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Socio-spatial patterns of home care use in Ontario, Canada:
a case study
Peter Kitchen
Allison Williams
Raymond W. Pong
Donna Wilson
RDC Research Paper No. 40
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Socio-spatial patterns of home care use in Ontario, Canada:
a case study
Peter Kitchen
Allison Williams
Raymond W. Pong
Donna Wilson
RDC Research Paper No. 40
April 2012
We are grateful to the Ministry for making selected administrative data files available and for its financial
support and also to CHEPA (The Centre for Health Economics and Policy Analysis) and SEDAP (Social and
Economic Dimensions of an Aging Population) for their support. The authors alone are responsible for the
views expressed here.
Socio-spatial patterns of home care use in Ontario, Canada: a case study
Peter Kitchen, Allison Williams, Raymond W. Pong, and Donna Wilson
First published as:
Kitchen, P., A. Williams, R.W. Pong, and D. Wilson. 2011. “Socio-spatial patterns of home care use in Ontario,
Canada: a case study”. Health and Place 17: 195-206.
Copyright notice:
© 2010 Elsevier Ltd.
Link to online edition of the journal at:
doi: 10.1016/j.healthplace.2010.09.014
All Rights Reserved
Health & Place 17 (2011) 195–206
Contents lists available at ScienceDirect
Health & Place
journal homepage: www.elsevier.com/locate/healthplace
Socio-spatial patterns of home care use in Ontario, Canada: A case study
Peter Kitchen a,n, Allison Williams a, Raymond W. Pong b, Donna Wilson c
a
b
c
School of Geography & Earth Sciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada L8S 4K1
Centre for Rural and Northern Health Research, Laurentian University, Canada
Faculty of Nursing, University of Alberta, Canada
a r t i c l e in f o
abstract
Article history:
Received 1 February 2010
Received in revised form
7 July 2010
Accepted 29 September 2010
Available online 13 November 2010
Home care is the fastest growing segment of Canada’s health care system. Since the mid-1990s, the
management and delivery of home care has changed dramatically in the province of Ontario. The
objective of this paper is to examine the socio-spatial characteristics of home care use (both formal and
informal) in Ontario among residents aged 20 and over. Data are drawn from two cycles of the Canadian
Community Health Survey (CCHS Cycle 3.1 2005 and Cycle 4.1 2007) and are analyzed at a number of
geographical scales and across the urban to rural continuum. The study found that rural residents were
more likely than their urban counterparts to receive government-funded home care, particularly nursing
care services. However, rural residents were less likely to receive nursing care that was self-financed
through for-profit agencies and were more reliant on informal care provided by a family member. The
study also revealed that women and seniors were far more dependent on services that they paid for as
compared to informal services. People with lower incomes and poorer health status, as well as rural
residents, were also more likely to use informal services. The paper postulates that the introduction of
managed competition in Ontario’s home care sector may be effective in more populated parts of the
province, including large cities, but at the same time may have left a void in access to for-profit formal
services in rural and remote regions.
& 2010 Elsevier Ltd. All rights reserved.
Keywords:
Home care
Health disparities
Urban–rural continuum
Formal and informal care
1. Introduction
Over the past several decades, Canada’s health care system has
undergone considerable change. With an aging population and
rising health care costs, provincial governments have implemented
policies aimed at improving the efficiency and quality of care while
attempting to keep costs under control (Baranek et al., 2004; CHCA,
2009). It is recognized that in many situations, care in the home is a
desirable alternative to hospitalization or admittance to a longterm care facility. Most people prefer to receive care at home when
recovering from an injury, receiving treatment for a chronic
condition or when dying. Home care is now the fastest growing
sector of health care in Canada. This growth has been attributed to a
number of factors including an aging population, the search for
cost-effective alternatives to institutional care, advancements in
technology and treatment, shortage of acute and long-terms beds,
an increased demand for home care by patients and their families
and changing attitudes towards institutional care (Côté and Fox,
2007; Kotecha and Birtwhistle, 2009).
At the same time, a growing body of research is showing
significant differences in health status and utilization of health
n
Corresponding author. Tel.: + 1 905 525 9140 20112; fax: +1 905 546 0463.
E-mail address: [email protected] (P. Kitchen).
1353-8292/$ - see front matter & 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.healthplace.2010.09.014
services between urban and rural Canadians (DesMeules, 2006;
CIHI, 2008; Pong et al., 2010). Both the ‘‘Romanow Report’’
(Romanow Report, 2002) and the ‘‘Kirby Report’’ (Kirby and
LeBreton, 2002) have drawn attention to the health of Canadians
living in rural and remote areas and indicated that access to health
services is an important challenge. In particular, access to medical
specialists and hospitals with advanced acute-care services is more
difficult due to a shortage of local services or greater distances from
urban centres.
Home care is defined by the Canadian Home Care Association
(CHCA, 2008a, p. viii) as ‘‘an array of services for people of all ages,
provided in the home and community setting, that encompass
health promotion and teaching, curative intervention, end-of-life
care, rehabilitation, support and maintenance, social adaptation
and integration, and support for the informal (family) caregiver.’’
This paper seeks to contribute to the research on health disparities
by comparing the use of home care in Ontario by residents aged 20
and over in urban and rural areas and among different regions
of the province. The following three research questions are posed:
(1) To what extent do rural residents rely on home care services
compared to their urban counterparts? (2) What are the predominant social, health and geographic determinants of home
care use and (3) How have policy changes affected the availability of home care services in rural and remote communities of
Ontario?
196
P. Kitchen et al. / Health & Place 17 (2011) 195–206
This study employs data from the Canadian Community Health
Survey (CCHS) for 2005 and 2007. The CCHS is released on an
annual basis by Statistics Canada and contains several questions on
home care utilization that is funded and not funded by government
as well as perceptions of unmet home care needs. Based on the
CCHS survey questions, three types of home care are examined: (1)
formal home care services that are at least partially paid for by
government. (These services are typically provided through nonprofit agencies and involve nursing, therapy, counseling, personal
care, housework and the preparation and delivery of meals.) (2)
Formal home care that is paid for entirely by the user and which is
typically provided by private, for-profit agencies and (3) informal
home care provided by family members, friends or neighbours. In
addition, the paper investigates patterns of home care use across
the urban to rural continuum and among different regions of the
province. Statistics Canada’s Metropolitan Influence Zones (MIZ)
measure a person’s proximity to an urban area based on geographical location and the proportion of residents commuting to work
in urban centres.
The paper is divided into four sections. The first is a review of the
literature on home care in Canada, focusing on key policy changes
in Ontario and challenges associated with the delivery of home care
in rural and remote areas. The second outlines the methods
employed in the research and the third presents the results of
the data analysis. The fourth section discusses policy issues related
to variations in home care use in Ontario. Although this is a case
study focusing on Ontario, it has implications for other regions of
Canada and internationally since few studies have focused on the
socio-spatial characteristics of home care use.
1.1. Setting the scene: growth and change in home care in Canada
There is a large body of literature devoted to home care in
Canada, the majority of which deals with the economic and policy
issues associated with the people and organizations that deliver
home care services. By comparison, less research has focused on the
use of home care, particularly the socio-spatial characteristics of
the people receiving these services. Clearly, there is an important
link between the provision and use of home care services, which
will be explored in this paper.
Home care was not that common in Canada until the 1970s, but
since then has grown rapidly with each province taking a different
approach. There are no national standards for home care nor is
there a pan-Canadian program; a situation that Seggewiss (2009)
argues has led to a ‘‘patchwork of programs across the nation, with
access and availability conditional on geographic region, if not
chance’’. Home care is not an insured service under the Canada
Health Act, which applies only to insured health services that cover
hospital care (acute, rehabilitation and chronic) and medical
services (CHCA, 2009). While the provinces and territories all
provide home care services, there are significant variations in
access, costs and wait times (Seggewiss, 2009).
Over the past 30 years, home care has undergone dramatic
change in Canada’s largest province of Ontario. A number of authors
have documented the restructuring of Ontario’s health system in
the 1980s and 1990s and its impact on home care (for example,
see Baranek et al., 1999, 2004; Armstrong and Armstrong, 2003;
Williams, 1996, 2006; England et al., 2008). Central to this restructuring was closing or merging of dozens of hospitals in the 1990s
and the concurrent shift of care to the home coupled with the
opening of some health services, including home care, to market
forces. England et al. (2008) provide an excellent review of this
period of change in Ontario (led by the Progressive Conservative
government from 1995 to 2003) and its effect on the management
and delivery of home care.
Perhaps the most important change was the creation in
1996–98 of 43 Community Care Access Centres (CCACs), which
replaced 38 home care programs and 36 placement coordination
services in the province. By 2007, the 43 CCACs had been reduced to
14, which were coterminous with the geographic boundaries of the
province’s 14 Local Health Integration Networks (LHINs). The
mandate of CCACs is to provide a single point of access to manage
and coordinate long-term care and home care services in their
regions. They do not provide any services themselves but employ
case managers to arrange access to contracted services. CCACs use
competitive bidding for contracts from local nonprofit and privatefor-profit agencies to provide nursing, homemaking, personal
support, and other services (England et al., 2008). Prior to the
creation of the CCACs, home care was delivered by nonprofit
agencies such as the Victorian Order of Nurses and Meals on
Wheels.
The introduction of managed competition in Ontario’s home
care sector is a contentious issue and has been the focus of much
research during the last decade. For instance, Abelson et al. (2004)
assessed the quality of home care services under this policy
environment in the Hamilton, Ontario CCAC; Aronson et al.
(2004) examined the employment conditions of support workers
employed by for-profit, non-unionized agencies; Zeytinoglu et al.
(2009) studied casualized employment and turnover intention
among home care workers in the province and Woodward et al.
(2004) considered the attributes that contribute to continuity
of home care under the competitive bidding model. In a pair of
studies, Randall and Williams (2006, 2009) assessed the impact of
Ontario’s managed competition reform on rehabilitation home care
services from the perspective of professional providers.
In a study relevant to the objectives of this paper, Cloutier-Fisher
and Skinner (2006) considered the effect of managed competition
on voluntary sector providers of long-term care to elderly populations in small rural areas of Ontario. Based on a series of keyinformant interviews with service providers from the voluntary
sector, the authors contend that managed competition has
contributed ‘‘to a loss of service and a reduction in service availability and access for people living in rural areas’’ (Cloutier-Fisher
and Skinner, 2006, p. 107). On a more positive note, in a study of
home care nursing services delivered under managed competition
in 11 CCACs in Ontario, Doran et al. (2007) found that contract
characteristics (longer and shorter contracts; nonprofit and forprofit) were largely not related to the consistency of principal nurse
visits or client outcomes. The research also revealed that clients
cared for by for-profit agencies reported slightly higher satisfaction
with care and better mental health outcomes than clients cared for
by not-for-profit agencies. It should be pointed out that the authors
did not directly consider regional geographic variations or urban–
rural residency although they did select CCACs from each region of
the province.
As stated, less attention has been paid to the socio-spatial
aspects of home care use in Canada. This is surprising in light of the
immense geography of the country and the fact that residents living
in rural and remote regions often experience very different health
outcomes. A number of researchers have addressed issues of home
care in rural and remote areas. Authors such as Angus et al. (2005),
Chapell et al. (2008), Sims-Gould and Martin Matthews (2008) and
Forbes and Edge (2009) have recently contributed to a better
understanding of the challenges associated with caregiving and
patient needs in the rural setting. It is important to situate rural
home care within the context of the unique circumstances in
which many rural residents live. As Kulig (2010) points out, life
expectancy for both men and women is lower in rural Canada
while the incidence of respiratory disease is higher as are overall
mortality rates, especially those related to circulatory diseases,
injuries and suicide. At the same time, access to primary care,
P. Kitchen et al. / Health & Place 17 (2011) 195–206
medical specialists and acute care hospitals is often far more
difficult in rural areas as is accessing home care services. This
should be cause for concern as accessibility is one of the five
principles of the Canada Health Act. However, it appears that to
date, unequal accessibility due to geographic impediments has not
received the same amount of policy attention.
The Canadian Home Care Association (CHCA, 2006, 2008b)
describes a number of challenges that rural home care programs
face. Chief among these is a lack of health human resources (e.g.,
doctors, nurses, home support workers) as well as a limited number
of informal/family caregivers in rural and remote communities.
These challenges are compounded by a net out-migration of young
people, fewer support systems and local resources, limited means
of transportation, and the need to travel long distances and many
hours to see very few clients (CHCA, 2008b, p. 6). Furthermore,
Forbes and Edge (2009, p. 121) describe how the absence of
intermediary services (e.g. Meals on Wheels, caregiver respite
programs, supportive housing), specialty services, and long-term
care beds in rural and remote communities often result in
premature admission to acute care and long-term care facilities,
‘‘which may be at a distance and result in the splitting up of family
units and increased costs to the health care system’’.
An under-explored area of research is the effect of managed
competition on the quality and availability of home care services in
rural and remote regions. Several organizations including the
Canadian Home Care Association (CHCA, 2008b), the Canadian
Healthcare Association (CHCA, 2009) and the Health Council of
Canada (2008) have pointed to the potential problem of for-profit
agencies choosing not to compete for home care contracts
in situations where they are less able to make a profit,
particularly in remote areas with small or dispersed populations
and a shortage of health care professionals. In these situations, a
gap in home care provision may exist, one in which family
members and under-resourced nonprofit agencies will attempt
to fill.
1.2. Characteristics of home care use in Canada
Only a handful of studies have employed survey data to examine
the social and geographic characteristics of home care use in
Canada. Using cross-sectional data from the first three cycles of
the National Population Health Survey (NPHS 1994/95, 1996/97,
1998/99), Forbes et al. (2003) investigated individual determinants
of use of publicly funded home care by Canadian 18 years or older.
In a follow-up study, Forbes and Janzen (2004) drew data from two
cross-sectional cycles of the NPHS (1996/97 and 1998/99) to
investigate the characteristics associated with the use of publicly
funded home care services among rural and urban Canadians
aged 18 or over. The study examined 13 independent variables
including age, gender, education, income, perceived health, activity
restriction, and chronic condition. Rural was defined as ‘‘the
population living outside places of 1,000 people or more, or a
population living outside places with densities of 400 or more
people per square kilometer based on the previous census’’ (Forbes
and Janzen, 2004, p. 229). The study found that rural residents are
increasingly less likely to receive personal care assistance and rural
home care users appear to have more resources (e.g. higher levels of
education) that likely influence their ability to access and receive
home care services. In another study, Mitchell et al. (2006) used
longitudinal data from the Manitoba Study of Health and Aging
(MSHA) to examine rural-urban differences in home care service
use over time. At baseline (1991/92), data on 885 communitydwelling, cognitively intact adults aged 65 or over not receiving
home care were collected. Place of residence was categorized as
urban/small town zone or predominantly rural area in Manitoba.
197
The authors found that urban residents were more likely to receive
home care than those in small town-zones or predominantly
rural areas.
In research focusing on Ontario, Hall and Coyte (2001) acquired
household data from the 1994/95 NPHS and linked it to the
Ontario Home Care Administrative System database to evaluate
the relevant predictors of home care utilization. The sample
employed in the analysis was 3830 individuals aged 25 and
over, with164 (4.3%) receiving home care one year following the
survey. The authors found that the use of formal home care is
uncommon in Ontario with only 4.3% of sample respondents
receiving this service. Furthermore, just 14% of older individuals
(65 and over) from the sample received home care one year after
the survey.
In the early 2000s, the Canadian Community Health Survey
(CCHS) began to replace the NPHS as Statistics Canada’s primary
health survey. The CCHS is now conducted on an annual basis, with
each data release containing information provided by Canadians
who self report. Carrie re (2006) used data from the 2003 CCHS to
investigate the use of formal and informal home care among older
persons in Canada. In this study, formal home care encompassed
government-subsidized health care or homemaker services, and
care purchased from private agencies or provided by volunteers.
Informal home care is help provided by family, friends or
neighbours (Carrie re, 2006). The study found that most seniors
relied on formal care and that women were more like to receive
home care regardless of the source – formal, informal or mixed. It
also revealed that large proportions of seniors who required
assistance with activities of daily living did not receive any form
of home care.
Wilkins (2006) employed data from the 1994/95 NPHS and 2003
CCHS to examine changes in the use of government subsidized
home care in Canada and found that the average age of recipients
fell from 65 to 62 over this 8-year period. Also, the number of
household residents who needed help with personal activities of
daily living or with moving about in their homes increased
substantially between 1994/95 and 2003. Wilkins (2006)
contends that despite government-subsidized home care
services reaching greater numbers of people in 2003, a smaller
share of individuals with these basic needs received care.
Each of these studies has made an important contribution to the
literature. As indicated, a growing body of research points to the
existence of regional health disparities and differences in access to
health services in Canada. Combined with an aging population,
significant changes in provincial home care policies and the fact
that home care is the fastest growing sector of the health system,
there is a pressing need to better understand the socio-spatial
factors associated with the use of home care services in Canada.
2. Methods
The authors applied for and were granted permission to use
Statistics Canada’s CCHS master files, specifically to gain access to
variables denoting the urban or rural residence of respondents. The
CCHS includes a module where respondents are asked questions
about the home care services that they have received during the
12 months prior to the survey. Table 1 shows the three questions
from the CCHS that are analyzed in this research.
Two levels of geography were examined. The first is the Local
Health Integration Network (LHIN). Ontario has 14 LHINS, which
are not-for-profit agencies that were created by the Government of
Ontario in 2006 with a mandate to plan, integrate and fund health
care services in its region including hospitals, Community Care
Access Centres (CCACs), community support services, long-term
care, community health centres, and home care. There is one CCAC
198
P. Kitchen et al. / Health & Place 17 (2011) 195–206
Table 1
Canadian Community Health Survey (CCHS) questions.
Variable name
Concept
Question
If ‘Yes’, type of care
received
Variable name
Concept
Question
If ‘Yes’ type of care
received
Variable name
Concept
Question
If ‘Yes’, reason for
unmet needs
HMCE_09
Received home care services - cost covered by
government.
Have you received any home care services in the past 12
months, with the cost being entirely or partially
covered by government? (‘Yes’, ‘No’, ‘N/A’)
(1) Nursing care (e.g. dressing changes, preparing
medications, VON visits)
(2) Health services (e.g. physiotherapy, occupational or
speech therapy, nutrition counseling)
(3) Personal care (e.g. bathing, foot care)
(4) Housework (e.g. cleaning, laundry)
(5) Meals (preparation or delivery)
HMCE_11
Received home care services - cost not covered by
government
Have you received any [other] home care services in the
past 12 months, with the cost not covered by
government (for example: care provided by a private
agency or by a spouse or friends)? (‘Yes’, ‘No’, ‘N/A’)
(1) Nurse from private agency
(2) Homemaker or other support services from
private agency
(3) From neighbour or friend
(4) From family member or spouse
HMCE_14
Self-perceived unmet home care needs.
During the past 12 months, was there ever a time when
you felt that you needed home care services but you
didn’t receive them? (‘Yes’, ‘No’, ‘N/A’)
(1) Not available in area
(2) Cost
within each LHIN and they cover the same geographic area
although they are separate administrative entities.
The second level of geography is the Public Health Unit (PHU)
of which there are 36 across Ontario. Each PHU is an official
health agency established by a group of urban and rural municipalities to administer, among others, health promotion and
disease prevention programs. Although PHUs have no direct role
in the provision of home care services, they are included in this
research to demonstrate a more detailed geographic variability of
home care use. The geographic boundaries of PHU are nested
within the LHINs.
There are various definitions of ‘‘rural’’ in Canada and other
countries and ‘‘rural’’ can mean different types of communities (Du
Plesssis et al., 2002; Bollman and Clemenson, 2008). For instance,
rural can refer to a community within relatively close driving
distance to a major metropolitan area, such as Toronto, or it can
refer to remote areas, many hundreds of kilometers from the
nearest city. There have been developments over time in
differentiating rural from remote and rural from urban. Wilson
et al. (2009) outlined various definitions of rural as related to
distance from a city, travel time and population density.
The CCHS master file contains two measures of rurality. The first
is a variable (GEODUR2) that divides the residence of each
respondent into two categories—urban or rural with rural defined
as a place that has a population less than 1000. The second is a
variable (GEODSTAT) that employs metropolitan area (CMA) and
census agglomeration (CA) influence zones (MIZ). CMAs and CAs
contain large urban areas, together with neighbouring census
subdivisions (municipalities) that have a high degree of social
and economic integration with the urban core. A Metropolitan
Influence Zone (MIZ) refers to the population living outside the
commuting zones of larger urban centres (CMAs and CAs). Statistics
Canada classifies four zones.1
This study examined the total population aged 20 and over
receiving home care services in Ontario. Data from CCHS Cycle 3.1
(2005, n¼36,629) and Cycle 4.1 (2007, n¼19,631) were analyzed.
The two cycles were pooled to create a single data set (n¼ 56,260),
representing the total population aged 20 and over in Ontario and
including people who received home care (n ¼1687) and people
who did not (n ¼54,573). Pooling was necessary as the total
number of people receiving government-funded home care in
Ontario is relatively small (about 3%) and a larger sample size is
required to compare residents living in certain geographic areas,
particularly in the Moderate and Weak/No MIZ, where the number
of respondents is insufficient in a single CCHS cycle for most
statistical analyses. Also, home care policy was fairly stable in
Ontario between 2005 and 2007, with most of the major changes
occurring in the late 1990s and early 2000s. For these reasons, the
authors felt that combining the two CCHS cycles was justified.
However, the pooling of data presented a challenge with respect
to the weight variable attached to each individual in the survey. The
weight variable represents an estimate of the total population. In a
recent article, Thomas and Wannell (2009) proposed several
methods for adjusting weights when combining cycles of the
CCHS. The authors recommended that weights be scaled by a
constant factor, ai ¼1/k. If two cycles are combined, this means
a ¼0.5. Following this approach, the master weight for each
individual in the two Cycles (3.1 and 4.1) was divided by 2
creating a new adjusted weight.
The authors also felt that it was important to examine the adult
population aged 20 or over for two reasons. First, it created a larger
sample size thus permitting a more detailed statistical analysis.
Second, it is evident that home care is an important health service
for many people and not just for seniors. Table 2 shows that in
2005/07, nearly 124,000 people in Ontario aged 20–64 received
government-funded home care (44% of the total) and another
129,000 received non-government-funded home care (50% of the
total).
The data analysis involved four steps: (1) descriptive statistics,
(2) mapping, (3) contingency tables and (4) logistic regression. In
the first step, simple descriptive statistics were produced showing
the basic socio-economic and geographic characteristics of home
care use (both government and non-government funded) in
Ontario. In the second step, mapping software (ESRI ArcGIS) was
employed to create a choropleth map showing the geographic
distribution of government-funded home care use in the province’s
14 LHIN regions and 36 Public Health Unit regions. The third step in
the data analysis was the use of contingency tables to measure the
strength of the relationship between home care use and geography.
Specifically, the use of government and non-government funded
home care by type (i.e. nursing, meal preparation, homemaking,
etc.), was examined across four metropolitan influence zones
(CMA/CA, strong MIZ, moderate MIZ, weak/no MIZ). The fourth
step involved logistic regression analyses of the CCHS data. A series
of models were devised where the dependent variable represents
people who have received home care and the independent variables denote a number of socio-demographic (gender, age, marital
status, income, education), health (self-rated health status)
and geographic (urban–rural, MIZ) characteristics. Regression
1
Strong MIZ: At least 30% of the municipality’s resident employed labour force
commute to work in anyCMA or CA; Moderate MIZ: At least 5%, but less than 30% of
the municipality’s resident employed labour forcecommute to work in any CMA or
CA; Weak MIZ: more than 0%, but less than 5% of the municipality’s resident
employed labour forcecommute to work in any CMA or CA; No MIZ: Fewer than 40 or
none of the municipality’s resident employed labour force commute to work in any
CMA or CA.
P. Kitchen et al. / Health & Place 17 (2011) 195–206
Table 2
Population aged 20 and over receiving home care services in Ontario, 2005/2007.
Government-funded home
care services
Total
Percenta
Total
% Health unit pop.
aged 20 and over
Percenta
Total receiving 281,938
Sex
Male
108,429
Female
173,509
3.0
260,169
2.7
38.5
61.5
84,603
175,566
32.5
67.5
Age
20–34
35–49
50–64
65 and over
30,098
47,060
46,642
158,138
10.7
16.5
16.5
56.1
29,384
51,043
48,680
131,062
11.3
19.6
18.7
50.4
Location
Urban
Rural
231,437
50,501
82.1
17.9
229,956
30,213
88.4
11.6
a
Table 3
Received home care services in Ontario, 2005/2007: Aged 20 and over by public
health unit.
Non-government funded home
care services
Total
199
Percent of total population aged 20 and over in Ontario.
coefficients are employed to estimate odds ratios for each of the
independent variables in the model. The objective is to identify the
significant factors influencing the use of home care in Ontario, be
they socio-economic, health or geographic.
2.1. Social and geographic characteristics of home care use in Ontario
2.1.1. Overall use
Table 2 provides a summary of home care use in Ontario. In
2005/07, approximately 282,000 people aged 20 and over received
government-funded home care services, representing 3% of the
total population in this age group. The majority of users were
women (61.5%) and seniors aged 65 or over (56.1%). The share of
government-funded home care services provided to urban and
rural residents essentially reflects the urban–rural population
distribution in Ontario: 82% urban and 18% rural. Table 2 also
shows that slightly fewer people, about 260,000 (2.7%), received
non-government funded services with a substantially higher
proportion of women receiving this type of home care (67.5%).
In addition, seniors (50.4%) and rural residents (11.6%) were less
likely to receive non-government funded home care than
government-funded services. In 2005/07, 57,532 people in
Ontario received both types of home care, representing 0.6% of
the population aged 20 and over, and 10% of total home care users.
Two-thirds (66%) of these dual users of home care were seniors.
2.1.2. Geography
The analysis of the CCHS data revealed a fairly even distribution of
home care provision across Ontario’s14 LHIN regions. However, a
more variable pattern of utilization emerged among the province’s 36
Public Health Unit (PHU) regions. Table 3 shows that PHUs with large
rural catchment areas had the largest proportions of governmentfunded home care users. These include Eastern Ontario and Leeds in
the eastern part of the province, Muskoka–Parry Sound and Haliburton in the north central part, and Chatham-Kent in southwestern
Ontario. The lowest use was apparent in the more heavily populated
urban regions of the Greater Toronto Area (Durham, York, Peel),
Hamilton and Niagara and in south central Ontario (Waterloo and
Brant). Fig. 1 shows the use of government-funded home care in
Ontario’s LHINs and PHUs. The map reflects the data in Table 3, which
clearly shows the highest rates of use (4–7%), were in the rural areas of
central and eastern Ontario, and in the southwestern portion of the
province. The lowest rates of use (1–3.9%) were in the regions of
Ottawa and Kingston in eastern Ontario, the Greater Toronto Area, and
in Windsor-Essex in the southernmost tip of the province.
Government-funded home care services
Highest use
Eastern Ontario
Muskoka-Parry Sound
Leeds, Grenville & Lanark District
Haliburton, Kawartha, Pine Ridge District
Chatham-Kent
9841
6366
7837
7800
4292
6.7
6.7
6.0
6.0
5.4
9092
13,976
6561
16,531
982
2.1
1.9
1.8
1.8
1.0
Non-government funded home care services
Highest use
Peterborough County-City
7177
Niagara Regional Area
21,600
Renfrew County & District
4510
Muskoka-Parry Sound
5972
Lambton
5965
7.1
6.6
6.3
6.3
6.2
Lowest use
Durham Regional
City of Hamilton
The District of Algoma
Huron County
Brant County
1.6
1.5
1.3
1.3
0.8
Lowest use
Durham Regional
York Regional
Waterloo
Peel Regional
Brant County
6824
5972
1121
556
1537
2.1.3. Home care use across the urban to rural continuum
A series of contingency tables were created to measure the
extent of home care use across four geographic areas (MIZ)
representing the urban to rural continuum. The results are presented in Figs. 2–8. Fig. 2 reveals that the use of government and
non-government funded home care services was fairly even in the
four zones with the Moderate MIZ having a slightly higher
proportion of users of each type of service. Figs. 3 and 4
illustrate the use of five types of government-funded home care
services. First, the use of nursing care (dressing changes, preparing
medications, etc.), was evenly distributed in three zones (CMA/CA,
Strong MIZ, Weak/No MIZ) but substantially higher in the Moderate
MIZ. Second, the use of personal care (e.g. bathing, foot care) was
less in the Weak/No MIZ. Third, possibly reflecting levels of
availability, the use of health services (e.g. physiotherapy,
nutrition counseling) dropped from urban to rural and was the
lowest in the Moderate MIZ and Weak/No MIZ. Fourth, there was no
difference in the four MIZ among people receiving housework
support (e.g. cleaning, laundry) as a type of government-funded
home care. Finally, as illustrated in Fig. 4, people residing in the
Weak/No MIZ were much more likely to receive meals (42%) than
their rural or urban counterparts.
Figs. 5 and 6 display the use of four types of non-government
funded home care, which was further subdivided into two
categories: (1) self-financed formal care, involving a nurse or
homemaker and (2) informal services, involving care from a
neighbour/friend or family member. Fig. 5 demonstrates that
when paying out-of-pocket, the use of a nurse or homemaker
dropped across the urban to rural continuum (from 7.5% in
CMA/CAs to 2.5% in the Weak/No MIZ for a nurse and from
14.7% in CMA/CAs to 10% in the Weak/No MIZ for a
homemaker). Fig. 6 shows a small difference in respondents
receiving home care from a relative or friend (19.5% in CMA/CAs
and 17.5% the Weak/No MIZ). However, Fig. 6 reveals a greater
200
P. Kitchen et al. / Health & Place 17 (2011) 195–206
Fig. 1. Received government home care services: Ontario, 2005/07 (precent of population aged 20 and over). Provincial total: 3.0%.
Percentage
5
4
4.5
3
2.8
2
3.8
3.7
3.2
3.2
2.8
3.1
1
0
Non-Government Funded Services
Government Funded Services
CMA/CA
Moderate MIZ
Strong MIZ
Weak or no MIZ
70
60
50
40
30
20
10
0
55.4
63.0
54.0
56.0
20.8
14.0
Nurse
20.2
16.2
12.0
Personal care
CMA/CA
Strong MIZ
Moderate MIZ
16.8
10.1
Health services
Weak or no MIZ
Fig. 3. Population aged 20 and over receiving government-funded home care services: Ontario, 2005/07 by place of residence.
50
Percentage
Percentage
Fig. 2. Population aged 20 and over receiving home care services: Ontario, 2005/07 by place of residence.
40
42.0
32.3
33.0
32.7
32.7
30
23.1
27.0
23.2
20
10
0
House work
CMA/CA
Strong MIZ
Meals
Moderate MIZ
Weak or no MIZ
Fig. 4. Population aged 20 and over receiving government funded home care services: Ontario, 2005/07 by place of residence.
12.2
P. Kitchen et al. / Health & Place 17 (2011) 195–206
14.7
16
Percentage
201
10.4
12
9.6
10.0
7.5
8
4.2
4
2.5
2.4
0
Nurse
CMA/CA
Homemaker
Strong MIZ
Moderate MIZ
Weak or no MIZ
Percentage
Fig. 5. Population aged 20 and over receiving non-government funded home care services: Ontario, 2005/07 by place of residence.
80
70
60
50
40
30
20
10
0
62.0
24.0
19.5
20.5
72.3
68.3
17.5
Neighbour/friend
CMA/CA
69.8
Family member
Strong MIZ
Moderate MIZ
Weak or no MIZ
Percentage
Fig. 6. Population aged 20 and over receiving non-government funded home care services: Ontario, 2005/07 by place of residence.
100
90
80
70
60
50
40
30
20
10
0
73.2
21.4
15.6
11.9
80.4
85.0
81.0
12.1
Informal
Self-Financed Formal Care
CMA/CA
Moderate MIZ
Strong MIZ
Weak or no MIZ
Fig. 7. Population aged 20 and over receiving non-government funded home care services: Ontario, 2005/07 by place of residence.
Percentage
25
21.6
20
24.4
22.3
16.7
15.6
12.8
15
19.6
16.7
10
5
2.0
1.8
2.0
1.9
0
Unmet needs
Care not rec'd: Not available in area
CMA/CA
Strong MIZ
Moderate MIZ
Care not rec'd: Cost
Weak or no MIZ
Fig. 8. Self-perceived unmet home care needs and reason why care not received population aged 20 and over: Ontario, 2005/07 by place of residence.
reliance on care from family members between urban and rural
areas (62% in CMA/CAs and 68.3% in the Weak/No MIZ). Fig. 7 is a
summary of the data presented in Figs. 5 and 6 and shows a clear
drop across the urban to rural continuum in the use of home care
services that were self-financed and an increased reliance on
informal care. These trends may reflect the inability of rural
residents to pay for some home care services and/or the lack of
availability of for-profit home care services in rural and
remote areas.
Fig. 8 shows that perception of unmet home care needs was
identical across the urban to rural continuum with about 2% of
respondents in each of the four zones reporting unmet needs.
However, when asked about the reasons for these unmet needs,
important differences were evident between urban and rural
residents. Far more rural residents reported that home care
services were not available in their area, particularly residents of
Moderate MIZ. (This CCHS question, however, does not distinguish
the type of unmet home care service). Interestingly, the cost of
202
P. Kitchen et al. / Health & Place 17 (2011) 195–206
Table 4
Sample characteristics for independent variables: population aged 20 and over in
Ontario (all respondents, n¼46,862) a.
Variable
Gender
Male
Female
Age
20–34
35–49
50–64
65 and over
Marital status
Single
Married/common Law
Separated/divorced
Widowed
Household income
Under $20,000
$20,000–$49,999
$50,000–$79,999
$80,000 and over
Education
Less than High School
High School
College/Trades Cert.
University
Self-rated health
Excellent/very good
Good
Fair/poor
Rural residence
Urban
Rural
Place of residence
CMA/CA
Strongly Infl. MIZ
Moderately Infl. MIZ
Weakly/Not Infl. MIZ
a
21,321 (45.5%)
25,541 (54.5%)
10,381
13,100
12,454
10,927
(22.2%)
(27.9%)
(26.6%)
(23.3%)
8686
27,906
5444
4824
(18.5%)
(59.5%)
(11.6%)
(10.3%)
5967
14,862
11,692
14,341
(12.7%)
(31.7%)
(24.9%)
(30.6%)
5904
8622
18,041
14,492
(12.6%)
(18.5%)
(38.5%)
(30.5%)
26,928 (57.5%)
13,210 (28.2%)
6724 (14.3%)
37,319 (79.6%)
9543 (20.4%)
36,638
3882
3814
2528
(78.2%)
(8.3%)
(8.1%)
(5.4%)
Missing cases (n ¼9938) were dropped for the regression analyses.
home care was cited as a factor for unmet needs far more frequently
among urban residents than those living in more rural and remote
areas of Ontario.
2.1.4. Determinants of home care use
A series of four logistic regression analyses was performed on
the pooled 2005/07 CCHS data to assess the most significant
determinants of home care use in Ontario. Each regression included
three models where the independent variables were phased into
the analysis. The sample characteristics of the eight independent
variables are listed in Table 4. The data are reflective of the entire
CCHS sample where there were higher proportions of female (55%);
married (60%) and university educated (30%) respondents
compared to the actual population. As shown in Table 4, only
one health variable (self-rated health) was included in the analysis.
Previous studies on home care (e.g. Hall and Coyte, 2001; Forbes
et al., 2003) included additional variables such as the presence of a
chronic condition and participation/activity limitation among
respondents. The first round of analysis for this paper included
these two variables. However, the results pointed to a high degree
of inter-correlation between self-rated health and the presence of a
chronic condition or participation/activity limitation. This finding
suggests that a person who rates his or her health as fair or poor is
likely to suffer from at least one chronic illness and to experience
some activity limitation. For this reason, the decision was made to
include self-rated health as the sole health-related variable in the
data analysis.
Table 5 shows the results of the first regression analysis where
respondents who received government-funded home care services
were treated as the dependent variable, with the independent
variables having significant odds ratios (po0.05 and 0.01) marked
with asterisks. Model 1 consists of five socio-economic and one
health variable. In Model 2, the urban–rural variable was added to
the analysis to test the effect of place of residence on the use of
government-funded home care. In Model 3, the urban–rural
variable was replaced by the variable denoting the four geographic
zones (MIZ) to determine the influence of distance from an urban
centre on the likelihood of receiving home care services. The results
indicate that older people were three times more likely (OR¼3.16)
to receive government-funded home care than people aged 20–34.
People in the lowest income households (under $20,000) were
nearly twice as likely (OR¼1.93) to receive government-funded
home care than those in the highest income households
($80,000+). People who rated their health as ‘Fair/Poor’ were 6
times more likely to receive government-funded home care than
those who reported ‘Excellent/Very Good’ health. Rural residents
(OR¼1.35) and those residing in the Moderate MIZ (OR¼1.31)
were more likely to receive government-funded home care services
than their urban counterparts.
Tables 6 and 7 display the results of two regression analyses
where the use of non-government funded home care was divided
into two categories: self-financed formal care (Table 6) and
informal services (Table 7). As shown in Table 1, the CCHS
includes a single question on non-government funded home care
and does not make a distinction between services which were paid
for, such as a nurse or homemaker, or which were provided by a
friend or family member. In an effort to reflect this important
difference, the original CCHS variable was re-coded to create
separate categories of non-government-funded home care. When
comparing the results of the two analyses (independent variables
with significant odds ratios) several important differences are
apparent. First, women and seniors were far more reliant on
home care services, which they paid for (Table 6) than on
informal services (Table 7). Second, people living in households
with lower incomes, particularly under $50,000, relied more on
informal services. Third, there was a marked difference in health
status, with people reporting ‘Fair/Poor’ health far more likely to be
dependent on informal services (OR¼9.62). Fourth, geography was
not a significant determinant of home care that was self-financed
but rural residents were more likely to receive home care from
informal caregivers (OR¼1.23).
Table 8 sheds light on the factors influencing perception of unmet
home care needs in Ontario. The CCHS question refers specifically to
home care services not received when needed. The regression
models suggest that this perception was strongest among women
(OR¼2.24), those aged 35–49 (OR¼1.81), and residents of households with income less than $50,000 (OR¼2.02 and 1.67). In
addition, respondents with a university education were more likely
to report unmet needs than those with a high school diploma
(OR¼0.57). Health was a factor in these perceptions, especially
among respondents reporting ‘Fair/Poor’ health (OR¼9.98). Finally,
place of residence and rurality did not influence perceptions of
unmet home care needs.
3. Discussion
The data analysis revealed several key findings with respect to
home care provision in Ontario. In 2005/07, 3% of residents aged 20
or over received some form of government-funded home care, 2.7%
received non-government funded services, and 0.6% received both
types. Most home care recipients were women and seniors.
Reflecting the province’s population distribution, the vast majority
P. Kitchen et al. / Health & Place 17 (2011) 195–206
203
Table 5
Odds ratios for receiving government-funded home care services: Ontario, age 20 and over, 2005/07.
Variable
Model 1
Model 2
Model 2
Male
Female
Age 20–34
Age 35–49
Age 50–64
Age 65 and over
Single
Married/common Law
Separated/divorced
Widowed
$80,000 and over
Under $20,000
$20,000–$49,999
$50,000–$79,999
University
Less than High School
High School
College/Trades Certif
Self-rated health
Excellent/very good
Good
Fair/poor
Rural residence
Urban
Rural
Place of residence
CMA/CA
Strongly influenced
Moderately influenced
Weakly/not influenced
Reference
1.28 (1.13-1.45)nn
Reference
0.93 (0.75–1.16)
1.10 (0.88–1.37)
3.16 (2.55–3.91)nn
Reference
1.34 (1.09–1.66)nn
1.12 (0.84–1.48)
2.08 (1.60–2.70)nn
Reference
1.93 (1.57–2.38)nn
1.38 (1.17–1.63)nn
1.07 (0.90–1.28)
Reference
0.90 (0.75–1.08)
0.87 (0.72–1.04)
1.34 (1.06–1.69)nn
Reference
1.29 (1.14–1.46)nn
Reference
0.93 (0.74–1.15)
1.08 (0.87–1.35)
3.14 (2.53–3.89)nn
Reference
1.32 (1.06–1.63)nn
1.12 (0.84–1.48)
2.07 (1.59–2.69)nn
Reference
1.92 (1.56–2.37)nn
1.37 (1.15–1.61)nn
1.06 (0.89–1.27)
Reference
0.90 (0.75–1.07)
0.87 (0.72–1.04)
1.33 (1.06–1.68)nn
Reference
1.28 (1.14–1.45)nn
Reference
0.93 (0.75–1.16)
1.09 (0.87–1.36)
3.15 (2.54–3.91)nn
Reference
1.33 (1.07–1.64)nn
1.12 (0.84–1.49)
2.07 (1.59–2.69)nn
Reference
1.91 (1.55–2.35)nn
1.36 (1.15–1.61)nn
1.06 (0.89–1.27)
Reference
0.90 (0.75–1.08)
0.87 (0.72–1.04)
1.34 (1.06–1.69)nn
Reference
1.80 (1.54–2.10)nn
6.16 (5.31–7.13)nn
Reference
1.81 (1.55–2.12)nn
6.23 (5.38–7.22)nn
Reference
1.81 (1.55–2.11)nn
6.18 (5.34–7.17)nn
Reference
1.35 (1.15–1.57)nn
Reference
1.18 (0.92–1.51)
1.31 (1.02–1.67)nn
1.04 (0.74–1.48)
95% CI in brackets.
nn
p o0.01.
Table 6
Odds ratios for receiving self-financed formal home care: Ontario, age 20 and over, 2005/07.
Variable
Model 1
Model 2
Model 3
Male
Female
Age 20–34
Age 35–49
Age 50–64
Age 65 and over
Single
Married/common Law
Separated/divorced
Widowed
$80,000 and over
Under $20,000
$20,000 to $49,999
$50,000 to $79,999
University
Less than High School
High School
College/Trades Certif.
Self-rated health
Excellent/very good
Good
Fair/poor
Rural residence
Urban
Rural
Place of residence
CMA/CA
Strongly influenced
Moderately influenced
Weakly/not influenced
Reference
2.59 (1.92–3.49)nn
Reference
1.55 (0.93–2.59)
1.66 (0.97–2.83)
5.07 (3.00–8.55)nn
Reference
1.07 (0.65–1.75)
1.43 (0.78–2.61)
2.21 (1.25–3.89)nn
Reference
1.15 (0.73–1.79)
1.01 (0.71–1.43)
0.84 (0.58–1.23)
Reference
0.71 (0.48–1.06)
0.55 (0.34–0.87)n
1.03 (0.60–1.75)
Reference
2.60 (1.93–3.51)nn
Reference
1.54 (0.92–2.58)
1.64 (0.96–2.80)
5.05 (2.99–8.53)nn
Reference
1.05 (0.64–1.72)
1.43 (0.78–2.62)
2.19 (1.24–3.87)nn
Reference
1.13 (0.72–1.78)
1.00 (0.71–1.42)
0.83 (0.57–1.22)
Reference
0.70 (0.47–1.05)
0.54 (0.34–0.86)n
1.03 (0.60–1.75)
Reference
2.58 (1.91–3.48)nn
Reference
1.55 (0.92–2.59)
1.67 (0.98–2.85)
5.09 (3.02–8.60) nn
Reference
1.08 (0.66–1.76)
1.43 (0.78–2.61)
2.21 (1.25–3.90) nn
Reference
1.17 (0.75–1.83)
1.03 (0.73–1.46)
0.85 (0.58–1.24)
Reference
0.72 (0.48–1.07)
0.55 (0.35–0.87)n
1.03 (0.60–1.76)
Reference
1.62 (1.18–2.23)nn
3.66 (2.66–5.03)nn
Reference
1.63 (1.18–2.24)nn
3.70 (2.69–5.09)nn
Reference
95% CI in brackets.
n
p o 0.05
p o0.01
nn
Reference
1.26 (0.89–1.78)
Reference
1.14 (0.64–1.92)
0.61 (0.29–1.28)
0.46 (1.55–1.37)
204
P. Kitchen et al. / Health & Place 17 (2011) 195–206
Table 7
Odds ratios for receiving informal home care: Ontario, age 20 and over, 2005/07
Variable
Model 1
Model 2
Model 3
Male
Female
Age 20–34
Age 35–49
Age 50–64
Age 65 and over
Single
Married/common Law
Separated/divorced
Widowed
$80,000 and over
Under $20,000
$20,000 to $49,999
$50,000 to $79,999
University
Less than High School
High School
College/Trades Certif.
Self-rated health
Excellent/very good
Good
Fair/poor
Rural residence
Urban
Rural
Place of residence
CMA/CA
Strongly influenced
Moderately influenced
Weakly/not influenced
Reference
1.54 (1.34–1.77)nn
Reference
0.90 (0.72–1.13)
0.83 (0.65–1.05)
1.73 (1.36–2.19) nn
Reference
1.13 (0.90–1.41)
1.28 (0.96–1.71)
2.11 (1.58–2.82)nn
Reference
1.70 (1.33–2.18)nn
1.86 (1.53–2.25)nn
1.44 (1.18–1.76)nn
Reference
0.94 (0.76–1.15)
0.70 (0.57–0.88)nn
1.18 (0.91–1.53)
Reference
1.55 (1.35–1.79)nn
Reference
0.90 (0.72–1.12)
0.82 (0.65–1.04)
1.72 (1.36–2.18)nn
Reference
1.11 (0.89–1.39)
1.28 (0.96–1.71)
2.10 (1.58–2.81)nn
Reference
1.70 (1.32–2.18)nn
1.85 (1.53–2.24)nn
1.44 (1.17–1.76)nn
Reference
0.93 (0.76–1.13)
0.70 (0.56–0.87)nn
1.18 (0.90–1.53)
Reference
1.55 (1.35–1.78)nn
Reference
0.90 (0.72–1.13)
0.83 (0.65–1.05)
1.73 (1.36–2.19)nn
Reference
1.11 (0.89–1.39)
1.28 (0.96–1.71)
2.10 (1.57–2.80)nn
Reference
1.68 (1.31–2.15)nn
1.83 (1.51–2.22)nn
1.43 (1.17–1.75)nn
Reference
0.92 (0.75–1.13)
0.70 (0.56–0.87)nn
1.18 (0.91–1.53)
Reference
2.41 (2.01–2.90)nn
9.62 (8.07–11.45)nn
Reference
2.42 (2.02–2.91)nn
9.69 (8.13–11.54)nn
Reference
2.42 (2.01–2.91)nn
9.67 (8.12–11.51)nn
Reference
1.23 (1.02–1.47)n
Reference
1.28 (0.98–1.68)
1.29 (0.97–1.71)
1.08 (0.73–1.60)
95% CI in brackets.
n
p o 0.05
p o0.01,
nn
of home care users (more than 80%) lived in urban areas. However,
rural residents were more likely than their urban counterparts to
receive government-funded home care, particularly nursing care.
With respect to non-government funded services, rural residents
were less likely to receive nursing care and were more reliant on
informal care provided by family members, relatives or friends.
This may suggest that skilled nursing services not funded by
government were less available to people living in rural areas or
that rural residents were less able to afford nursing services that
had to be purchased.
In terms of the socio-demographic, health and geographic
predictors of home care use, the data analysis revealed that the
use of government-funded home care was more prevalent among
women, seniors, the widowed, those with lower incomes and
poorer health and people residing in rural areas of Ontario. Two
types of non-government funded home care were examined (selffinanced formal services and informal services) and a similar set of
predictors were uncovered: women and seniors were more dependent on services that they paid for while those with lower income
and poorer health and people residing in rural areas were more
likely to receive informal care.
In total, about 6% of Ontario’s population aged 20 and over used
some form of home care in 2005/07. However, utilization of home
care services is expected to increase as the older population grows
in size and as deinstitutionalization and community-based care are
further promoted by the provincial government. Ontario’s ‘‘Aging
at Home Strategy’’, announced in 2007, indicates the province’s
intent to encourage Ontarians to age in place. Thus, it is opportune
to examine patterns of home care utilization—who the home care
users are, where are they located and what services they use. This
study pays special attention to the geographic patterns of home
care use—not only how rural and urban Ontarians differ in their use
of home care, but also differences in utilization by residents of
different types of rural areas. Pong et al. (2010) have identified
rural–urban differences in the way health services are used by
Canadians. However, that study focuses mostly on the use of
physician and hospital services that are covered by Canada’s
medicare system. This article complements the Pong et al.
(2010) study by revealing similar differences in home care use
between rural and urban Ontarians and between Ontarians living
in different regions. Insights gained from examining regional
variations in health care utilization patterns can help guide
policy-making and program planning. Another reason for paying
attention to rural residents’ home care utilization patterns stems
from the fact that rural Canadians tend to be older—those who are
more likely to need home care.
This study has shown that different regions of Ontario exhibited
different patterns of home care utilization. For instance, the highest
use of government-funded home care occurred in the eastern and
northern parts of the province and the lowest rates of use appeared
around the Greater Toronto Area. Thus, rather than adopting an
one-size-fits-all home care policy or program, Ontario should
encourage LHINs to adopt policies or design programs that best
fit their regional needs or preferences. Similarly, residents in
different types of rural areas use home care services differently.
For instance, residents in Moderate and Weak/No MIZ were less
likely to use nursing services that they have to purchase. Instead,
they rely more on informal care. There is a need for the provincial
ministry of health or LHINs, particularly those with large rural
catchment areas, to examine the reasons behind such disparities
and how home care-dependent residents living in the most
vulnerable areas can be supported. Informal care is an area that
has not received much public or government attention, possibly
because it is often considered to be a family matter and not a public
P. Kitchen et al. / Health & Place 17 (2011) 195–206
205
Table 8
Odds ratios for self-perceived unmet home care needs: Ontario, age 20 and over, 2005/07.
Variable
Model 1
Model 2
Model 3
Male
Female
Age 20–34
Age 35–49
Age 50–64
Age 65 and over
Single
Married/common Law
Separated/divorced
Widowed
$80,000 and over
Under $20,000
$20,000 to $49,999
$50,000 to $79,999
University
Less than High School
High School
College/Trades Certif
Self-rated health
Excellent/very good
Good
Fair/poor
Rural residence
Urban
Rural
Place of residence
CMA/CA
Strongly influenced
Moderately influenced
Weakly/not influenced
Reference
2.24 (1.93–2.61)nn
Reference
1.81 (1.44–2.28)nn
1.41 (1.10–1.81)nn
1.35 (1.03–1.77)n
Reference
0.74 (0.60–0.91)nn
1.10 (0.85–1.42)
1.61 (1.20–2.15)nn
Reference
2.02 (1.59–2.56)nn
1.67 (1.38–2.03)nn
1.22 (0.99–1.49)
Reference
0.84 (0.68–1.05)
0.57 (0.45–0.73)nn
1.09 (0.84–1.43)
Reference
2.25 (1.93–2.61)nn
Reference
1.81 (1.44–2.27)nn
1.41 (1.10–1.80)nn
1.35 (1.02–1.77)n
Reference
0.73 (0.59–0.90)nn
1.10 (0.85–1.42)
1.61 (1.20–2.15)nn
Reference
2.02 (1.59–2.56)nn
1.67 (1.38–2.03)nn
1.22 (0.99–1.49)
Reference
0.84 (0.68–1.05)
0.57 (0.45–0.73)nn
1.09 (0.84–1.42)
Reference
2.24 (1.92–2.60)nn
Reference
1.81 (1.44–2.27)nn
1.42 (1.12–1.81)nn
1.35 (1.03–1.77)n
Reference
0.74 (0.60–0.91)
1.10 (0.85–1.42)
1.61 (1.21–2.16)
Reference
2.03 (1.60–2.58)nn
1.68 (1.39–2.04)nn
1.22 (0.99–1.50)n
Reference
0.85 (0.68–1.06)
0.57 (0.45–0.73)nn
1.09 (0.84–1.42)
Reference
2.16 (1.79–2.61)nn
9.98 (8.37–11.89)nn
Reference
2.16 (1.79–2.61)nn
10.00 (8.3–11.9)nn
Reference
2.16 (1.79–2.61)nn
9.97 (8.36–11.8)nn
Reference
1.08 (0.89–1.31)
Reference
0.96 (0.71–1.32)
0.89 (0.64–1.25)
0.74 (0.46–1.19)
95% CI in brackets.
n
p o 0.05.
p o0.01.
nn
policy issue. But, as this and other studies have shown, informal
care and services provided by volunteers have a vital role to play in
supporting those who need care but have chosen to stay at home,
especially those who live in areas where formal services may be
scarce, unavailable or not affordable (Pong, 2009; Williams, 2006).
The paper described how Ontario went through a major
reorganization of its home care sector starting in the mid-1990s
with the creation of CCACs and the adoption of a mixed market
approach to the delivery of services. Nonprofit agencies were
forced to compete for home care contracts with private for-profit
operators. While the merits of this policy shift can be debated,
findings from this study suggest that managed competition works
reasonably well for patients and their families if they reside in or
close to urban areas. Overall, there is an acceptable range of
professional services (e.g. nurses, homemakers, therapists) that
are available—be they publicly funded or offered by the private
sector. Also, because of their higher socio-economic status, it is
likely that urban residents are better able to self-finance home care
services compared to their rural counterparts. However, we can
speculate that managed competition may not work as well in more
remote areas as market conditions in less populated areas may be
less congenial to private enterprises in home care services. This
may result in increased pressure on families, friends and volunteers
to provide informal care often in difficult conditions. The Ontario
government should consider providing more funding for nonprofit
home care agencies in rural areas with part of the funds used to
attract and retain health care professionals.
From a policy perspective, another aspect is equity in access to
health care. This is an important issue in the Canadian health care
system, particularly since accessibility is one of the five principles of
the Canada Health Act, which undergirds the national Medicare
system. Substantial regional disparities in utilization suggest
potential inequity in access to health care based on where people
live and their socio-economic status. This study has found considerable urban–rural and intra-rural variations in use of different types
of home care. Whether such regional variations constitute inequity
and the causes of such variations deserve further investigation.
From an international perspective, a parallel can be drawn
between Canada and other nations. For instance, several countries
in Western Europe reserve state funded health care services for
lower-income people and have invested heavily in home care
services. Countries such as Germany and the Netherlands have
created a single funding stream for home care (WHO, 2008). In a
recent paper, Szebehely (2009) compared resources for eldercare
services in Canada and Sweden. Sweden is one the most generous
countries in the world spending 2.74% of its GDP on eldercare
services compared to 0.99% on average in the OECD and in Canada.
Like Canada, there has been a growth in non-public eldercare
services in Sweden, although private sector involvement is still
comparatively small (Szebehely, 2009, p. 113).
There are a number of avenues for further research on home
care. One topic that warrants additional study is the effect of
managed competition on the availability and quality of home care
services in rural and remote regions. This could be achieved
through a research program which combines quantitative and
qualitative analysis. For example, survey data (e.g. CCHS) could be
analyzed of users of multiple types of home care (nonprofit, private
for-profit and informal) in a sample of Ontario’s northern and rural
LHINs and by metropolitan influence zone (MIZ). This analysis
would be complemented by a series of in-depth interviews with
officials at the local CCASs to acquire a better understanding of the
challenges of rural and remote home care delivery in a competitive
market setting. Such a study would have important policy implications for Ontario and could be used as the basis for international
206
P. Kitchen et al. / Health & Place 17 (2011) 195–206
research comparing the province to countries such as Sweden. In
addition to employing a mixed-market home care system, Sweden
also shares similar geographic characteristics with Ontario: vast
expanses of land, a harsh climate and sparsely populated regions.
References
Abelson, J., Tedford Gold, S., Woodward, C., O’Connor, D., Hutchinson, B., 2004.
Managing under managed community care: the experiences of clients, providers and managers in Ontario’scompetitive home care sector. Health Policy 68,
359–372.
Angus, J., Kontos, P., Dyck, I., McKeever, P., Poland, B., 2005. The personal significance
of home: habitus and the experience of receiving long-term home care.
Sociology of Health and Illness 27 (2), 161–187.
Aronson, J., Denton, M., Zeytinoglu, I., 2004. Market-modelled home care in Ontario:
deteriorating working conditions and dwindling community capacity. Canadian
Public Policy xxx (1), 111–125.
Armstrong, P., Armstrong, H., 2003. Wasting Away: The Undermining of Canadian
Health Care. Oxford University Press, Oxford.
Baranek, P.M., Deber, R., Williams, A.P., 1999. Policy trade-offs in ‘‘home care’’: the
Ontario example. Canadian Public Administration 42 (1), 69–92.
Baranek, P.M., Deber, B., Williams, A.P., 2004. Almost Home: Reforming Home and
Community Care in Ontario. University of Toronto Press, Toronto.
Bollman, R., Clemenson, H., 2008. Structure and change in Canada’s rural demography: an update to 2006 with provincial data. Statistics Canada, Ottawa. Cat.
no. 21-601-M-No. 90.
Canadian Health Care Association (CHCA), 2009. Home care in Canada: from the
margins to the mainstream, Ottawa. /www.cha.caS.
Canadian Home Care Association (CHCA). 2006. The delivery of home care services
in rural and remote communities in Canada. /www.cdnhomecare.caS.
Canadian Home Care Association (CHCA). 2008a. Portraits of home care in Canada.
Executive summary. /www.cdnhomecare.caS.
Canadian Home Care Association (CHCA). 2008b. A scan of options for delivering
home care in rural, remote and northern regions of Canada. Final report. /www.
cdnhomecare.caS.
Canadian Institute for Health Information (CIHI). 2008. Reducing gaps in health: a
focus on socio-economic status in urban Canada, Ottawa, Ontario.
Carrie re, G., 2006. Seniors’ use of home care. Health reports, 17, 4, Statistics Canada,
Catalogue 82-003.
Chapell, N., Schroeder, B., Gibbens, M., 2008. Respite for rural and remote caregivers.
In: Keating, N. (Ed.), Rural Ageing: A Good Place to Grow Old?. The Policy Press
Bristol, pp. 53–62.
Cloutier-Fisher, D., Skinner, M.W., 2006. Levelling the playing field? Exploring the
implications of managed competition for voluntary sector providers of longterm care in small town Ontario. Health & Place 12, 97–109.
Côté, A., Fox, G., 2007. The Future of Homecare in Canada. Roundtable Outcomes and
Recommendations for the Future. Public Policy Forum, Ottawa.
DesMeules, M., 2006. How Healthy are Rural Canadians? An Assessment of their
Health Status and Health Determinants. Canadian Institute for Health Information, Ottawa, Ontario.
Doran, D., Pickard, J., Harris, J., 2007. The relationship between characteristics of home
care nursing service contracts under managed competition and continuity of care
and client outcomes: evidence from Ontario. Health Care Policy 2 (4), 97–113.
Du Plesssis, V., Beshiri, R., Bollman, R., Clemenson, H., 2002. Definitions of ‘‘rural’’.
Statistics Canada, Ottawa. Cat. no. 21-601-MIE-No. 061.
England, K., Eakin, J., Gastaldo, D., McKeever, P., 2008. Neoliberalizing home care:
managed competition and restructuring home care in Ontario. In: England, K.,
Ward, K. (Eds.), Neoliberlization: States, Networks, Peoples. John Wiley & Sons,
Oxford, pp. 169–194.
Forbes, D., Stewart, N., Morgan, D., Anderson, M., Parent, K., Janzen, B., 2003.
Individual determinants of home-care nursing and housework assistance. CJNR
35 (4), 14–36.
Forbes, D., Janzen, B., 2004. Comparison of urban and rural users and non-users of
home care in Canada. Journal of Rural Medicine 9 (4), 227–235.
Forbes, D.A., Edge, D.S., 2009. Canadian home care policy and practice in rural and
remote settings: challenges and solutions. Journal of Agromedicine 14,
119–124.
Hall, R., Coyte, P., 2001. Determinants of home care utilization: who uses home care
in Ontario? Canadian Journal on Aging 2 175–192.
Health Council of Canada, 2008. Fixing the Foundation: an Update on Primary Health
Care and Home Care Renewal in Canada. Health Council, Toronto /www.
healthcouncilcanada.caS.
Kirby, M.J.L., LeBreton, M., 2002. The Health of Canadians—The Federal Role,
vol. 6. Recommendations for Reform. Standing Senate Committee on Social
Affairs, Science and Technology, The Senate, Parliament of Canada, Ottawa,
Ontario.
Kotecha, J.A., Birtwhistle, R.V., 2009. Fast facts: National Physician Survey. Access to
home care. Canadian Family Physician 54, 1702.
Kulig, J.C., 2010. Rural health research in Canada: assessing our progress. CJNR 42 (1),
7–11.
Mitchell, L., Strain, L., Blandford, A., 2006. Indicators of home care use in urban and
rural settings. Canadian Journal on Aging 26 (3), 275–280.
Pong, R., 2009. What would happen if informal caregivers go on strike? Unpublished
report prepared for the Change Foundation.
Pong, R., et al., 2010. Patterns of health services utilization in rural Canada. Chronic
Diseases in Canada 30 (Suppl. 1), 1–36.
Randall, G.E., Williams, A.P., 2006. Exploring limits to market-based reform:
managed competition and rehabilitation home care services in Ontario. Social
Science and Medicine 62, 1594–1604.
Randall, G.E., Williams, A.P., 2009. Health-care reform and the dimensions of
professional autonomy. Canadian Public Administration 52 (1), 51–69.
Romanow Report. Commission on the Future of Health Care in Canada, 2002.
Building on Values: The Future of Health Care in Canada. Government of Canada,
Ottawa.
Seggewiss, K., 2009. Variations in home care programs across Canada demonstrate
need for national standards and pan-Canadian program. CMAJ 180 (12), 90–91.
Sims-Gould, J., Matin Matthews, A., 2008. Distance, privacy and independence: rural
homecare. In: Keating, N. (Ed.), Rural Ageing: A Good Place to Grow Old? The
Policy Press, Bristol, pp. 43–52.
Szebehely, M., 2009. Are there lessons to learn from Sweden? In: Armstrong (Ed.),
A Place to Call Home. Long-Term Care in Canada. Halifax & Winnipeg, Fernwood
Publishing, pp. 111–118.
Thomas, S., Wannell, B., 2009. Combining cycles of the Canadian Community Health
Survey. Health Reports 20, 1, Statistics Canada, Catalogue no. 82-003-XPE.
Williams, A., 1996. The development of Ontario’s Home Care Program: a critical
geographic analysis. Social Science and Medicine 42 (6), 937–948.
Williams, A.M., 2006. Restructuring home care in the 1990s: geographical differentiation in Ontario, Canada. Health & Place 12, 222–238.
Wilkins, K., 2006. Government subsidized home care. Health Reports 17(4), 39–42.
Statistics Canada catalogue 82-003.
Wilson, D.M., Fillion, L., Thomas, R., Justice, C., 2009. The ‘‘good’’ rural death: a report
of an Ethnographic study in Alberta, Canada. Journal of Palliative Care 25 (1),
21–29.
Woodward, C.A., Abelson, J., Tedford, S., Hutchison, B., 2004. What is important to
continuity in home care? Perspectives of key stakeholders. Social Science and
Medicine 58, 177–192.
World Health Organization (WHO), 2008. Home care in Europe: the solid facts.
Zeytinoglu, I., Denton, M., Davies, S., Millen Plenderleith, J., 2009. Casualized
employment and turnover intention: home care workers in Ontario, Canada.
Health Policy 91, 258–268.