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The professional claims and struggles involved in the design of non-traditional health care places are rarely problematized in applied health research, perhaps because they tend to fade away once the new design is implemented. This paper offers insights into such professional tensions and their impact on health care delivery by examining the design of two dialysis service delivery models in Quebec, Canada. The satellite units were hosted in two small hospitals and staffed by recently trained nurses. The mobile unit was a bus fitted to accommodate five dialysis stations. It was staffed by experienced nurses and travelled back and forth between a university teaching hospital and two sites. In both projects, nephrologists supervised from a distance via a videoconferencing system. In this paper, we draw mainly from interviews with managers (mostly nurses) and physicians (n = 18), and from on-site observations. Nephrologists, medical internists, and managers all supported the goal of providing 'closer-to-patient' services. However, they held varying opinions on how to best materialize this goal. By comparing two models involving different clinical and spatial logics, we underscore the ways in which the design of non-traditional health care places opens up space for the re-negotiation of clinical norms. Instead of relatively straightforward conflicts between professions, we observed subtle but inexorable tensions within and beyond professional groups, who sought to measure up to 'ideal standards' while acknowledging the contingencies of health care places. Keywords: Design; Professionalization; Place; Health technology; Dialysis; Closer-to-patient services; Normativity; Canada

A clear emphasis on the patient's view is discernible in the health services research literature of the past decades. Such a switch to patients' perspectives has been greatly facilitated by a wider acceptance and use of qualitative methods. In particular, focus groups are often used to uncover the range and depth of experiences of health services users and chronically ill individuals. Although this method contributes to a better understanding of patients' perspectives and practices, a number of analytical considerations have been overlooked. The aim of this paper is to consider how to conceptualise and analyse interactions in focus group research. We argue that focus groups are social spaces in which participants co-construct the 'patient's view' by sharing, contesting and acquiring knowledge. Focus groups conducted with home care patients in Quebec, Canada (on antibiotic intravenous therapy, parenteral nutrition, peritoneal dialysis and oxygen therapy) are used to illustrate three interactive processes at work in focus groups: (1) establishing oneself as experienced and knowledgeable; (2) establishing oneself as in search of information and advice; and (3) validating or challenging one another's knowledge claims. We develop an analytical template focused on the subtle dynamics underpinning the various and at times competing claims of patients. This template acknowledges the processes through which participants attribute authority to the claims of others, including the focus group moderator. We find that focus group research does not derive epistemological authority simply from the identity of its participants. Rather, an emerging consensus about what constitutes the patient's view is the result of context-dependent social interactions that need to be scrutinised. Keywords: Patient's perspectives; Focus group methodology; High-tech home care; Experiential knowledge; Canada

Social capital has been the focus of considerable academic and policy interest in recent years. Despite this interest, the concept remains undertheorized: there is an urgent need for a critical engagement with this literature that goes beyond summary. This paper lays a foundation for a critical dialogue between social capital and health promotion, by examining problematics in the conceptualization and practice of social capital building and linking these to models of community development, a cornerstone health promotion strategy. In so doing, the paper contributes to the existing literature by providing a theoretical exposition and critique of various threads in social capital discourse, and linking these threads explicitly to community development practice. Distinctions between communitarian, institutional and critical approaches to social capital are elaborated, and the relationships between these three approaches and three models of community development--social planning, locality development, and social action--are discussed. The existing social capital literature is then critically examined in relation to three key themes common to both literatures: community integration, public participation, and power relations. This examination suggests that social capital cannot be conceived in isolation from economic and political structures, since social connections are contingent on, and structured by, access to material resources. This runs counter to many current policy discourses, which focus on the importance of connection and cohesion without addressing fundamental inequities in access to resources. This paper posits that approaches to community development and social capital should emphasise the importance of a conscious concern with social justice. A construction of social capital which explicitly endorses the importance of transformative social engagement, while at the same time recognising the potential negative consequences of social capital development, could help community organizers build communities in ways that truly promote health. Keywords: Social capital; Health promotion; Community development

The rapid growth of the Internet is increasingly international with young people being the early adopters in most countries. However, the quality of Internet access looms as a major barrier hidden behind Internet use statistics. The goal of this study was to provide an in-depth evaluation of young people's perspectives on using the Internet to obtain health information and resources (e-health). Using an inductive qualitative research design, 27 focus groups were conducted in Ontario, Canada. The 210 young participants were selected to reflect diversity in age, sex, geographic location, cultural identity and risk. A major finding was how the quality of Internet access influenced young people's ability to obtain health information and resources. Quality of Internet access was affected by four key factors: 1. Privacy, 2. Gate-keeping, 3. Timeliness and 4. Functionality. Privacy was particularly relevant to these young people in getting access to sensitive health information (e.g. sexual activities). Variations in access quality also impacted participation in mutual support, fostering social networks and getting specific health questions answered. These results serve as a warning about using Internet penetration statistics alone as a measure of access. Concerted attention is needed on improving the quality of Internet access for achieving the potential of e-health. This is imperative for addressing the digital divide affecting populations both within countries and globally between countries. Keywords: Internet; Telemedicine; Health promotion; Young people; e-Health

In this paper we examine the recent ascendancy of a 'population health' perspective on the 'determinants of health' in health policy circles as conceptualized by health economists and social epidemiologists such as Evans and Stoddart [Evans and Stoddart (1990) Producing health, consuming health care. Social Science & Medicine 31(12), 1347-1363]. Their view, that the financing of health care systems may actually be deleterious for the health status of populations by drawing attention away from the (economic) determinants of health, has arguably become the 'core' of the discourse of 'population health'. While applauding the efforts of these and other members of the Canadian Institute for Advanced Research for 'pushing the envelope', we nevertheless have misgivings about their conceptualization of both the 'problem' and its 'solutions', as well as about the implications of their perspective for policy. From our critique, we build an alternative point of view based on a political economy perspective. We point out that Evans and Stoddart's evidence is open to alternative interpretations-and, in fact, that their conclusions regarding the importance of wealth creation do not directly reflect the evidence presented, and are indicative of an oversimplified link between wealth and health. Their view also lacks an explicit substantive theory of society and of social change, and provides convenient cover for those who wish to dismantle the welfare state in the name of deficit reduction. Our alternative to the 'provider dominance' theory of Evans and Stoddart and colleagues stresses that the factors or forces producing health status, which Evans and Stoddart describe, are contained within a larger whole (advanced industrial capitalism) which gives the parts their character and shapes their interrelationships. We contend that this alternative view better explains both how we arrived at a situation in which health care systems are as costly or extensive as they are, and suggests different policy avenues to those enunciated by Evans, Stoddart and their confreres. Key words - inequities in health, population health, health care

Calls for household surveys to provide information on service utilization in less developed countries raise questions regarding the accuracy and reliability of reporting. This paper compares reported to recorded health service utilization for diarrhoea and any other morbidity over a 2-week and 3-month period for information obtained from a household survey in Grenada, West Indies. A sensitivity analysis is used to derive minimum and maximum estimates of the accuracy of reported utilization. Over-reporting utilization was found to be between 33 and 62% for diarrhoea and 49 and 81% for any other morbidity. Under-reporting of all utilization was estimated to be between 47 and 65%. These results cast doubt on the utility of household surveys as a reliable source of information regarding service utilization.

Examines the ascendancy of the `population health' perspective on the determinants of health, while highlighting the role of economics and social status on the acquisition of adequate health care. Reference to some of the social determinants of health status; Details on the ratio of health care expenditures to the gross national product.