database in Ontario. The RAI-HC is mandated for use in Ontario to assess all long-stay home care clients (those expected to receive home care service for at least 60 days). This assessment contains over 300 items about sociodemographic and clinical characteristics, diagnoses, service use and geriatric conditions, such as functional abilities and cognition. The study samples included long-stay home care clients older than 65 years of age. The descriptive analyses (N=264,030) demonstrated that older home care clients with HF are a more complex group than home care clients without HF, with more comorbidity and higher use of medications and health care services. From the analyses examining pharmacotherapy use (N=176,860), rates of use of first-line pharmacotherapy were low, with only 30% of clients with HF receiving recommended combination first-line therapies, a similar proportion receiving no therapies and the remainder receiving at least one therapy. The multivariate analyses revealed that hypertension and diabetes mellitus diagnoses affect first-line therapy use. Regardless of clinical subgroup, use of these therapies was less likely among older clients and those with functional impairment, airway disease or behavioural symptoms. Longitudinal analyses were done using Cox proportional hazards regression modeling (N=9,283) in which individuals were followed for nine months after each RAI-HC assessment. Results from these analyses showed that female gender and living alone reduced the risk of all outcomes except LTC admission, while age over 85 years generally increased the risk of all examined outcomes. Comprehensive clinical indicators, the Changes in Health, End-stage disease, Signs and Symptoms (CHESS) scale and Method for Assigning Priority Level (MAPLe) algorithm, increased the risk of all outcomes except new cognitive decline. ACE inhibitor use was protective of LTC admission and functional decline, but not mortality, long-stay hospitalizations or cognitive decline. The complexity of older individuals with HF could impair self-care abilities and points to the need for initiatives to help such individuals manage their care at home with appropriate support and services. The low rates of use of first-line pharmacotherapy among older home care clients with HF highlights the need for better understanding of which factors affect prescribing practices. Better evidence, that is more applicable to older individuals with HF, is needed about the therapeutic benefits of first-line therapies to help enhance the evidence base and improve patient care.

Background: Quality of life (QoL) of long term care facility (LTC) residents is being recognized as an important outcome of care by LTC providers, researchers, and policy makers. For residents, measurement of QoL is a valued opportunity to express their perception of the quality of their daily life in the LTC facility. For clinicians, self-reported QoL provides useful information in planning and implementing resident-centred care. Purpose: The purposes of this study were: (1) to examine the distributional and psychometric properties of the interRAI Self-Report Nursing Home Quality of Life Survey (interRAI_QoL Survey); and (2) to explore the relationship of selected socio-demographic and clinical characteristics of residents and LTC facility attributes with residents’ self-reported QoL. Methodology: This was a cross-sectional observational study. A convenience sample of 48 volunteer LTC facilities from six Canadian provinces was involved in this study. Nine hundred and twenty eight (928) residents agreed to participate in this study. Resident inclusion required an interRAI Cognitive Performance Scale score of 0 (intact) to 3 (moderate impairment). Residents’ self-reported QoL was measured by trained surveyors using the interRAI_QoL Survey instrument. Residents’ socio-demographic and clinical characteristics were obtained from the most recentResident Assessment Instrument –Minimum Data Set 2.0 prior to the QoL interviews. LTC facility attributes were measured by a survey form specifically designed for this purpose. Descriptive statistics were used to describe the participating LTC facilities, the sample of residents, and residents’ self-reported QoL. Psychometric tests for reliability (test-retest and internal consistency) and validity (content and convergent) were conducted. Bivariate analyses were conducted to examine the relatioships between QoL and resident and facility charateristics. Multivariate linear and logistic regression analyses were conducted to identify predictors of residents’ QoL. Results: The study confirmed the feasibility of assessing LTC facility residents’ self-reported QoL. The findings showed positive ratings of some aspects of residents’ daily lives while negative ratings in other aspects. Psychometric tests showed that the interRAI_QoL Survey instrument had test-retest reliability, internal consistency, content validity and construct (convergent) validity. Several resident and facility characteristics were associated with self-reported QoL. Religiosity and highest education level attained were significantly and positively associated with QoL. Other resident characteristics such as age, gender and marital status were not. Mild cognitive impairment, depression, aggressive behaviour, hearing impairment, bowel and bladder incontinence, and extensive assistance in activities of daily living were significantly but negatively associated with QoL. LTC facility ownership showed significant association with QoL. Residents in municipal LTC facilities followed by private LTC facilities reported higer QoL in contrast to charitable LTC facilities. Profit status, accreditation and leadership stability were not associated with QoL. Residents in rural settings reported significantly higher QoL than those in urban settings. Facility size (measured in number of beds), registered nurse hours of care, nursing staff turnover, and ratios of registered to non-registered nursing staff did not have a significant association with QoL. However, higher management hours and total hours of care had significant and positive associations with residents’ overall QoL. Multiple linear regression showed that residents’ religiosity, degree of social engagement, post secondary education, dependence in activities of daily living, and positive global disposition, and LTC facilities situated in rural settings and ownership type together accounted for 24% (adjusted R2=0.24) of the variance in overall QoL (the dependent variable). In logistic regression, low QoL was used as the binary dependent variable. Residents who were religious, were socially engaged and had a positive global disposition were less likely to report low QoL. In contrast, residents with dependence in activities of daily living and post secondary education were more likely to report low QoL. Residents in LTC facilities located in rural settings and operated by municipal or private operators were less likely to report low QoL compared to charitable facilities. Strengths and Limitations: This study had several strengths, including a sample of 928 residents who self-reported on their QoL and the use of RAI-MDS 2.0 for objective, external indicators of QoL. This study had several limitations, including response bias due to method of sample selection, inability to draw causal inferences due to study design; limited generalizability due to use of a convenience sample, lack of monitoring of surveyors for the integrity of resident interviews, and exclusion of residents with cognitive performance scale scores of more than three or inability to communicate in English. Future research should address these limitations. As well, future research should conduct more stringent psychometric analyses such as factor analysis and use multi-level modeling procedures. Implications: The findings of this study have implications for improving residents’ QoL, LTC facility programming, future research, and social policy development. Conclusion: QoL can be measured from resident self-reports in LTC facilities. Self-reports from residents may be used by clinicians to plan and implement resident-centred care. There are significant associations of residents’ QoL with select resident socio-demographic and clinical characteristics and facility attributes. Some of these resident characteristics and facility attributes may serve as predictors of QoL.

Introduction: Cancer survivors continue to experience psychological distress and challenges in their daily lives long after the completion of treatment. Caregivers play a pivotal role in the lives of cancer survivors by providing support in various domains of their lives. The cancer experience between support persons and cancer survivors is intertwined. The interdependence theory will serve as a theoretical framework to guide the purposes of this study. Objective:The purpose of this research was to gain a better understanding of unmet needs of caregivers supporting long-term cancer survivors and explore how fulfilling the needs of caregivers influenced the psychological well-being of cancer survivors. Specifically, an emphasis was placed on exploring the level of dependence present in marital relationships, and how this impacted the relationship between caregiver unmet needs and the psychological outcomes of cancer survivors. Method: Data was drawn from The Cancer Support Persons’ Unmet Needs Survey (SPUNS) (Campbell et al., 2009) and The Cancer Survivors’ Unmet Needs Survey (SUNS) (Campbell et al., 2009). Regression models tested for significant interactions between caregiver unmet needs and factors influencing survivor dependence with psychological distress in cancer survivors. Results: Findings revealed main effects between caregivers’ depression, anxiety, and stress with the respective psychological outcomes in cancer survivors. Caregivers’ concerns about the future predicted elevated depression in cancer survivors. Caregivers with needs pertaining to information or emotions predicted higher anxiety in cancer survivors. Information needs, future concerns, and health care access and continuity needs of caregivers predicted higher survivor stress. Conversely, work and financial needs of caregivers predicted lower depression, anxiety and stress in cancer survivors. Significant interactions were found for caregivers’ concerns about the future by recurrence of diagnosis with decreased survivor anxiety, health care needs of support persons by recurrence of illness with increased survivor anxiety, caregivers’ personal needs by severity of illness with higher survivor anxiety, support persons’ emotional needs by severity of illness with lower survivor anxiety, caregivers’ emotional needs by severity of illness and decreased survivor stress, and finally, support persons’ health care needs by severity of illness with higher survivor stress. Conclusion: Findings did not fully support the hypotheses of this present study. Nonetheless, the significant results revealed in the findings would be useful to generate alternative hypotheses in future studies regarding interdependence, unmet needs and psychological well-being. The findings for the present study will also provide direction towards improvement in treating caregivers and cancer patients as a conglomerate, and inform programs, services and policies in cancer care.

Introduction: Cancer poses a substantial burden on the health of Canadians. Although advancements in screening and treatment have reduced, cancer-related morbidity and quality of life remain important concerns throughout cancer treatment and survivorship. <p>Purpose: This study examined the impact of Iyengar yoga on quality of life and other cancer-related symptoms among people with cancer. <p>Methods: All individuals registered for the Fall 2006 and Winter 2007, 10-week Iyengar yoga programs, offered by CancerCare Manitoba through private donations, were invited to participate in the study. Participants were asked to complete standard self-report questionnaires and participant diaries at baseline, week-5, week-10, and 6 weeks following the last class. The interventions impact on study outcomes were determined using repeated measures ANOVAs and paired samples t-tests. Six participant interviews and a review of participant diaries were conducted and analyzed using categorical aggregation and direct interpretation to identify other relevant issues as raised by participants and to document any negative effects of the program.<p>Results: Nineteen female participants completed the yoga intervention. The mean age of the sample was 50 years and the majority self-identified as Caucasian. Approximately one third had breast cancer and 63% were undergoing treatment for cancer at baseline. Results from the questionnaires showed statistically significant improvements in quality of life, mood disturbance, spiritual well-being, anxiety, nausea, pain, participants most bothersome symptom at baseline, and trait anxiety. Results from the interviews and participant diaries showed that participants experienced increases in social support, relaxation, mental concentration, and in flexibility, strength, and mobility in problem areas. Participants also expressed that their Iyengar yoga practice was empowering and supported their need to take an active role in their health and take a holistic approach to care. It was suggested that Iyengar yoga might contribute to the benefits reported through an ability to facilitate the development of coping skills or mindfulness.<p>Conclusions: The Iyengar yoga program for people living with cancer offered by CancerCare Manitoba can be considered a complex, multi-level, multi-modal intervention. Although, due to design limitations, neither causality nor a dose-response relationship between the Iyengar yoga intervention and the improvements in cancer-related outcomes could be inferred, the present study lends support to the assertion that Iyengar yoga is beneficial to the well-being of those living with cancer.

Syftet med denna C-uppsats var att undersöka hur skolpersonalen upplever det stöd som finns tillgängligt för eleverna på skolan. Studien genomfördes på en skola i Västsverige där tillvägagångssättet i studien var intervjuer med sex personer ur skolpersonalen. Deltagarna i undersökningen var sex personer med olika arbetsuppgifter på skolan där professionerna: skolsköterska, skolkurator och lärare innefattades. Metoden som användes var kvalitativ metod. Det finns väldigt få forskningsrapporter som belyser frågeställningar om elevhälsans tillgänglighet sett ur ett personalrelaterat perspektiv inom den kvalitativa forskningsmetoden. Inom kvantitativ forskningsmetod finns det något fler tillgängliga forskningsrapporter men de är fortfarande relativt få. Denna undersökning resulterade i sex stycken olika teman som beskriver hur och i vilken utsträckning skolpersonalen upplever att de finns tillgängliga för eleverna. I denna uppsats används till största del beteckningen elevhälsa, vilket innefattar det arbete som skolpersonalen utför för att eleverna ska må bra, såväl fysiskt som psykiskt och enligt existerande lagar och regler. Uppsatsen avslutas med en diskussionsdel där väsentliga delar och tankar om framtida arbete inom dessa frågor tas upp. / The purpose of this thesis was to investigate how school personnel experience available student support. The study was conducted at a school in western Sweden, using interviews with six participants from the school personnel. Participants in the study were six people with different professions at the school where the professions: school nurse, school curator and teachers were included. The method used was a qualitative method. There are very few research reports that highlight issues of availability of student health, from a personnel-related perspective with the qualitative research method. With quantitative research method, there are more available research reports but they are still relatively few. This study resulted in six different themes that describe how and to what extent school personnel feel that they are available to students. This essay for the most part used the term student health, which includes the work of school personnel involved for the students’ well-being, both physically and mentally, following existing laws and regulations. The essay concludes with a discussion on essential elements and ideas about future work with these issues.