Qualitative Research on Health Professionals' Awareness and Perceptions of Heat Health Issues and Health Canada Materials: Report on Qualitative Findings Fall 2017

Submitted to:
DEPARTMENT OF HEALTH/PHAC
HC.cpab.csims.internal-interne.sgici.dgcap.SC@canada.ca

Prepared by:
Leger

Ce rapport est aussi disponible en français.

EP363-140000-012- Series C Qualitative
Contract Number HT372-173310/001/CY
POR number: 027-17
Awarded September 22, 2017
Project 14224-003
March 23, 2018

Table of contents

• Executive Summary
  • 1.1 Background and Objectives
  • 1.2 Methodology
  • 1.3 Overview of Qualitative Findings
  • 1.4 Note on the Interpretation of Research Findings
  • 1.5 Political Neutrality Statement and Contact Information
• Appendix A - Recruitment Guide
• Appendix B - Discussion Guide: Study of Health Professionals' Awareness and Perceptions of Heat Health Issues and Health Canada Materials
• Appendix C - Links to Health Canada's Material

Executive Summary

Leger is pleased to present Health Canada with these findings from a series of focus groups on the awareness and perceptions of heat issues and Health Canada Materials on the subject. This report was prepared by Leger, the research firm contracted by the Department of Health/PHAC (contract number: HT372-173310/001/CY, awarded September 22, 2017).

1.1 Background and Objectives

Via funding allocated through the 2016 and 2017 Budgets, the Climate Change and Innovation Bureau is mandated to (a) increase Canadians' knowledge, capacity, and tools related to climate change and its associated health risks, and (b) increase Canadians' resiliency to extreme heat. Specific responsibilities include developing and disseminating heat health information and training to our key target audiences: healthcare and public health professionals.

Many materials and heat health guidelines have been developed by the Bureau, including a number of guidelines for extreme heat events (designed for health professionals), and more general brochures (designed for the public). At present, there is a need to evaluate their utility more systematically, and to ensure the most effective materials are provided. It is important to confirm that any Health Canada (HC) materials used by health professionals are not only meeting their needs, but also effective in transmitting accurate and appropriate information to their patients with respect to health protection measures related to extreme heat. By gathering qualitative information from front-line health professionals (e.g. family physicians), the Bureau will be able to (a) assess perceptions and awareness of heat health issues and HC's heat program, (b) better understand any associated behaviors (e.g. distribution/use of HC materials, and advice given to patients), and (c) gather specific feedback on HC extreme heat publications in order to identify strengths, weaknesses, and areas in need of updating.

Specifically, the qualitative research objectives were to:

• assess perceptions and awareness levels of heat health issues and Health Canada's heat program;
• gain a better understanding of the distribution and use of Health Canada's heat health materials by family physicians;
• understand any concerns from family physicians related to the heat health of their patients;
• understand and examine any barriers family physicians encounter when transferring heat health information to their patients; and
• gather feedback on Health Canada's extreme heat publications in order to identify strengths, weaknesses, and areas in need of updating.

1.2 Methodology

Methodology

As outlined in the Statement of Work, a total of eight (8) "mini" groups were conducted in four (4) different cities: Montreal, Toronto, Halifax, and Vancouver (i.e. two "mini" groups per city). Groups were comprised of family physicians, reflecting a good mix of age, gender, and area of specialty. Physicians who took part in the groups had an average of 20 years of experience; some participants had over 30 years of experience, while others were just starting in the profession (i.e. one candidate had two years of experience). Most of the doctors were generalists practicing in a clinic or in a hospital, but some had a specialty, such as gerontology, chronic pain, pediatrics, dietetics, travel medicine, palliative care, mental health, or immigrant health. Wherever possible, groups were held in professional facilities equipped a one-way mirror.

Recruitment

Leger was responsible for participant recruitment. Leger recruited five (5) physicians for each group to ensure that at least three (3) showed up. The recruitment screener (see Appendix A) was developed by Leger in collaboration with the project authority so that the physician profiles clearly matched the research objectives.

The recruitment screener informed participants of all their rights under Canada's Privacy legislation and the Standards for the Conduct of Government of Canada Public Opinion Research. Specifically, their confidentiality was guaranteed, their participation was voluntary, and the results of the research would be made available to the public through Library and Archives Canada.

General practitioners were selected from a physician panel at Consumer Vision (a wholly owned subsidiary of Leger, which was responsible for all of the qualitative work). If, however, the panel had proved insufficient in one city or another, random calling from available lists of GPs could have been used to supplement panel recruiting.

Incentive

Participants received an honorarium of $200. Participant incentive payment signature sheets were used, and a summary outlining (a) the total number of participants, and (b) the corresponding incentives paid, was completed and signed by each focus group host. These sheets (with family names removed to protect participants' confidentiality) were submitted to Health Canada.

Locations and dates

The following locations and dates were finalized in conjunction with the project authority. Evening groups were held between 5:30PM (first group) and 7:30PM (second group).

Moderation

Groups lasted approximately 90 minutes, and were conducted in English (except in Montreal, where the groups were conducted in French).

1.3 Overview of Qualitative Findings

Extreme heat is relatively important, yet not a vital issue for physicians

• Though relatively important, extreme heat is not viewed as a major problem. It is, however, expected to grow in importance in the coming years because of global warming. As such, physicians expect that climate change will have a direct impact on this issue in Canada.
• The subject of extreme heat isn't a priority for family doctors. They do not have enough time to think about it, and since they believe it's a very rare problem, they don't consider it to be an issue in their daily practices. They mentioned that other professionals in the health care system, such as emergency physicians and responders, nurses, home care workers, and pharmacists, should be more preoccupied with this phenomenon, compared to the average physician working in a clinic.
• Physicians don't immediately think about doing prevention, but when they do, it is mostly to advise patients who intend to travel. Even then, physicians tend to focus on hydration and putting on sunscreen, while neglecting to address the specific effects of heat. They don't advise on how to keep a home cool, ways to cool off the body, or other types of information that can be found in the documents reviewed in the "mini" groups.
• Physicians who practise in coastal regions (like Halifax or Vancouver) tend to think there are more cases of extreme heat in central Canada, and downplayed the effects of heat for their patients and region. In turn, physicians practising in central Canada did not feel extreme heat was a major issue, like it would be in warmer countries. As a result, the degree of the problem was minimized in every group because participants tended to compare themselves with other, warmer regions.
• In all four cities, physicians usually believed they had underestimated the risks and impact of heat on their patients' health AFTER reading the Health Canada documentation sent to them for review prior to the discussions.

Health Canada's role in broadcasting information about Extreme Heat was unknown to participants

• Participants had never seen the Health Canada documents on extreme heat presented to them prior to coming to the groups. They also hadn't received any other communications about the issue from other sources. For most participants, the Health Canada documents were the first official pieces of information they could remember seeing that addressed the issue of heat illness.
• Some said they do not understand why Health Canada is working on the matter of extreme heat, as it is a matter that should be addressed by each Canadian province, while others would like to have more information about it - and/or even training - as this problem will likely grow over time (although they did not mention what kind of training they would like).
• Most physicians believed that among the documents reviewed, the factsheets were particularly important, and needed to be distributed or made available to all health care workers. Many compared these documents to the important and valuable information they receive in the fall about the upcoming flu season.

Succinct documents will be used mostly as a reference

• Physicians found the documents to be a good reminder, and could be useful as a reference, but they were too lengthy and not clearly targeted to them. To feel targeted, the documentation needs to be short, simple, and clear, and contain calls-to-action, color, statistics, graphs and charts, and a list of symptoms that they can easily and quickly review.

Prioritizing other health care workers and facility managers before physicians

• Physicians feel that the information in the documents should be targeted to other health care workers and facility managers before being sent to them. Nurses, paramedics, social workers, and other home care workers would be more likely to see a patient showing signs and symptoms of heat stroke or exhaustion; as such, the factsheets would be more vital to them. On the preventative medicine side, physicians generally feel pharmacists would play a key role in educating patients about which medication classes are directly impacted by heat. Pharmacists are not only qualified to understand how heat will affect certain patients (depending on what they are prescribed), they're also more likely to talk to patients on a regular basis. However, having pharmacists hand out information can be counterproductive for some physicians, as some patients tend to be "scared" by pharmacists' warnings and then do not follow their treatment plan, or decide to stop treatment on a hot day.
• To physicians, extreme heat is a "public health" issue, not primarily a physician issue. They believe that public education is important, and that a great way to reach the population would be through public service announcements in traditional media or at the time of issuing Environment Canada warnings (in the form of tips and reminders about what to do). Physicians believe extreme heat is an issue that should be talked about by physicians and health professionals, yes, but by everyone else, as well: it is everyone's responsibility to know what to do in case of extreme heat.

Language barriers may be the biggest obstacle in reaching all Canadians

• Language barriers due to immigration represent a major potential obstacle preventing the population from being well informed about heat illness. Often, recent immigrants are misinformed about Canada's climate and put themselves at risk without even knowing it, or even knowing what they could do in case of an emergency. This information could be especially important to recent immigrants who come from warmer countries because they tend to downplay the effect and nature of heat in Canada.

The elderly and infants are the most vulnerable, but extreme heat is mainly driven by socio-economic factors and social isolation

• In terms of age, physicians recognize that those most at risk are the old and the young, but the discussion on primary targets soon focused on socio-economic factors that lead to a greater risk of heat illness, such as older buildings that do not offering air conditioning, social isolation, and a lack of nearby cooling areas.

Regional differences

• It should be noted that if the report does not directly name a region or directly reports a noticeable difference between locations, the reader should assume that no significant regional differences were apparent. As such, much of this report will be from a national perspective.

1.4 Note on the Interpretation of Research Findings

The views and observations expressed in this document do not reflect those of the Department of Health/PHAC. This report was compiled by Leger and based on the research conducted specifically for this project. The analysis presented represents what Leger believes were the most salient points during the focus group sessions. All words and sentences in quotation marks are actual verbatim comments from participants, selected by Leger for their capacity to directly convey the views and opinions of participants, in their own words.

Findings from these the focus groups should be considered directional only, and results should not be projected as representative of the entire Canadian population. It is intended to provide deeper insight into the underlying reasons for opinions or lack thereof.

1.5 Political Neutrality Statement and Contact Information

Leger certifies that the final deliverables fully comply with the Government of Canada's political neutrality requirements outlined in the Communications Policy of the Government of Canada and Procedures for Planning and Contracting Public Opinion Research.

Additional information

Supplier name: Leger
PWGSC Contract Number: HT372-173310/001/CY
Contract Award Date: September 22, 2017
The contract value for this project is $42,990.00 (excluding HST).

To obtain more information on this study, please email HC.cpab.csims.internal-interne.sgici.dgcap.SC@canada.ca

Christian Bourque, Executive Vice-President and Associate

Appendix A - Recruitment Guide

Public Opinion Research: Study of Health Professionals' Awareness and Perceptions of Heat Health Issues and Health Canada Materials - 2017

Hello, my name is [name] from Leger Research. We are conducting a series of focus group discussions with family physicians' behalf of Health Canada. The research is related to health issues of concern to all Canadians and we think that you'll find the topic interesting.

Your participation in the research is completely voluntary and the purpose is to understand the opinions and experiences of Canadians not to sell any service or product.

The sessions will be audio and video recorded for research purposes. Representatives of Health Canada will also be observing the discussions. The information is being collected under Section 4 of the Department of Health Act and other applicable privacy laws. The full names of participants will not be provided to the government or any other third party. Also, the results from the discussions will be grouped together in a report, which will contain non-identifying information. Would you be interested in participating?

• Yes Continue to Q1
• No Terminate call

Recruitment

1. Group 1 : Montreal, Monday, November 27th - 17h30
2. Group 2 : Montreal, Monday, November 27th - 19h30
3. Group 3 : Toronto, Tuesday, November 28th - 17h30
4. Group 4 : Toronto, Tuesday, November 28th - 19h30
5. Group 5 : Halifax, Wednesday, November 29th - 17h30
6. Group 6 : Halifax, Wednesday, November 29th - 19h30
7. Group 7 : Vancouver, Monday/ Tuesday, December 4th/5th - 17h30
8. Group 8 : Vancouver, Monday/ Tuesday, December 4th/5th - 19h30

Q-1 Do you or any member of your household or immediate family currently work for?

TICK ALL THAT APPLY

• Advertising company 1 TERMINATE
• Marketing/Market Research company 2 TERMINATE
• A pharmaceutical company 3 TERMINATE
• A biotechnology Company 4 TERMINATE
• A government healthcare agency 5 TERMINATE
• None of the above / Aucune de ces réponses 6
• I prefer not to answer 9 TERMINATE

INDICATE GENDER, PLEASE TRACK WITHOUT ASKING DO NOT ASK

Q-2 Gender

• Men 1
• Women 2

Q-3 What age group do you belong to?

• Under 25 1
• Between 25 and 34 2
• Between 35 and 44 3
• Between 45 and 54 4
• Between 55 and 64 5
• 65 and older 6
• I prefer not to answer 9 TERMINATE

Q-4 Which of the following medical sub-specialties do you practise?

• Family Practice/ General Practice 1
• Internal Medicine 2
• Endocrinology 3
• Sports and exercise medicine 4
• Gerontology 5
• Environmental Health 6
• Pediatrics 7
• Emergency medicine 8
• Immigrant health 9
• Indigenous/Aboriginal health 10
• Respirology 11
• Cardiology 12
• I prefer not to answer 99 TERMINATE

Q-5 Approximately how many years have you been practising medicine, post fellowship in Canada?

• Less than 10 years 1
• More than 10 years 2
• I prefer not to answer 9 TERMINATE

Q-6 Is your medical practice located in an urban or a suburban area?

• Urban (i.e. located within the city) 1
• Suburban (i.e. located immediately outside the city) 2
• I prefer not to answer 9 TERMINATE

Q-7 Do you have experience using Health Canada heat health publications and information to advise or treat patients?

• Yes 1
• No 2
• I prefer not to answer 9 TERMINATE

Q-8 Can you tell approximately, what is the percentage of your practice are…

• Young children? 1
• Elderly? 2
• Women? 3
• New Canadians? 4
• Indigenous/Aboriginal Persons? 5
• Other? 6
• Refusal 96

Q-9 Which of the following ethnic groups do you consider yourself to be a part of?

• White 1
• Chinese 2
• South Asian (e.g. East Indian, Pakistani, Sri Lankan, etc.) 3
• Black 4
• Filipino 5
• Latin American 6
• Southeast Asian (e.g. Cambodian, Indonesian, Laotian, Vietnamese, etc.) 7
• Arab 8
• West Asian (e.g. Afghan, Iranian, etc.) 9
• Japanese 10
• Korean 11
• Other / Refusal 96

Invitation

We are thrilled to have you as one of our participants in this study; your profile perfectly fits the target respondent we are looking for. We would like to invite you to participate in a focus group which will be facilitated by an experienced professional moderator, and will last approximately 90 minutes. The session will take place at [location], on [date/time].

For your participation in the in facility you will receive a cash gratuity of $[amount].

Please note that the session will be video and audio recorded and may be video-streamed (see definition below). Your interview may also be observed by people who are directly working on the research study.

Video-streaming for this project is defined as a sequence of images sent over a secure, encrypted internet connection to those directly working on the research study.

Are you interested in participating in this research study?

• Yes
• No TERMINATE

The information provided by you will be kept confidential and will only be disclosed to those who are directly working on the research that is relevant to the topic of discussion.

Representatives of our client may be observing the discussion, but will not have access to any of your private information. You will be asked to sign a consent form in order to participate in this research. Would you be willing to do this?

• Yes
• No TERMINATE

Thank you very much for your collaboration!

Take the doctor's email address, we will have to send him Health Canada documents, which will be used as a basis for the discussion.

We kindly ask them to read it before the discussion session.

• Doctor's information:
• E-mail :

Appendix B - Discussion Guide: Study of Health Professionals' Awareness and Perceptions of Heat Health Issues and Health Canada Materials

2017/11/15

Introduction (10 MINS)

• Introduce moderator and welcome participants to the focus group.
• As we indicated during the recruiting process, we are conducting focus group discussions on behalf of the Government of Canada (Health Canada).
• The focus of tonight's discussion is to get your perception and opinion regarding heat health issues as well as your opinion on Health Canada's materials (Extreme Heat Events Guidelines: User Guide and Technical Guide and associated Fact Sheets for Health Care Workers) on this topic.
• The discussion will last approximately 90 minutes.

Explanation

• Other people who are also involved in this study will be listening to the focus groups. My colleague - who is an analyst at Leger - will be taking notes.
• It is also important for you to know that your responses today will in no way affect your dealings with the Government of Canada.
• Confidentiality - Please note that anything you say during these groups will be held in the strictest confidence. We do not attribute comments to specific people. Our report summarizes the findings from the groups but does not mention anyone by name. The report will be available through Library and Archives Canada.
• We are going to take attendance for your incentive and to certify that you have participated.

Describe how a discussion group functions:

• Discussion groups are designed to encourage an open and honest discussion. My role as a moderator is to guide the discussion and encourage everyone to participate. Another function of the moderator is to ensure that the discussion stays on the topic and on time.
• Your role is to answer questions and voice your opinions. We are looking for all opinions in a focus group, so don't hold back if you have a comment, even if you feel your opinion may be different from others in the group. There may or may not be others who share your point of view. Everyone's opinion is important and should be respected.
• I would also like to stress that there are no wrong answers. We are simply looking for your opinions and attitudes. This is not a test of your knowledge. We did not expect you to do anything in preparation for this group.
• It is also important that you talk loud enough for everyone to hear and that you talk one at a time so I can follow the discussion.

Please note that I am not an employee of the Government of Canada and may not be able to answer all of your questions.

• Moderator introduces herself/himself.
• Participants should introduce themselves, using their first names only.
• Which medical subspecialities do you practise? How many years have you been practising medicine? Where is your medical practice located? What kinds of patients do see in your practice?

As stated earlier, the objectives of today's focus group are to better understand your opinion and perception regarding heat health issues and your opinion regarding Health Canada materials on this issue.

Section 1: Perceptions and Awareness of Heat Health issues and Health Canada's Heat Program (20 MINS)

• Before e-mailing the material to you for the review for the focus group discussion, were you aware of Health Canada's material regarding heat health issues? What do you know about Health Canada's activities and guidance for preventing and addressing heat-related illnesses and deaths?
• Which Health Canada documents were you familiar with? Any others? Have you read them all? How often do you refer to them?
• What is your general opinion of these Health Canada documents? Are they useful or not for physicians, why or why not?
• In addition to Health Canada, do you use other sources, documents on the subject of heat-related health problems? Whether for you and / or your patients?

If yes, PROBE: Which ones?

• What would enable you to better help your patients stay healthy during extreme heat events?
• What training format would be most helpful to you to learn about preventing, diagnosing, and treating heat illness? Some examples of training include: online training courses, continuing education courses, online resources, in-person courses, etc.
• In your opinion, how can Health Canada help family physicians provide appropriate health advice to their patients during extreme heat events, and prevent, diagnose and treat heat illness?

For material / document mentioned:

• How do you use this material? Is it for you or your patient?
• Exactly how do you use it? How often do you refer to it?
• What content is useful for you? What are the material's strengths? What do you like about this material? What are the material's weaknesses?
• And what content is useful for your patients?
• Are they equally effective for all your patients?

Section 2: Concerns about the Heat Health of their Patients (5 MINS)

To begin, let's talk a little bit about heat health issues - i.e. health issues associated with extreme heat events (heat waves).

• What do you know about heat health issues?
• Do you consider that heat-related health issues are important in Canada?
• And in your practice, are health issues associated with extreme heat important?
• Is this a concern for your patients' health?
• Do you have patients who are more at risk of suffering from heat health illnesses?
• Do you feel this is an important issue considering the profile of your patients?
• What are your main concerns about the health of your patients during extreme heat events?
• Do you have to treat many patients with heat-related health issues (heat illnesses) each year? In general, how often does this happen each year?
• In your opinion, what are the main factors influencing your patients' ability to protect their own health during extreme heat events? (e.g. language barriers, access to cooling areas, socioeconomic status, etc.)
• What would enable you to better help your patients stay healthy during extreme heat events?
• In your opinion, how can Health Canada help family physicians provide appropriate health advice to their patients during extreme heat events, and prevent, diagnose and treat heat illness?

Section 3: Sources of Information and Barriers when Transferring Heat Health Information to Patients (15 MINS)

• Do you consider yourself well acquainted with health issues related to extreme heat (e.g. heat illness)? Is it something you find rather routine, need to brush up on, etc.?
• Do you have enough information on this subject? Do you consider yourself well prepared for dealing with heat-related health issues?

PROBE

If not, PROBE: what is missing to be better prepared to deal with these kinds of issues?

• Do you give advice to your patients regarding heat health issues?

If so, PROBE: which patients?

If so, PROBE: what type of advice do you usually give your patients at risk of and/or suffering from heat health issues?

If so, PROBE: Do you have leave-behinds or brochures or any material to hand out to these patients?

• Do you encounter any difficulties when transferring information to patients related to heat health issues? What kinds of barriers/difficulties?
• Are there some types of patients with whom you have more difficulties when transferring information related to heat health?
• In your opinion, what is the best way to transfer health information to patients who are vulnerable to extreme heat, and those who care for them?
• How do you deal with these difficulties? Have you developed tips for conveying heat health information?
• What are your main sources of information about extreme heat-related health problems? If you had to look for information about this, what would be your sources?
• How do you currently obtain and/or receive information about preventing, diagnosing and treating heat illnesses during extreme heat events? How do you use this information in your practice?
• With respect to health issues related to extreme heat, is Health Canada credible as a source of information?
• PROBE: Why YES or Why NOT?

Section 4: Feedback on Health Canada's Extreme Heat Publications in order to Identify Strengths, Weaknesses and Areas for Improvement (40 MINS)

FOR EACH OF THE FOUR DOCUMENTS (ALWAYS START WITH USER GUIDE)

1. EXTREME HEAT EVENTS GUIDELINES USER GUIDE

2. EXTREME HEAT EVENTS GUIDELINES TECHNICAL GUIDE

3. FACTSHEET - ACUTE CARE DURING EXTREME HEAT

4. FACTSHEET - COMMUNITY CARE DURING EXTREME HEAT

5. FACTSHEET - HEALTH FACILITIES PREPARATION FOR EXTREME HEAT

• Had you seen this document before we sent it to you for this discussion group?
• What do you think about it? What is your general opinion?
• Do you use it in your practice?

If YES, PROBE: How do you use it?

If NOT, why don't you use it?

• What are their strengths? What do you like about them?
• What are their weaknesses? What improvement could be done on these documents?
• Is the information contained in this document clear for you? AND For your patients?
• Are the documents useful for your patients? Are they more useful for some type of patients? Why? Which ones?

OR

• Are they less useful for some type of patients? Why? Which ones?

  PROBE:

  • Elderly
  • Youth/young/children
  • Athletes/physically active/individuals working outdoors
  • Ethnic groups / New Canadians
  • Individuals with low socioeconomic status
  • First Nations or Indigenous people
  • Women (including pregnant women)
  • Are there other groups you can think of?
• Do you think these documents help you advise your patients on the importance of protecting their health during extreme heat events? Why is that?
• Do you think your patients follow physician advice related to heat health?
• Do you think these documents are effective? Are they equally effective for all of your patients? Why or why not? With which types of patients are they less effective?
• How do you think these documents could be more effective among patients whose heat health needs are not met?
• What changes would you make to this/these document(s) to make it/them more relevant, effective and useful for physicians? How would you improve distribution, access and use of Health Canada publications and online materials by family physicians?

Section 5: Conclusion (5 minutes)

Once all concepts have been covered, ask the concluding question below.

We are basically done. Do you have any further comments or suggestions for Health Canada on how they could better inform you and Canadian citizens about extreme heat health issues?

Thank you very much for your time and comments.

Appendix C - Links to Health Canada's Material

• Acute Care during Extreme Heat: Recommendations and Information for Health Care Workers
• Community Care during Extreme Heat: Heat Illness: Prevention and Preliminary Care
• Health Facilities Preparation for Extreme Heat: Recommendations for Retirement and Care Facility Managers
• Extreme Heat Events Guidelines: User Guide for Health Care Workers and Health Administrators
• Extreme Heat Events Guidelines: Technical Guide for Health Care Workers