Table 2 Themes and Exemplar Quotations – Adaptation and Post- Visit Phases of BETTER HEALTH

Theme:

1. Significant intersecting health and social challenges in coping with everyday life

 a) Living in poverty

[Interviewer asked about the health of people in the neighbourhood]

Participant: “Generally, it’s poor. There’s a lot of people running around broke, myself included. I get my cheque, I pay my rent, I pay my phone, and I get my bus pass.” (Focus Group (FG) 2)

[Interviewer asked if people in the neighbourhood were able to make ends meet]

Participant: “You’re always trying to figure out how you’re going to get your food, how you’re going to get to the food bank. You know, what food bank…like what time of the month is it? Am I allowed to go again? Like it’s just your whole life is on survival. You can’t look past it.” (Interview 1)

 b) Coping with stressful lives

[Interviewer asked about the health of people in the neighbourhood]

Participant: “Well, there’s probably lots of health problems. Probably a lot of drug abuse. There's probably a lot of nutritional problems…I think they're just too sick. It’s they’ve got a sickness, a disease. They just… They can't fight it. Physically and mentally, emotionally maybe…And we’ve got a big homeless problem here.”

[Interviewer] “So I wonder if you think there may be a connection there in terms of like people living on the streets and people abusing drugs or people not eating well.”

[Participant] “Yeah, it’s all connected [addictions, poverty, poor nutrition]…yeah for sure it is. People just give up.” (FG4)

[Interviewer asked about the impact that stress has on wellbeing]

Participant: “I suffered [job] burnout like a couple of years back. And it was devastating, right. Like I mean it literally threw me to the ground…And you think that, oh, you’re fine. And then you come home and that’s it, like then you realize all that stuff that you were taking in and you weren’t doing proper self-care.” (FG5)

 c) Being socially isolated & experiencing loneliness

[Interviewer asked about the health of people in their neighbourhood. Participant 1 discussed poverty, then Participant 2 talked about sadness and loneliness]

[Participant 1]”I’ve got one [homeless person] living with me right now. I’m putting him up because he was sleeping in an abandoned house. And I met him in the hostel.” [Participant 2]. They’re pretty poorly, aren’t they? Don’t you see? You see a lot of sadness, you see a lot of loneliness.” (FG2)

[Interviewer asked about people taking walks in neighbourhood. Participant commented that they see people more during Spring and Summer months. They went on to describe concerns about isolation]

Participant: “I think that’s one of the real downfalls now of the way we’re all going. We’re all kind of locking ourselves up in our homes and we’re not getting out there… Because social isolation they say is just as bad as smoking, right, to your health.” (FG2)

 d) Living with mental health issues (perceived depression & anxiety)

[Interviewer asked if the Participant thought they were at risk of developing chronic disease] Participant: “I’ve got depression, anxiety. Yeah, lots of those kind of things. “ (Interview 4)

[Interviewer”:… what do you think causes some people to be healthy and some people unhealthy?”]

Participant: “Well, I gained like, I don't know, 60, 70 pounds because I was stressed out. Really stressed out. So I went to chocolate. And I didn’t sleep. So it all works together, right. And even now like I lost 21 pounds and then in December, Christmastime, and then I kind of spiraled down because just my circumstances and my mindset against that, and lack of sleep and whatever. And I was trying to do too much, and I felt overwhelmed.” (FG3)

 e) Addictions

[The Participant described what they viewed as ‘unhealthy’ behaviours in their neighbourhood]

“They’re just partying in the streets because they don’t …That’s the way they know how to live, is daily drugs and they don't have no food. I don’t understand why they wouldn't buy food. But they have a disease, right?” (Interview 1)

[The Interviewer asked about unhealthy behaviours in the neighbourhood]

Participant: “…I mean not just alcohol, we’re talking about, you know, drugs, pills, cocaine, whatever… And until they can face it [addictions] and try to get, you know, a grip at least on their addiction, try to do some harm reduction, it’s just you just… You know, I wouldn't eat for a week. You know what I mean? Like you can’t think straight and try to solve problems. So the first step was trying to get my harm reduction on my drug addiction. Trying to get a little control of it….” (Interview 1)

Subtheme: Disease prevention was a lower priority for many

[Interviewer asked about views on meeting with a nurse in the community to improve their health]

Participant: “I think it’s [disease prevention] very important. I think it’s a great idea because people just… Some people are… What’s the word I’m looking for? Some people are very obsessed with certain parts of their life, and their health kind of just seems to take a backseat to everything.” (Interview 5)

[Interviewer asked about linkages between struggling to make ends meet and other health issues]

Participant: “You know, when you’re in a position where things are fairly relaxed, you can look ahead because you’re not as concerned about the immediate. The immediate’s taken care of. And I think that that really places a lot of burden on their health in particular. And I know that among them, among people who are impoverished too, that smoking is more, drugs are more, more dangerous behaviours, less self-care, less ability to have self-care.” (FG6)

Subtheme: Different attitudes toward disease prevention in men compared to women

[Participant 2]”I’ve had my same doctor, honey, for the last 20 years. I can’t see myself going to any other doctor because…” [Participant 1] “It’s a guy thing too. Guys don’t go to a doctor as much or they wait longer to go.” (FG2)

“The thing is I always thought women are better at seeing doctors than men are. Men tend to avoid it at all cost…I think for men, a lot of times it’s admitting to somehow being weak because you’re ill. Which is stupid. I think women are a lot more intelligent about their health than men are. Men just ignore things. Like I mean how many times have you been sick and you just to hell with it, you know, I’m not even taking the day off. I’m going into work and I’m just going to persevere through it.” (FG1 (male))

Subtheme:Social influences on health—the “company you keep”

[Interviewer asked for feedback on BETTER toolkit. The participants described ways to improve health]

Participant: “I talked to these people that are involved in this [walking group], and they developed relationships and what have you around these groups. And they’re doing activities… And you’d walk 16 k [kilometres] or 10 k or 5 k or 10 k. What you want to do is you want to form groups that are social…” (FG3)

Participant 1: “Yeah, I used to have 50 or 60 [friends]. Now I’ve got 5 because I don’t want to party and drink and smoke anymore, right. So it is, it’s a social thing.”[Participant 5: “A question, is it good to be healthy and not having friends?” [laughs]

Participant 1: “Well, I’m not going to preach but I have a church that is very… Yeah, I find the community really good there.” (FG2)

Theme:

2. Personal desire to change (i.e. being motivated) and readiness for change were key to improving health behaviours

[Interviewer asked about making choices to live healthy lives as compared to unhealthy lives]

Participant: “I think that you have to kind of get to a mental state to be happy, and then you know that you can fix your body. You have to know in yourself that what is bad is not bad forever. It's only how you feel. And then you make that choice that I want to feel better.” (FG2)

[Interviewer] “I think you’re a very good example in that you do take those steps to look after yourself. What makes you so different from other people though?” [Participant] “They (others) just don't have…you know, the get up to say, you know what, I want to change, you know.” (FG4)

[Interviewer asked about advice on how to follow through on personal preventive care goals]

Participant: “For me it was just an understanding that my health was not good and I needed to change. I think an acceptance that, you know, you’re not perfect and that you can improve and you have to stay focused on it. You have to want it… And to me I just had to understand that it was not a good position I was in and it had to change. It's desire to change, I think.” (FG1)

 a) Residents found it difficult to change health behaviours

[Interviewer asked if there was anything that participants had tried to do to improve their health]

Participant: “Biking is good. It’s something that I don’t do but I should do all these things. I know what I should do. I just don’t do it. But I know what I have to do. I just don’t do it. Laziness… I’m lazy. I’ve got to get off the couch. I’ve got to put the remote down and start doing things, you know. I know I have to get healthy. It’s very difficult. Yeah, it’s very difficult.” (FG2)

[Interviewer asked if people were worried about developing chronic disease such as high blood pressure]

Participant: “And I have had breast cancer. And I worry… I don’t… Like I take my blood pressure on a regular basis. There are things that I should be doing that would make that better. In terms of activity, it would make it better than it is. And I don't know why I’m not. Because I know. I know it logically.” (FG6)

 b) Wanting better health as motivation

[Interviewer asked about motivation to make lifestyle changes]

Participant: “I want better health. I’m getting older and you feel ouches and ouches with the weight. It’s not so much… It's not to be…to lose weight and look, you know, sexy or anything, it’s for my heart, for my organs and stuff, I want to eat healthy, so I can live longer.” (Interview 1)

[Interviewer: “So in your opinion what leads some people to be healthy and some people not to be healthy?]

Participant 2: “I think in my opinion it’s people that want to prolong their life, that don't want to be hospitalized or, you know, on medication. I think that’s my fear. That’s why like I’m trying to take a step. Because as I said, I don't want to be on medication. Or like where I see my friends that are on… “Oh, I’m on this and this and this and this.” And I’m like, wow, like you know, you’re younger than me and you’re on like medication that…so many different types of medication. But I’m trying to eat healthy with a small budget.” (Interview 2)

 c) Readiness for change was identified as an important factor in changing health behaviours

[Interviewer asked about making choices to live healthy lives as compared to unhealthy lives]

Participant: “I think that you have to kind of get to a mental state to be happy, and then you know that you can fix your body. You know, I’ve been through so many ups and downs…And then you make that choice that I want to feel better.” (FG2)

“I worry from the smoking. Now, if somebody said I got cancer tomorrow, would I quit smoking? I always thought I would. But you know, I don't know. Like what does it take? It’s just one of those things that the heart and the head haven’t gotten together.” (Interview 1)

 d) The right timing was a key contributor – participants became aware of BETTER HEALTH at a pivotal time in their lives when they were primed for change

N/A

“ I think for me, it was really good timing. As I said, I had just retired. So I was thinking, well, how are things…what am I going to do in the next… You know, how will I keep myself busy and occupied? So it was really good timing, that I was quite motivated to look at some…look at where my life was and what I wanted. (FG4)

 e) Participants perceived that a “wake-up call” or health scare provided motivation to change health behaviours; otherwise disease prevention was not a high priority

Participant 1: “I quit drinking, six months ago maybe?” Participant 2: “Because he almost died. He was in the hospital. He had to go to the hospital.”[Participant 1: “My liver and everything shut down.” [Interviewer: “So that was the wake-up call?”] Participant 1:“Yeah.” [laughs] (FG4)

“A few years ago I had a stroke on April Fool’s Day. It was a perfect day for… I love that day. It was a beautiful day. But my blood pressure was high but I didn’t bother doing anything about it. It was a big mistake. I didn’t do a thing. And I found out the hard way. A blood clot in the brain. It messes you up. That’s what the education was in the hospital. I didn’t know salt was the cause, and smoking and caffeine. I knew that. What can I say, live and learn.” (FG4)

Theme:

3. Value of accessible community programs and resources

Participant: “Now that I’m financially tied [limited finances], I find I go to the library a lot more. I don’t take books out as much but I go there for all my movies, right. I go there to read the newspapers. And you know what, a lot of people who are on fixed incomes or aren’t working or whatever, that’s where they go too. They go there to get on the computers, they go there to see you.(FG1)

“As I was preparing for retirement, I found that very distracting and stressful – about what that was going to look like and I’d be very lonesome. So I joined the seniors centre before I retired. Well, I’ve done stuff with them – with the seniors centre…”(FG4)

Subtheme: Valuing guidance and assistance to connect to resources

Interviewer asked about meeting with someone to help make different lifestyle choices or referrals}

Participant: “…Like I got lucky. Somebody actually told me, ‘did you know?’ I had somebody take me by the hand, this guy, this big guy, the nicest guy you could ever ask, ‘this is where you go to eat’. Because I didn’t know. I had lived as a shut-in for 5 years.’This is where you go.’ He took me down to St. Vincent’s. And I went, ‘Oh wow, really! This is where you go for lunch’. Make people aware.” ( FG2)

[Interviewer: “So did you ask for resources within the community that would have maybe aligned with what you were more interested in?]

Participant: Yes. And she (PP) engaged me at that level. And also returned some telephone calls when I asked about, for instance, salt water pools – are there any salt water pools here in Durham? … Or eating seasonally and eating organic vegetables as much as possible, and how difficult that is. And part of that being that it’s hard for me to get a farmers market. Or even for a CSA, a farm share – Community Shared Agriculture – it's hard for me to go to the farm and pick that up on a weekly basis or a bi-weekly basis or whatever. And I said nobody delivers. You know, they deliver to downtown. And she said, “No, [name of company] Organics delivers.” So great, so she put me in touch with [name of company] Organics.” (FG3)

Theme:

4. PPs enabled participants to change health behaviours through a client-centred approach to education and goal setting

 a) Reported health behaviour changes

  i. Participants described making positive changes including more exercise, quitting smoking, more social connections

N/A

Participant 1: “I started doing exercises [After PP visit].”

Participant 2: “I’ve got guinea pigs. So I said that’s a good way for me to start eating vegetables. Because they eat the vegetables so I have to constantly buy and stock up on vegetables. So I said I’ll eat with them [laughs]. I’ve got to get some willpower.” (FG1)

  ii. The majority of participants had immediate follow through on some goals but not everyone still maintained changes after 1 year

N/A

“I actually did go to my doctor after the encouragement by the nurse. I actually went… I did it more frequently. And I made some tests like in advance because of…it was suggested by the nurse.” (FG1)

 b) The PP enabled participants to make changes

  i. Participants appreciated the process of setting small goals which were tailored to them

N/A

Participant 1:…like I would say, oh, I want to lose like maybe 10 pounds over 6 months. And then she [Nurse] made me break it down to like okay, you lose .5 pounds every week or something like that. [laughs] Participant 2: Yeah, she did that with me too.[Participant 1: She’d get you to be real. [laughs]

Participant 2: Yeah” (Participants, FG5)

  ii. The tools used by PPs were perceived as accessible, easy to use and provided good reminders for participants

“I think it’s [prevention prescription] terrific because… I don’t really know many people who know their blood pressure. I don't know my cholesterol. I don't know anybody who does know their cholesterol…But to have this, yeah. Like for a lot of people that I know, like if you could just put it down on a piece of paper and put it in front of them, like they might change. They’ll take notice. They will make an effort. Or not, you know. But if it’s there right in front of them, you know, they can sort of look at it as like, you know, tests don’t lie, facts are facts. It's in front of you and it’s yours.” (FG1)

“I only realized I hit my goals because I kept them like you [referring to another FG participant]. I kept them posted. I knew and understood what they were. And I brought everything, all those sheets, I brought them to my doctor. And he went through everything. And he kind of kept me focused too.” (FG1)

  iii. The PP visit was perceived to have value by educating participants (a type of “wake-up call”) about their health and encouraging positive health behaviours

“If you don’t have the vision to want to be healthy, you’re not going to go that route. But I think if you get a little bit of a push, talking to people or assisting you, you start thinking, you know, let me eat healthier. You know what I mean?” (Interview 1)

“Because some people need that push. Some people might listen to a professional instead of their friend. Because I do have a friend that is overweight. She needs to lose that weight. But there's nobody there… I mean I tell her. She’s not going to listen. Like some people are stubborn. But sometimes when it’s explained, they might listen.” (FG3)

“Well, I thought about it, right. About changes. And she [public health nurse PP] was the wake-up call. Like I knew I had to eat more vegetables. I knew I had to eat less fat. So that part, you know, I knew I had to make a change there. But hearing her say it, it seemed like it was more of a goal rather than when I was on before I saw her… So I know. I know what has to be done. But the little push came from her when she was explaining to me about the vegetables, incorporating all the vegetables with your protein, and stuff like that. She made it sound a lot easier because I’m not a cook.” (FG5)

  iv. Public health and public health nurses were trusted sources of health information

N/A

“Just to have someone, like another woman [referring to public health nurse PP] who’s knowledgeable about what’s important and about health, and to be able to help me walk through some of the extra steps that I need to take. And to give me more information. Because I used to think that the mammogram was… Like by the time you have a mammogram, if they detect it, it’s too late, you know. And she said, “No, it’s quite the contrary.” So that was like a misconception on my part. And she did educate me.” (FG3)

Theme:

5. Feeling listened to and being understood was critically important when interacting with Prevention Practitioners (PPs) about their health

“Well, it helps me [meeting one-on-one with nurse in the community] because then I walk away…I feel like I’m more… I used to be shy at one point. But I’m only shy with some people now when I meet them at first. And then once I get to know them, I’m fine. But it’s just that initial reaction. Should I trust them, are they going to tell everybody my secrets?” (Interview 3)

“I like that one-on-one interaction. I think it’s important that I can sit there … and tell her what my goals are and what my aspirations are.” (FG1)

“And like with the nurse, I remember saying… She says, “No, you can ask any question.” And like she was listening and she was taking her time. It’s not the same as being in a doctor’s office where it’s rush, rush, rush… So I think it’s very important for people to have like a rapport, like a more slower pace. I think it’s important. And then you can get more information and go at your own pace” (FG3)

 a) The PP was perceived as a health professional with knowledge and skills to provide disease prevention care with knowledge of community resources

[Interviewer asked about views on potential visits with a PP public health nurse]

Participant: “…having a professional who is informed about the system, the big picture. ‘Oh, did you know that you can get this done? Well, yeah, we’ll make that appointment for you.” (FG2)

[Interviewer asked about views on visit with PP public health nurse]

Participant: "Like I think that if you had a regular… If you have a regular practitioner, I don't know that it has to be a doctor. And I think that that’s a good use of that. Because she [PP] had wonderful, wonderful knowledge.” (FG6)