Populations in Europe are becoming increasingly ethnically diverse, and health risks differ between ethnic groups. The aim of the HELIUS  study is to unravel the mechanisms underlying the impact of ethnicity on communicable and non-communicable diseases.HELIUS is a large-scale prospective cohort study being carried out in Amsterdam, the Netherlands. The sample is made up of Amsterdam residents of Surinamese (with Afro-Caribbean Surinamese and South Asian-Surinamese as the main ethnic groups), Turkish, Moroccan, Ghanaian, and ethnic Dutch origin. HELIUS focuses on three disease categories: cardiovascular disease (including diabetes), mental health (depressive disorders and substance use disorders), and infectious diseases. The explanatory mechanisms being studied include genetic profile, culture, migration history, ethnic identity, socio-economic factors and discrimination. These might affect disease risks through specific risk factors including health-related behaviour and living and working conditions. Every five years, participants complete a standardized questionnaire and undergo a medical examination. Biological samples are obtained for diagnostic tests and storage. Participants’ data are linked to morbidity and mortality registries. The aim is to recruit a minimum of 5,000 respondents per ethnic group, to a total of 30,000 participants.This paper describes the rationale, conceptual framework, and design and methods of the HELIUS study. HELIUS will contribute to an understanding of inequalities in health between ethnic groups and the mechanisms that link ethnicity to health in Europe. Prospective population-based cohort studies have significantly increased our understanding of risk factors for the major causes of the global burden of disease. This knowledge has provided a firm basis for effective preventive and treatment strategies. For example, the identification of the main risk factors for cardiovascular disease (such as hypertension and smoking) in the Framingham Heart Study has formed the basis for a dramatic reduction in cardiovascular morbidity and mortality since the 1970s [Most large population-based cohort studies have excluded ethnic minority populations . The maiOften, the disease risk profile of ethnic minority populations differs from that of the majority population – sometimes in favour, but mostly to the detriment of minority populations. Well-documented examples are a higher prevalence of coronary heart disease among people originating from the South Asian subcontinent , a higheBecause of these epidemiological differences, the findings of published cohort studies cannot automatically be generalized to the European population as a whole. In addition, due to a lack of studies that include a substantial number of respondents from ethnic minority groups, current cohort studies do not allow for an exploration of inequalities in health between ethnic groups. Therefore, there is an urgent need for population-based cohort studies that include substantial numbers of different ethnic groups, including a comparison group from the host population ,10. Theshttp://www.heliusstudy.nl/en/home). The aim is to unravel the causes of the unequal burden of disease across ethnic groups, and ultimately enable the improvement of health care and prevention strategies. The study is being carried out in Amsterdam, the Netherlands, and is an initiative of the Academic Medical Center (AMC) and the Public Health Service of Amsterdam (GGD Amsterdam). This paper outlines the conceptual framework underlying the HELIUS study as well as the design and methods used.HELIUS  is a prospective cohort study that aims to fill this gap in our knowledge , behavioural (e.g. smoking), psychosocial (e.g. stress), and biological (e.g. hypertension) exposures that trigger pathogenic processes, and can therefore be perceived as a direct cause of a disease . If the Second, it is important to examine the causal pathways that link the concept of ethnicity to the risk factors that are proximate to diseases. It is no coincidence that these risk factors are unevenly distributed across ethnic groups: this distribution is rooted in these ethnic groups’ characteristics, such as their genetic profile, cultural orientation, and the social conditions they are exposed to as a result of migration ,16. As sThe literature on ethnicity and health indicates at least the following pathways that link ethnicity to health through proximal risk factors: genetic profile, culture, migration history, ethnic identity, socio-economic position, and discrimination -20. TheyEthnic groups vary in the frequency of certain genetic diseases. Examples include haemoglobinopathies , which are more common in populations from most Arab countries . These cCulture can be seen as a ‘lens’ through which an individual perceives, interprets, and copes with the world or environment in which he or she lives. It includes norms, values, and beliefs that are socially transmitted. These aspects might affect health through health-related behaviour and health care use in particular ,28.The role of cultural factors in the association between ethnicity and health is seldom studied directly. Instead, ethnicity is often used synonymously with culture, and the association between ethnicity and health that cannot be explained by such things as socio-economic status is then assumed to reflect the influence of culture . This apBecause of the lack of empirical studies that actually measure cultural factors and specify the pathways that link culture to health, no conclusions can be drawn on the importance of culture as an explanation for ethnic inequalities in health . In addiFuture studies of the role of cultural factors thus requires that these factors be investigated directly, using measures based on a theoretical model that specifies the causal pathway that links culture to a specific health outcome. In addition, it should be acknowledged that the culture of an ethnic minority population has a dynamic character, and is influenced by the host population as well as by contacts with the country of origin. Finally, the role of a cultural explanation should be assessed in comparison to other potentially relevant explanatory mechanisms.The Dutch classification of ethnicity in terms of country of birth can be viewed at least in part as an index of migration, given the distinction that can be made between first generation (immigrants) and second generation (offspring of immigrants). Other dimensions of migration history are not captured by the country of birth classification. Additional indicators might provide further insight into the differences in migration history of people who share the same country of birth. These include:•The place (and/or type) of residence or region where a person grew up. For example, an increase in the risk of cardiovascular disease has been observed in people in developing countries who migrated from rural to urban areas, probably as a result of changes in environment and lifestyle .•The time of residence in the host country. This might be a useful indicator for describing such things as similarities between first-generation migrants who migrated at a very young age and second-generation migrants who were born in that country.•The dynamics of the relationships with family in the country of origin, which might also act as a stressor .identity. Ethnic identity indicates the individual’s feelings or emotional attachment towards a specific ethnic group [Probably the most well-known definition of ethnicity is that of Weber, who states that ‘We shall call “ethnic groups” those human groups that entertain a subjective belief in their common descent because of similarities of physical type or of customs or both, or because of memories of colonization and migration’ . Inherenic group . It can ic group .Identity is clearly a dimension of ethnicity in that it influences the occurrence of health problems, operating through a psychosocial or behavioural mechanism, social participation, or buffering the effects of discrimination ,37. We aEthnic minority groups have a lower average socio-economic status than the host population. Given the association between socio-economic status and health, it is likely that ethnic inequalities in health are socio-economic in nature, at least in part ,19. The bias in studies on ethnic inequalities in health, as a confounder of the real effect of ethnicity [Differences in socio-economic status are frequently considered a potential source of thnicity . To assethnicity .The results of previous studies on the role of socio-economic indicators indicate that ethnic differences are greatly reduced – and sometimes even disappear – when socio-economic factors are taken into account. However, many questions remain. These include the variation between ethnic groups in the way socio-economic characteristics and health are related , and theDiscrimination in the context of ethnicity can be described as unequal treatment of individuals from different ethnic backgrounds. Institutional discrimination involves discriminatory policies or practices carried out by institutions, resulting in such things as an adverse socio-economic position or inadequate health care. Interpersonal discrimination refers to directly perceived discriminatory interactions between individuals, including insults or unfair treatment at work or in public places.As with culture, discrimination has been inferred as a possible explanation after socio-economic factors have been taken into account. Studies that actually assess discrimination indicate a relationship between experiences of interpersonal discrimination and perceived general health, mental health problems, and raised blood pressure ,42. ManyThe objective of the HELIUS study is to assess ethnic inequalities in the incidence and prognosis of major diseases, and to analyse the causes of these inequalities. The ultimate aim is to contribute to the evidence base for the improvement of health care and prevention strategies in different ethnic groups. HELIUS focuses on three of the major causes of the global burden of disease: cardiovascular disease (including diabetes), mental health , and infectious diseases. With regard to the explanations for ethnic inequalities in health, HELIUS focuses on proximal risk factors  as well as on the underlying mechanisms as specified in the conceptual model presented in the previous section .The HELIUS study was designed as a prospective cohort study, and is being carried out in Amsterdam, the Netherlands. It includes people with an ethnic Dutch background along with individuals with Afro-Caribbean Surinamese, South Asian-Surinamese, Turkish, Moroccan, and Ghanaian backgrounds. The ethnic minority groups included in the HELIUS study are the largest ethnic minority groups in Amsterdam. Many ethnic minorities in the Netherlands live in the large cities: 35% of the present inhabitants of Amsterdam are of non-Western origin, with the largest subgroups being made up of people of Moroccan, Surinamese, and Turkish origin [HELIUS is designed to be a multigenerational study. Subjects in the age range of 18 to 70 years are randomly sampled, stratified by ethnic origin, through the municipality registry of Amsterdam (MRA). This registry contains data on the country of birth of residents and their parents, which are needed to determine ethnicity (see definition of ethnicity above). We intend to include a maximum of three relatives per index participant (i.e. a participant included from the MRA sample), which enables us to study family relations as well as different migration generations (based on place of birth). If the parents of an index participant live in Amsterdam, both parents as well as a sibling of the index participant are invited to participate. If an index participant has no parents living in Amsterdam but has one or more children of at least 18 years of age living in Amsterdam, a maximum of two children are invited, as well as the index participant’s partner.The goal of HELIUS is to include a minimum of 5,000 people per ethnic group. Baseline data collection of HELIUS started in January 2011, and will take approximately five years. Participants will be re-evaluated every five years.The HELIUS study has been approved by the Institutional Review Board of the AMC at the University of Amsterdam. During the informed consent procedure, we ask the participant’s permission 1) to report personal results relevant to the participant’s health to his or her general practitioner (GP); 2) to store his or her biological samples in the HELIUS biobank for future research relating to the three disease groups; 3) to link registries containing data relating to the participant’s health ; 4) to request the official cause of death from Statistics Netherlands (CBS) in the event that the participant dies during the course of the HELIUS study; and 5) to approach him or her for future additional studies and for this to request the municipal registry to update address information.Data are collected through a questionnaire/interview (I) and a physical examination (II). Biological samples are obtained during study visits (III).(I) Questionnaire/interviewIndividuals in the selected sample receive a written invitation along with written information regarding the study and a response card. If they agree to participate, they can choose to fill in the questionnaire on paper or online. Participants unable to fill in a questionnaire are offered assistance from a trained  interviewer. The questionnaire addresses the presence (or symptoms) of cardiovascular disease, mental health disorders, and infectious diseases as well as determinants or risk factors of these diseases and disorders Table .(II) Physical examinationThe physical examination takes place at a local research site, after the questionnaire has been completed at home or the interview has taken place. All participants receive a summary of their own main results  results), accompanied by an explanation and the recommendation to contact their GP if the results are abnormal. The GP receives a copy of these results. If a person does not give permission to forward a copy of the results to the GP, she or he is not allowed to participate in HELIUS.Table (III) Biological sample collection and testing and storage proceduresA trained research assistant or study nurse collects a fasting venous blood sample. All blood samples are manually processed and aliquoted immediately after collection by a trained technician. Samples of EDTA whole blood and heparin plasma are transported directly to the AMC Clinical Chemistry Laboratory for determination of haemoglobin, HbA1c, glucose, lipid profile, and creatinine levels. The remaining samples are transported to the Durrer Center for Cardiogenetic Research at the AMC, where samples are checked, registered, and stored at -80°C. These samples include EDTA whole blood, EDTA plasma, heparin plasma, serum, and platelet-poor citrate plasma. Genomic DNA is obtained from the buffy coat in the EDTA tube.Participants are asked to bring a morning urine sample to the physical examination. The urine sample is tested with a dipstick  on the spot, to determine pH, glucose, ketones, leucocytes, nitrite, protein, and erythrocytes. One sample is transported to the AMC Clinical Chemistry Laboratory for direct analyses of microalbumin and creatinine levels. In addition, together with the blood samples, urine samples are transported to the Durrer Center and stored at -80°C.A trained nurse or research assistant collects a throat swab during the physical examination visit to the study site. This is done using a dry sterile swab at the posterior nasopharynx, and the swab is then placed in a tube containing viral transport medium. A nasal swab is collected using a dry flocked sterile swab that is rubbed against the turbinate to ensure that the swab contains cells as well as mucus. Subsequently, the swab is inserted into the same tube with transport medium that contains the throat swab. The swabs in the transport medium are kept at room temperature until they are transported to the AMC Department of Medical Microbiology on the same day. The tubes containing swabs and transport medium are vortexed to release all material  from the swabs into the medium. Subsequently, the transport medium is divided into two aliquots and stored at -80°C for future viral culture and molecular detection of viral and bacterial pathogens.During the study visit, female participants are asked for a vaginal swab. They are provided with standardized instructions, after which they take a self-administered vaginal swab. A COPAN swab is used, and this is immediately placed into the accompanying plastic tube without fluid. The tubes with dry swabs are kept at +4°C at the research location until they are transported (within two weeks) to the Regional Reference Laboratory at GGD Amsterdam; there they are stored at -20°C for future determination of vaginal microbiome composition and detection of viral and bacterial pathogens.At the end of the physical examination visit, participants are given a faeces collection tube and a safety bag (for transport). They are asked to collect a morning stool sample in the pre-labelled tube, put this in the safety bag, and bring it to the research location within six hours after collection. At the research location, the sample is temporarily stored at -20°C until transportation to the AMC, where the samples are checked by a study nurse and stored at -80°C for later analysis of microbiota composition.By February of 2013, approximately 5,000 respondents had been included in HELIUS. The main objective of the study’s next stage is to increase the number of respondents to 10,000 by the end of 2013, with approximately 1,650 participants per ethnic group. The objective of the following stage is to further increase the number to a total of 30,000 respondents.At five-year intervals, all participants will be invited for a follow-up health examination. During follow-up, baseline measurements will be repeated to study the changes in risk factors and the incidence of cardiovascular disease, mental health disorders, and infectious diseases over time. In addition, participants’ data will be linked to registry data on a continuous basis for routinely collected data on health outcomes and health care  at the individual level. This use of existing data has several advantages. After providing adequate informed consent, the active cooperation of the participant is not required, thus reducing the burden for the participant. It also enhances completeness and quality of the data. Finally, it enables us to compare clinical data  with registry data (e.g. in the case of self-reported diagnoses such as diabetes mellitus and depression). Potentially useful databases/registries to be linked to the HELIUS data collection include local GP registries, hospital discharge registries, pharmacy data (prescriptions), health care insurance registries , and vaccination registries.To illustrate the statistical power of the total HELIUS cohort, with 5,000 participants per ethnic group, we present two examples with different designs. First, we consider cross-sectional research with respect to risk factors for depression with a prevalence of 7% in the general population. With 30,000 participants, the cohort will have at least 90% power to find a significant association between a risk factor and the presence of depression if the odds ratio is larger than 1.20 assuming a risk factor that has relative frequency of 20%. With respect to a difference between ethnic groups in the association of a risk factor with depression, the cohort with 5,000 participants per ethnic group will have at least 90% power to show a difference in odds ratios if the ratio of the odds ratios is 1.95 larger assuming a odds ratio of 1.5 in the reference ethnic group.As a second example of the statistical power, we consider longitudinal research with respect to a risk factor for acute myocardial infarction (MI). The total incidence in the general population is about 2.5 individuals per 1,000 participants per year, thus after a five year follow-up we will have about 375 participants with acute MI. With this number of cases there would be 90% power to find an association between a risk factor with prevalence of 20% and acute MI if the relative risk (RR) is 1.51. To find a true interaction between such risk factors and acute MI, the ratio of the relative risk must be 2.54.are included, the number of respondents from ethnic minority groups is generally too small to draw conclusions about specific ethnic groups. Consequently, the current evidence on the epidemiological profile of ethnic minorities is limited. Against this backdrop, the HELIUS study is unique in its goals and study population. We are not aware of other population-based cohort studies in Europe that include a broad range of ethnic groups, with a substantial number of respondents per group and a diversity of disease phenotypes. In their 2006 review of 72 cardiovascular cohort studies, Ranganathan and Bhopal concluded that even at the international level, only 15 of these were able, by design, to compare different ethnic groups. All of these were performed in the United States. Of the 41 studies in Europe, none was able to provide data according to ethnic group [Ethnic minority groups are excluded from most epidemiological studies in high-income countries in Europe. If they ic group .The association between ethnicity and health may differ between situations, countries, and over time, depending on the characteristics of ethnic groups. If, for example, ethnic inequalities in health in a specific setting have been shown to be related to unhealthy behaviour, this does not necessarily apply to other settings or time periods. Also, the characteristics that link ethnicity to behaviour may differ. Therefore, it is crucial to study the mechanisms that link ethnicity to health if the aim is to understand how ethnic inequalities in common diseases arise. When these mechanisms have been identified, the role of these factors in ethnic inequalities in health may potentially be generalized to other settings.By introducing ethnic heterogeneity, and by obtaining detailed information on the proximal risk factors and causal mechanisms underlying ethnic inequalities in health, the goal of HELIUS is to provide scientific evidence as to how ethnicity has an impact on the major causes of the global burden of disease. This evidence can be used to develop ethnically targeted interventions, and to target health care to the health needs of ethnic minority populations in high-income countries. HELIUS will thus contribute to the evidence base for the prevention of diseases and promotion of population health in general, and the reduction of ethnic inequalities in health in particular.The authors declare that they have no conflict of interest.All authors contributed to the conceptual framework, and the development of the design of the HELIUS study. They are all members of the executive board of the HELIUS study. KS drafted the manuscript. MBS, RJP, MP, AHS and AHZ commented on draft versions of the paper. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/402/prepub


The gap in health status of Canada’s Aboriginal peoples is a matter of ongoing concern; recognizing and understanding the social determinants of health is key to understanding the difference in health status and, in my view, key to achieving success in addressing and correcting this problem. However, it is important to realize that there are unique social determinants for Aboriginal peoples associated with their cultures, histories and colonization, and the current social, economic, political and geographic context.It is a sad fact that Canada’s Aboriginal people, whether living in rural communities or in urban centers, have a significantly lower life expectancy than non-Aboriginal Canadians. examined obesity and the related comorbidities—dyslipidemia, hypertension and diabetes—in a Manitoba First Nations community. As in other Aboriginal populations (e.g. in neighbouring Saskatchewan), they found the prevalence of obesity and these comorbidities is higher in women than in men, and that the comorbidities are common even in young adults. Undiagnosed hypertension is also common. In the same Manitoba First Nations community, Riediger et al. found a high cardiovascular risk due to low plasma apolipoprotein A1 levels, particularly among women.Bruce et al. studied arthritis in the national Aboriginal population, focusing on the differences between the northern territories and the 10 provinces in the south. They used data from the 2006 Aboriginal Peoples Survey (APS), a post-census survey conducted by Statistics Canada that includes health, social and economic questions. The APS covers Inuit and Métis, as well as First Nations living outside of Indian reserves; on-reserve First Nations are covered by the 2002/03 Regional Longitudinal Health Survey conducted by the Assembly of First Nations. Because of oversampling of northern residents in the APS, effective comparisons can be made with the more populated south. Self-reported arthritis and rheumatism is the most common medical condition reported by Aboriginal people in Canada. In the south, where more than 90% of the Aboriginal population live, the overall prevalence is 20.1% compared with 25.3% for on-reserve First Nations in the same geographic area. The prevalence of arthritis or rheumatism in the north is considerably less , and is lower for both First Nations and Inuit in comparison with the south. A higher proportion of individuals with arthritis report at least one other chronic disease, and more people with arthritis consult health professionals, while fewer—perhaps not surprising—are employed, although cause and effect was not established.Ng et al. these also show the same gender bias, i.e. the gap in life expectancy is greater for Aboriginal women by about 2 years. The researchers found that the two leading causes of mortality in Aboriginal Canadians are circulatory system diseases and cancers, the former being elevated for both men and women compared with the non-Aboriginal population, the latter only for Aboriginal women. Many specific causes of death are remarkably elevated, particularly alcohol-related causes and external causes, including suicides and accidents; deaths amenable to medical intervention are elevated in both men and women.Tjepkema et al.1 looked at mortality of urban Aboriginal adults over an 11-year period (1991–2001), linking mortality registry data with census data and data on tax filers to achieve an urban Aboriginal cohort of some 25 500 among a total urban cohort of 2.6 million. The main variable, remaining life expectancy at age 25 years, is significantly lower for Aboriginals living in urban centers than for urban non-Aboriginal Canadians. For men, the life expectancy is 4.7 years lower; for women, 6.5 years. These differences are about the same as the overall figures that include on-reserve and non-urban residents recently published by the same researchers; ultimately offers hope: the community is engaged in projects to address, prevent and perhaps even reverse the otherwise inevitable increasing obesity predicted by the risk factors. Few details are given, but we are told that a project aiming to prevent gestational diabetes through controlling weight gain during pregnancy is under way; that the community operates a fitness center; that the health center offers education on diet, exercise and wellness; and that walking groups have been organized, as well as activity programs in the schools. In all of this, the investigators continue to work with the community. It is unfair to expect the same degree of follow-up with national survey data because action to utilize health information and transform behaviours and conditions generally requires local community engagement. However, it is important to work with national organizations to transform the health knowledge into action and policy.These descriptions and understandings of the health gap and risk factors for chronic diseases in Canada’s Aboriginal populations are important, but we need to understand all the causes and then move on to interventions that will address, prevent and reverse the problems. The four studies described here all take their fields of interest from the mere descriptive to understanding the physical, socioeconomic and societal risk factors. The next step, and perhaps the crucial one, is how to use the knowledge to correct the disparity. The study by Bruce et al. The CIHR Institute of Aboriginal Peoples’ Health (IAPH) supports community engagement, capacity building and network development as key platforms towards achieving health equity for Aboriginal peoples, and will continue to do so. But we need to move beyond this into the realms of intervention research  and knowledge translation  to define the models of good practice that will enable our communities to achieve their goals of health equity. Since health equity can never be achieved without the wholeness that includes the mental, physical, emotional and spiritual parts of our lives, we must go beyond the conventional social determinants of health to look at factors that include promotion of resilience through spirituality, culture, language revitalization, traditional activities and other forms of cultural connectedness. With follow-up by researchers and with local, regional and national community engagement, we hope to eventually eliminate the gap in health status that divides Canada’s Aboriginal peoples from the non-Aboriginal mainstream.The Canadian Institutes of Health Research (CIHR) embraces the need to reduce health inequities in Aboriginal peoples as one of its main strategic directions.


Oncology nursing continues to evolve in response to advances in cancer treatment, information and biotechnology. As new scientific and technological discoveries are integrated into cancer care, oncology nurses need to play a key role in the management of this patient population. The role of the oncology nurse has expanded significantly and can differ greatly across cultures. Sophisticated treatments and the growth of targeted therapies will create the challenge of ensuring that all nurses working in this arena are well-educated, independent thinkers. Thus the future success of oncology nurses will focus on enhancement of nursing practice through advanced education. The increased globalisation of healthcare offers exciting opportunities to accomplish this goal by allowing for collaborative relationships among oncology nurses across the globe. Historically, nurses have played a special role in the care of patients with cancer, a role that was especially significant in those few institutions devoted exclusively to cancer care before the United States of America National Cancer Act of 1971. However, the recognition of cancer as a major American health problem and the subsequent expanded research and treatment program against cancer, which has occurred during the past quarter-century, has been a catalyst for the development of oncology nursing as a separate specialty. At first many oncology nurses worked as nurses and data managers for cancer research studies, but as the treatments in oncology became increasingly complex so did the need for a collaborative relationship between the nurse and physician in order to provide unique comprehensive patient care.Today oncology nurses in the United States practise in a variety of settings, including acute-care hospitals, outpatient clinics, private oncologists’ offices, radiation therapy facilities, home healthcare agencies and community agencies. They may practise in surgical oncology, gynaecologic oncology, bone-marrow transplantation, radiation oncology, paediatric oncology or medical oncology. The majority are involved in direct patient care, with 35 percent working in a hospital/multi-hospital system, 40 percent in the outpatient/ambulatory care setting, 20 percent in radiation oncology, and 5 percent in hospice or home care . The rolNurses working in cancer care focus on patient assessment, education, symptom management, and supportive care. In medical oncology they play an integral role in the administration of antineoplastic agents and are responsible for safe drug handling; evaluation of laboratory data; calculation of drug dosages on the basis of body surface area; insertion of intravenous lines or accessing central venous devices; continuous and time intensive monitoring to address potential adverse reactions or drug interactions; and screening patients for inclusion in available research trials or protocols . In the As more complex treatment protocols are implemented, nurses working in oncology will need to expand their knowledge base on new drugs, new technologies, and biologic therapies. For example, The National Cancer Institute (NCI) announced in January 2006 that intraperitoneal (IP) combined with IV chemotherapy postoperatively was the preferred treatment method for advanced ovarian cancer. IP administration allows a high concentration of chemotherapy to come into direct contact with tumours and surrounding tissues and organs. The announcement stimulated the need for oncology nurses to become familiar with IP chemotherapy administration and patient management guidelines. These patients require constant monitoring of renal and cardiac function through laboratory values as well as intake and output to prevent fluid overload and electrolyte imbalances. The patients also need advanced nursing assessment to prevent any complications from the infusion.Advances in molecular science have led to new biologic therapies for patients with cancer. These biological agents have created a challenge and require nurses to have a thorough understanding of their mechanism of actions and side effect profile. Patients may continue on these medications at home thus requiring the nurse to do a complete assessment of the knowledge level of the patient and/or caregivers regarding the preparation and administration of the medication at home, as well as management of possible side effects in the home setting.In Asian countries the role of the oncology nurse continues to expand as cancer becomes a leading health concern. However, across Asia there is growing acknowledgement of the need to clarify the role of nurses in order to maximise their contribution to cancer care. Asia has many faces and is extraordinary in its diversity of cultures, habits, and healthcare systems. Oncology nurses in Asia function mainly in a caregiver role focusing on treatment delivery, education and symptom management. Specialisation is rarely seen. A study in 2005 by Gopal et al looked at information needs of women with newly-diagnosed breast cancer in Malaysia and the United Kingdom. Malaysian women in this study emphasised the importance of medical information on prognosis and spread of disease and the need for more education. Although nurses specialising in breast cancer are not features of the Malaysian healthcare system, the findings from this study support the view that specialised nurses may have a vital role to play .Standards of practice and competencies for oncology nurses appear to be similar across continents . OncologUniversally the oncology nurse has tremendous responsibility in educating the patient about his or her cancer treatment and often has better opportunities than any other member of the healthcare team to review the treatment plan. However, for some Asian countries the challenges of education extend well beyond diagnosis and treatment. In certain areas a diagnosis of cancer is taboo and rarely discussed within the family and never with outsiders. For example, breast cancer literature in Malay languages, even in the official Bahasa Melayu language, did not exist largely because of cultural mores regarding privacy about women's bodies, lack of education about the disease and the lack of public hospitals to prescreen women and provide early diagnosis as well as treatment options.The use of alternative medicines is also a common practice in Asian countries and oncology nurses in these areas need to be familiar with the role such medicines play in cancer treatment. According to the World Health Organization (WHO), up to 80 percent of developing countries' populations use traditional medicines as their primary source of health care . Those dIn 2000, the number of new cancer cases in Asia almost exceeded the combined incidence of new cancer cases in North America, Europe and Australia combined, and is predicted to increase further . WHO hasOne theme that rings true globally is the lack of nursing personnel . A nursiAccording to the 2005 ICN Asia Workforce there is little difference in wages, benefits and working conditions between nurses in the private hospitals and those in the public hospitals. However, Malaysian nurses in private hospitals are paid more than nurses in public hospitals. This contrasts with Taiwan where the starting salary for nurses in public hospitals is higher than that offered by private hospitals. In Singapore, the basic pay in both sectors is similar .Educational preparation also varies depending on the country. Thailand’s entry level into practice is at the baccalaureate level, but in other countries one can practise after completing a two-year diploma program. Most of the Asian countries require nurses to sit for licensing examinations in their national language, although this is a fairly new practice. In Thailand, the first national examination for nursing graduates was administered by the Nursing Council in 1998. Prior to this, graduation from an approved school of nursing or university was all that was required for licensing. The license is renewed every five years. In Taiwan approximately 25 percent of nurses have a baccalaureate degree . In contAdvanced nursing education varies tremendously between the U.S. and Asian countries. In the U.S. the development of the advanced practice role began over 35 years ago in response to a shortage of primary care providers in rural areas. In 1989, nurse practitioner programs were required to be master’s granting programs or post-master’s degree programs. In contrast, in Asia the role regarding advanced practice nursing first emerged in Taiwan in 1994. Before that nurses in Taiwan were reluctant to work in an advanced practice capacity as it was considered illegal. Today advanced nursing practice in this country is booming but the standards of education have not been well-developed. The majority of the advanced practice nurses are either junior college graduates with four years of clinical experience or bachelor degree nurses with two years of clinical experience . Short-tIt has been estimated that there will be another 20 million new cancer patients worldwide in 2020 . In the As stated previously, throughout Asia there is great diversity of educational preparation. Nurses are, at best, given a broad overview of cancer care in their basic educational programs, yet to practise in oncology, nurses must quickly learn the language of this discipline. Each type of cancer has a different etiology, pathophysiology, natural history and course of treatment. The number of chemotherapeutic agents and drug combinations, as well as targeted agents being added to treatment regimes is staggering. In radiation oncology, advances in technology have led to more defined treatment and a greater need for patient education.A decade ago, an oncology nurse could become an expert in one treatment modality such as surgical, medical or radiation oncology. Now patients frequently receive concomitant and sequential therapies that require assessment and management skills for all three modalities. Nurses now have subspecialties such as breast care nurses, palliative care nurses, stem-cell transplant nurses and so on. In the larger cities of Asia, nurses may be familiar with newer technology, but more education is needed for nurses working in remote, less-developed areas of the country. As relevant healthcare systems are put in place to manage the rapidly increasing numbers of cancer diagnosed in this part of the world, there will be a greater need for education of oncology nurses who have never been exposed to managing skin rashes from targeted therapies or radiation therapy equipment. For instance, the WHO estimates that the Asia-Pacific region needs 4,000 radiotherapy machines to treat its patients, but has only 1,200 . If an iAlthough some countries require their nurses to have continuing education credits, this is not the standard for all countries. Programs focusing specifically on oncology are rare for nurses practising outside a major city. This leaves a lack of further education on newer treatment modalities.Oncology nurses in Asia will also need to take an active role in developing prevention programs for cancer. The rapid rate of economic development in some Asian countries, along with the accompanying industrialisation and urbanisation, are contributing to an ever-increasing risk of common cancers. In Thailand 57 percent of boys begin smoking between the ages of 15 and 20, and unfortunately most countries in Asia have weak policies and programs for tobacco control [Abundant evidence in the U.S. has demonstrated the benefits of the advanced nursing practice -18. In tFor the oncology nurse, the learning curve is steep. The integration of targeted therapies into practice, advances in combined modality therapy and an increase in treatment delivery technology means that the oncology nurse must be well-educated to care for this population of patients. Oncology nurses must be able to think critically, analyse, reflect, problem-solve, and apply high-level knowledge that is evidence- and research-based to clinical interactions with patients who need their care. For some Asian countries, advanced practice nurses do not exist or they exist with a lack of role-clarity and educational preparation.With cancer rates in Asia on the rise and an increase in complex treatments, there is a greater need for the advanced practice nurse. Advances in information technology can allow us to bring educational opportunities to nurses across the globe and establish a uniform process of educating and credentialing advanced practice nurses. The oncology nurse of the future will need to become comfortable and flexible with technology. Creating a global advanced oncology nursing curriculum can help to bridge the gap between oncology nurses across continents and enhance education of nurses working in the cancer setting in Asia.


The prevalence of multiple chronic diseases is increasing and is a common problem for primary health care providers. This study sought to determine the patient and health system burden of multiple chronic diseases among adults in Ontario, Canada, with a focus on the ambulatory health care system .This population-based study used linked health administrative data from Ontario, Canada. Individuals, aged 20 years or older, who had a valid health card, were included. Validated case definitions were used to identify persons with at least one of the following nine chronic diseases: diabetes, congestive heart failure, acute myocardial infarction, stroke, hypertension, asthma, chronic obstructive lung disease, peripheral vascular disease and end stage renal failure. Prevalence estimates for chronic diseases were calculated for April 1, 2009. Ambulatory physician billing records for the two-year period, April 1, 2008 to March 31, 2010, were used to identify the number of outpatient ambulatory care visits.In 2009, 26.3% of Ontarians had one chronic disease, 10.3% had two diseases, and 5.6% had three or more diseases. Annual mean primary health care use increased significantly with each additional chronic disease. Overall, there were twice as many patient visits to primary health care providers compared to specialists across all chronic disease counts. Among those with multiple diseases, primary health care visits increased with advancing age, while specialist care dropped off. While persons with three or more diseases accounted for a disproportionate share of primary health care visits, the largest number of visits were made by those with no or one chronic disease.The burden of care for persons with multiple chronic diseases is considerable and falls largely on the primary health care provider. However persons with no or one chronic disease are responsible for the largest number of ambulatory health care visits overall. Continued investment in primary health care is needed both to care for those with multiple diseases and to prevent the accumulation of chronic diseases with aging. Chronic diseases, such as diabetes, heart disease and asthma, are the most prominent health care issues affecting Canadians. There iTo date, research exploring the burden of disease on the primary health care system in Canada-5 has beWe sought to extend what is known about the burden of multiple chronic diseases by using highly validated disease ascertainment methods to determine the association of chronic disease count and patterns of ambulatory care use  for the population of Ontario, Canada.This study was conducted using population-based data from the province of Ontario, Canada with a current total population of more than 13 million people. Data weThis study was approved by The Ottawa Hospital Research Ethics Board.We included all living adults, aged 20 years or older, identified in the Ontario Registered Persons Database who had a valid Ontario health card on April 1, 2009.To minimize inclusion of people who had potentially moved out of province, we excluded individuals who made no contact with the Ontario health care system within the five years prior to 2009. This criterion was evaluated by applying the five-year date of last contact restriction to all Ontario respondents from three cycles of the Canadian Community Health Survey . Of more than 150,000 respondents of the Canadian Community Health Survey, 99.8% of individuals who answered the survey had contact with the health care system within the five years prior to writing the survey. While this approach may exclude certain groups that have less contact with the health care system, such as younger, less sick adults, we feel that it ensures the most accurate estimate of the population residing in Ontario.Figure To identify persons in our population with a chronic disease we used pre-existing, validated health administrative data case definitions for the following nine chronic diseases: diabetes, congestive heart failure, acute myocardial infarction, stroke, hypertension, asthma, chronic obstructive lung disease, peripheral vascular disease and end stage renal failure. The specific details on the methods of disease ascertainment, including the technical case definitions used, are presented elsewhere-19. PrevWe used provincial billing records to identify the number of outpatient health care visits made to primary care and specialist physicians within a two-year period  and presented results as an annual rate. Due to the high number of outpatient visits, the analysis was completed on a 25% random sample of the total study population.We calculated chronic disease prevalence by disease count in the study population. To explore the health care burden on the patient, we calculated the mean annual number of ambulatory health care visits  per person and stratified results by disease count. The total annual number of ambulatory health care visits for all persons in each disease count group was calculated to provide an estimate of the overall burden on the primary health care system. The impact of age on utilization was estimated by stratification of results across age categories. All analysis was done in SAS version 9.2 .The prevalence of chronic diseases by disease count in Ontario on April 1, 2009 is presented in Table There is an increase in the mean number of health care visits to primary health care physicians with age, while health care visits to specialist physicians drop off at the highest age categories Figure . For exaThe objective of this study was to describe the burden of multiple chronic diseases on the patient and the ambulatory health care system. Our results demonstrate three key trends. First, while the burden of disease on the patient, as measured by mean number of ambulatory health care visits per year, was higher for those with multiple chronic diseases, the overall impact on the primary health care system was relatively small. Second, across all disease counts and ages there were many more visits to primary health care physicians compared to specialist physicians. This trend was evident even among the most elderly patients who, with age, had ever-increasing visits to primary health care physicians, while the number of visits to specialist physicians declined. Third, we found that, while the number of primary health care visits increased with age, the elderly with no diseases had many fewer visits per year, compared to younger adults with multiple chronic diseases.Our findings confirm what other research has suggested about the high burden of chronic disease on the individual patient,4,11. ReImportantly, our study demonstrates that patients with multiple chronic diseases do not drive overall primary health care use in Ontario because prevalence of multiple chronic diseases in the population remains low. The majority of primary health care visits continue to be made by adults who have no or one disease. Future research could assess time trends to see if this pattern is changing, given the predicted rise in the prevalence of multiple chronic diseases with the aging population.We acknowledge that a number of important chronic diseases were excluded from this study, such as depression and joint disease. This may have resulted in an overestimation of the number of persons with no or one disease. Although the exclusion of these diseases may change prevalence estimates and the associated number of visits, we do not believe this has an impact on the patterns of health care utilization we found. If anything, our results are an underestimation of the overall burden of multiple chronic diseases on the primary health care system. Validation studies for the ascertainment methods for additional chronic diseases in the Ontario databases are an ongoing effort at ICES.Canada has a strong primary health care system and primary health care providers act as gatekeepers to specialist services. Thus, it was not surprising to see that there were more primary health care visits in our study, particularly among the very elderly. The lower rate of specialist visits in the very elderly can be explained by factors such as fewer new disease diagnoses that require specialist consultation and primary care provider or patient preference for less intervention and testing. Our results are different from a U.S. study of Medicare beneficiaries where the burden of care for non-elderly patients (<65 years) with high levels of morbidity fell disproportionately on primary health care but this pattern did not hold for the elderly who had more specialist compared to primary health care visits. This maRecent attention has focused on determining the relative impact of age and chronic disease burden on health system utilization. In theiThis study has limitations common to all research using administrative data. These databases were constructed to serve a billing role and, thus, while they are rich in information, they were not created for research or disease ascertainment. To limit errors in our disease estimates we have used highly validated definitions of chronic diseases, but we acknowledge the possibility of over and under-ascertainment of disease. Furthermore, we estimated primary health care service use exclusively by looking at the number of visits and did not look at other health care services controlled by primary care, such as outpatient laboratory and diagnostic testing or number of prescriptions. Future research could explore these services to see if the patterns we identified hold.Primary health care plays a strong and vital role in managing chronic diseases. Results from this study show that the burden of care for persons in Ontario with chronic diseases, particularly the elderly, falls on the primary health care system. We found that, while people with multiple chronic diseases have more annual visits to their primary health care physician, the overall health system impact of multiple chronic diseases is still relatively small compared to the health care use of those with no or one chronic disease. These data support the continued investment in primary health care and the need for a strong focus on disease prevention to avoid the accumulation of chronic diseases.SAS: Statistical analysis system.The authors declare that they have no competing interests.EM contributed to the concept of the study and oversaw its implementation, helped guide the analysis, was the primary author and approved the final version of the manuscript. EG was responsible for the data analysis, participated in the editing of the manuscript and approved the final version of the manuscript. CB contributed to the implementation of the study, participated in the writing of the manuscript, and approved the final version of the manuscript. DM contributed to the concept of the study, oversaw its implementation, helped guide the analysis and participated in the writing and approved the final version of the manuscript. All authors read and approved the final manuscript.EM is a new investigator at the C.T. Lamont Primary Health Care Research Centre and Bruyère Research Institute, clinician scientist at the Department of Family Medicine University of Ottawa, Canada and a research fellow at the Institute for Clinical Evaluative Sciences. EG was an analyst at the Institute for Clinical Evaluative Sciences at the time this research was completed. CB is a Research Coordinator at Institute for Clinical Evaluative Sciences. DM is a Senior Scientist, Ottawa Hospital Research Institute, Adjunct Scientist, Institute for Clinical Evaluative Sciences, Chair in Applied Public Health Sciences, CIHR/PHAC, Associate Professor, University of Ottawa and University of Toronto, and Associate Scientist, C.T. Lamont Primary Health Care Research Centre and Bruyère Research Institute.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/12/452/prepub


Over the past 30 years, policy makers and professionals who provide services to older adults with chronic conditions and impairments have placed greater emphasis on conceptualizing aging in place as an attainable and worthwhile goal. Little is known, however, of the changes in how this concept has evolved in aging research. To track trends in aging in place, we examined scholarly articles published from 1980 to 2010 that included the concept in eleven academic gerontology journals. We report an increase in the absolute number and proportion of aging-in-place manuscripts published during this period, with marked growth in the 2000s. Topics related to the environment and services were the most commonly examined during 2000–2010 , with a substantial increase in manuscripts pertaining to technology and health/functioning. This underscores the increase in diversity of topics that surround the concept of aging-in-place literature in gerontological research. Over time, the goal of aging in place has become a focal concept by policy makers as well as researchers in their collective efforts to create communities that facilitate the widely recognized preference by a majority of older adults to remain in their homes and communities as long as possible –4. EfforCorresponding to greater policy aimed at facilitating aging in place, there has also emerged a growth in academic literature, reflecting the concerns of stakeholders , which illuminates a greater number of options aimed at stemming rising costs of care, and accommodating and facilitating the wishes of older adults to remain independent. Initial efforts to conceptualize and define aging in place as an important discussion topic focused on understanding older adults in terms of changes occurring both in themselves and in their surrounding environments. For instance, in describing the concept of environmental press,Lawton and Nahemow examinedOver the past 30 years, policy makers and professionals who provide services to older adults with chronic conditions and impairments, as well as researchers, have placed greater emphasis on conceptualizing aging in place as an attainable and worthwhile goal. Nevertheless, there is little known of the changes over time in the attention given to aging in place within gerontological literature. With respect to the quantity and substance of the literature on aging in place, the current study was designed to provide important insight as to the prominence of environmental, service based, technology, and health factors associated with an older adult's ability, inability, or choice to age in place. Moreover, given the increasing number of older adults who express a preference to remain in their home, understanding and tracing the evolution of this topic in gerontology is more timely today than ever before. Perhaps more importantly, in studying changes in empirically based aging in place publications, light can be shed on how such temporal changes may influence policy related to services, environment, and technology. In our analyses, we examined the trajectory of aging in place within the context of scholarly discussions in major gerontology journals. Specifically, the purpose of our research was to examine how the literature on aging in place has changed over time in highly visible gerontology journals, with a focus on analyzing trends related to the amount, location, and variety of research topics. We hypothesize that generally there would be an increased proportion of articles dedicated to the topic of aging in place, and that among those articles, the diversity of topics covered in publications would increase over time.In this study, we analyzed scholarly articles published from 1980 through 2010 in eleven leading gerontology journals with content areas that focus on research and/or policy pertaining to older adults. In a preliminary analysis, we examined a broad array of terms that capture the concept of aging in place. These included aging/ageing in place, aging/ageing at home, naturally occurring retirement community(s), elder friendly community(s), aging in the community, home independence, and staying put. For the terms that yielded less than 20 manuscripts within our 1980–2010 timeframe, we excluded these terms from our final search list. This left 3 critical search terms: aging/ageing in place, aging/ageing at home, and naturally occurring retirement community(s). Given that our interest was in examining trends in aging in place, we operationalized our definition of aging in place search items to include only the most commonly used terms. This approach results in a more conservative estimate of documenting trends in aging in place; nevertheless, given the minimal number of manuscripts that utilized the alternate terms pertaining to aging in place, this criteria should not substantially bias our results.Ageing & Society; Ageing International; Generations; The Gerontologist; Journal of Aging and Social Policy; Journal of Applied Gerontology; Journal of Gerontological Social Work; Journal of Gerontology; Journals of Gerontology Series B: Psychological Sciences and Social Sciences; Journal of Housing for the Elderly; Research on Aging. Next, the sum total of all articles for each journal and a grand total number of articles were calculated. These totals were used to compute the proportion of articles dedicated to the topic of aging in place over time. Retrieved articles were excluded from analyses if their contents were book or audiovisual reviews, conference abstracts, or editorials. Finally, we used the advanced search option on each journal's official website, where possible, to identify articles containing any of the three exact phrases and their variations in titles, abstracts, key words, or in the bodies of articles—articles were not counted in this step if key terms appeared only in the bibliographies of papers. For journal websites without this advanced search option, the advanced search option under Google Scholar was used for searching within the specific journal. A similar approach was used by Carr and colleagues [Journals were chosen based on the frequency of appearance of the 3 critical terms and their variations ) in a preliminary search using Google Scholar. If terms appeared in each journal 20 or more times during the 30-year period of interest, we included the journal in our main analysis. These journals included lleagues  in theirArticles that were retained were coded according to three criteria. First, articles were sorted according to whether their content dealt directly with the concept of aging in place (direct) or whether key terms were mentioned only in passing in articles primarily about other topics (indirect). Next, we indicated whether aging in place articles were focused on five areas that influence the capacity of older adults to age in place—these included subcategories for housing/environmental considerations ; community/social services ; assistive devices/technology ; health and functioning ; a miscellaneous category that contained factors that did not fit into the other four subcategories, such as issues pertaining to migratory patterns or municipal zoning regulations. Any single article could be categorized in one or more of these topic areas, depending on the range of scope of the article. Finally, we sorted articles by whether the content was primarily research oriented, or whether articles discussed policy pertaining to aging in place. Articles were categorized as research oriented if concepts of aging in place were analyzed empirically as an antecedent (an independent variable), a mediator (a process variable), or an outcome (a dependent variable). Articles were categorized as policy oriented if their content discussed program development or implementation of programs where aging in place was a stated goal. The search and review of manuscripts were conducted by two readers (SV and BAS), who determined the criteria for inclusion and categorization of manuscripts prior to review. Each reader independently reviewed the possible manuscripts. When the readers disagreed on the categorization of any article, disparate cases were discussed and an agreed upon consensus for classification was established and recorded, before data were analyzed. We conducted frequency analyses and computed the proportion of aging in place articles relative to the total articles published during the period of interest. We also conducted frequency analyses differentiated by whether articles mentioned aging in place as an indirect concept, or whether aging in place was the central issue discussed by the article (direct concept). Finally, we calculated the frequency of aging in place articles by subcategory topic , and by whether articles were research focused or policy focused.Among the journals examined, there was an increase in the publication of aging in place manuscripts from 1980 to 2010 . During When we considered the number of aging in place publications relative to the number of overall journal publications , the treUpon classifying articles as empirical research based and/or explicitly pertaining to or mentioning policy, we noted an increasing absolute number of both empirical and policy-related articles over time . InteresOur initial efforts to determine how aging in place has developed over time and across topics have yielded a number of important points. Of note in our analyses was the increase over time of the “other” category, which was comprised mostly of issues surrounding older adult migration between regions in the US, concerns surrounding older immigrant adults, and municipal-level factors, such as zoning regulations. In addition, we noted four other important trends in the literature that affect the ability of older people to age in place. First, aging in place publications span a wide spectrum ranging from broad to specific investigations. Some broad depictions of manuscripts discuss this concept within the context of the worldwide greying of our communities  and explSecond, with respect to the environment, aging in place has two prongs: aging in place in the home and in other structured settings in the community. While the definition of “home” varies  and continues to remain an essential component of aging in place, increasing attention has highlighted the importance of community care as a means to either support aging in place or as an initial step in fostering the goal of aging at home , 15. Third, aging in place is not a one-size-fits-all concept. There are multiple issues surrounding differences in aging in place among diverse populations. Such diversity arises from differences in preferences and access to services with regards to differences in rural versus urban settings , 17, incFourth, technology has become an increasingly important component to the literature on aging in place. The worker interactive networking project is an example of the growing number of studies that examine the influence of technology in supporting working-family caregivers of frail and memory-impaired older adults . Other sAlthough a number of articles focus on the importance of aging in place , others This study documents the increasing attention given to aging in place in the gerontological research community over the past 30 years. Our findings indicate the growing variety of topics pertaining to aging in place, ranging from housing and environment to health and technology. The relevance of this topic, we believe, has increased over time, in part due to the acknowledged preference of older persons (and younger persons with disabilities) to maintain independence, and to the greater availability of noninstitutional care. In addition, concerns about the escalating costs of institutional long-term care on the part of policy makers have made a priority of concerns by older persons and their families, regarding the desire to avoid relocation in order to receive needed assistance. As a result of this reprioritization, new grants have been initiated to foster aging in place efforts that are based on evidence-based research findings, under the auspices of the National Institute on Aging (NIA), the Administration on Aging (AoA), and other federal agencies.Although we believe that our findings illuminate a real and important growth in the quantity and diversity of aging-in-place publications, we acknowledge some limitations of the current study. Namely, by including only academic manuscripts in the eleven designated gerontology journals, we excluded books, scholarly publications from other related journals , and reports by organizations that have focused specific attention on this issue . Our selected search terms also limited the inclusion of some publications, because of different terminology used among countries and cultures. For instance, some Europeans often use the term “staying put,” while other articles have used “home independence” to encompass the concept of aging-in-place. The use of the selected search terms to study aging in place would represent a more conservative estimate of trends and may provide a selective perspective of the concept. The current study provides a general synopsis of the trends in aging in place literature from 1980 to 2010, but further studies that examine this body of work across a number of other categories are warranted . Despite these limitations, we believe our analyses illustrate the emergence and arrival of aging in place as a focal concept in the scholarly field of gerontology. In conjunction with worldwide population aging and the greater likelihood of surviving to an age when individuals are likely to require some form of daily assistance to achieve independent living, we have documented the concurrent growth in attention paid by gerontologists who often influence policy decisions regarding strategies and barriers to aging at home. Unfortunately, as of 2011, many barriers remain for older adults seeking alternatives to institutional care. This includs limited funding for programs that provide home modifications, service delivery issues, consumer awareness and training issues, and poor communication among government agencies that address health, housing, and services for older adults and people with disabilities . In addiAs a result of these challenges, there is a continued need for research and policy development that can be applied to address these problems. Specifically, researchers should continue to explore how policies, services, environment, and technology influence aging in place, as well as the degree to which aging in place research informs and influences policy and services. Perhaps the biggest question surrounding our results pertains to how trends in aging-in-place literature translate to the needs and services currently provided to older adults. Additional studies are warranted in order to address this important and pressing question. Although aging in place seems to have come of age over this 30-year time period, we expect that future trends will exhibit a greater diversity of aging-in-place topics and that this concept will continue its upward trajectory within gerontology publications.