Health Sciences - Theses, Dissertations, and other Required Graduate Degree Essays

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Factors Affecting the Use of Midwifery Services in Remote Nepal

Author: 
Peer reviewed: 
No, item is not peer reviewed.
Date created: 
2019-10-08
Abstract: 

Tens of thousands of mothers and hundreds of thousands of newborns die each year or have birth injuries. Families living in remote mountainous areas of Nepal are geographically marginalized, and women often deliver without skilled assistance. Human resources are few and often not trained to the level that international professional organizations recommend. Although the government has established birthing centers in communities in eastern Nepal’s remote, mountainous region of lower Solukhumbu, they are not fully utilized. This study of birthing in a remote area of Nepal examined factors associated with access to skilled birth attendants from both a health systems perspective and from the perspectives of mothers and community members. A concurrent, embedded, mixed methods study investigated mothers’, maternity staff and community members’ experiences with birth through semi-structured interviews. The skills of attending nurses, and the enabling factors such as infrastructure, equipment, and supplies in three levels of maternity facilities were examined through two surveys. Participant observation and field notes were additional methods used. Distance and cost were barriers for many women and lack of birth preparedness contributed to delays in reaching a facility if problems occurred. Although communities believed that health facilities save lives, some women preferred home births, citing institutional barriers arising from outdated and unnecessary obstetrical practices, and lack of choices for women. A shortage of skilled human resources and lack of adequate life-saving supplies and medications were found. Lack of infrastructure resulted in difficulty providing care and referrals. Skilled birth attendants were found to have gaps in life-saving skills. Infrastructure and supplies were inadequate in birthing centers. Improvements in quality of care to maintain cultural safety within birthing institutions require respect for women’s preferences, including birth companions and spiritual healers when requested. Frequent focussed midwifery skills refreshers are needed to improve ability to provide skilled and respectful care. Implementing a fully trained midwifery cohort in rural areas would be a longer term goal.

Document type: 
Thesis
File(s): 
Senior supervisor: 
Craig Janes
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) Ph.D.

Resources to support Indigenous reproductive health and justice in Toronto: A respondent-driven sampling study

Date created: 
2018-11-09
Abstract: 

In Canada, the reproductive health and rights of Indigenous women, two-spirit, trans, and gender diverse people are threatened by the complex nature of historic and ongoing colonialism. In the face of widespread oppression, however, Indigenous women, two-spirit, trans, and gender diverse people find ways to achieve wellness. To provide novel statistical information about Indigenous reproductive health, this Master’s thesis takes a strengths-based approach to understanding causes of wellness in a cohort of urban Indigenous women, two-spirit, trans, and gender diverse people of reproductive age (n=323). Through a community-based research partnership with the Seventh Generation Midwives of Toronto and the Well Living House, this study uses secondary data collected with respondent-driven sampling (RDS) methods for the community-driven health survey Our Health Counts Toronto. By drawing on community perspectives and Indigenous reproductive justice theories, we hypothesized that four different resources enhance wellness: (1) relationship to land; (2) traditional foods; (3) cultural connectedness; and, (4) Indigenous programs and services. Logistic regression modelling revealed that relationships to land, traditional foods, and Indigenous programs and services were statistically significant to wellness. This study may aid policy makers and service providers in promoting equitable reproductive health care for Indigenous peoples in Toronto and other Canadian cities. Furthermore, this study demonstrates the applicability of critical Indigenous theories and activism to the fields of population health and epidemiology.

Document type: 
Thesis
File(s): 
Senior supervisor: 
Nicole Berry
Scott Venners
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) M.Sc.

Nonmedical prescription opioid initiation, ongoing use, and related overdose among people who use drugs in Vancouver, Canada

Author: 
Date created: 
2018-12-12
Abstract: 

Background: The prevalence and harms associated with nonmedical prescription opioid use (NMPOU) have risen in Canada, and the prevailing policy response has restricted the supply of prescription opioids (POs) and promoted more responsible patient behaviour. Despite this quick action to address NMPOU, there are key knowledge gaps related to NMPOU initiation, ongoing use, and associated harms among people who use illegal street drugs (PWUD). Objectives: (i) conduct a systematized review of the extant literature related to NMPOU, (ii) identify the prevalence and correlates associated with NMPOU-related initiation trajectories and engaging in recent NMPOU, and (iii) investigate the impact of acquiring POs from physicians for the purposes of NMPOU. Methods: Multiple databases were systematically searched for extant literature on NMPOU. For the empirical studies, data were derived from the Vancouver Drug Users Study, which is an open prospective cohort study of youth and adult PWUD in Vancouver, Canada. Utilizing cross-sectional and longitudinal regression techniques and various sub-samples, I assessed the relationship between various risk factors and the following outcomes: engaging in recent NMPOU, initiating NMPOU before illegal street drugs (vs. after), initiating NMPOU using a physician prescription, and recent non-fatal overdose. Results: The review found some consistent indicators of risk related to NMPOU and gaps in knowledge related to NMPOU among hidden populations. In the empirical analyses, engaging in NMPOU was associated with a higher risk profile regardless of age and sex, and initiating NMPOU before illegal street drugs was also linked with a higher risk profile when compared with those who never engaged in NMPOU. Initiating NMPOU with a physician prescription was not a key indicator of high-intensity substance use or socio-structural vulnerability and acquiring POs using a physician prescription was not associated with recent non-fatal overdose. Conclusions: The results indicate that engaging in NMPOU is associated with a higher risk profile; however, NMPOU-related initiation trajectories and acquisition source do not appear to be a meaningful target for policy solutions or interventions. This dissertation provides some evidence for developing unique strategies to address ongoing NMPOU among younger and older PWUD that includes opioid agonist treatment and income generation opportunities.

Document type: 
Thesis
File(s): 
Senior supervisor: 
Will Small
Robert Hogg
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) Ph.D.

HIV subtype and Nef-mediated immune evasion function correlate with viral reservoir size in early-treated individuals

Author: 
Date created: 
2018-12-07
Abstract: 

The HIV accessory protein Nef is genetically diverse and modulates key immune evasion and pathogenic functions. Recent early HIV-specific adaptive immune responses were identified as correlates of HIV reservoir size. So, we hypothesized that viral factors facilitating evasion of such responses might also influence reservoir establishment and/or persistence. Plasma HIV RNA-derived nef clones were isolated from 30 acute/early-infected individuals and assessed for their CD4 and HLA-I downregulation function in vitro. We explored the relationships between baseline clinical, immunologic and virologic characteristics, and HIV reservoir size measured 48 weeks following initiation of suppressive cART. Nef-mediated HLA downregulation correlated positively with reservoir size. Furthermore, this function was retained in final multivariable models adjusting for established clinical and immunologic correlates of reservoir size. HIV subtype B infection also emerged as a significant correlate of reservoir size on cART. Results highlight potentially important role of viral factors in modulating viral reservoir establishment and persistence.

Document type: 
Thesis
File(s): 
Senior supervisor: 
Zabrina Brumme
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) M.Sc.

A randomized air filter intervention study of air pollution and fetal growth in a highly polluted community: the Ulaanbaatar Gestation and Air Pollution Research (UGAAR) study

Author: 
Date created: 
2018-10-01
Abstract: 

Background: Gestational exposure to fine particulate matter (PM2.5) and cadmium may impair fetal growth. Portable high efficiency particulate air (HEPA) filter air cleaners can reduce indoor PM2.5, but their effect on fetal growth has not been evaluated. Objectives: We assessed (1) HEPA cleaner effectiveness in reducing residential indoor PM2.5 and maternal blood cadmium, (2) the effect of HEPA cleaners on fetal growth, and (3) the relationship between maternal cadmium exposure and fetal growth, among non-smoking pregnant women in Ulaanbaatar, Mongolia. Methods: We randomized 540 participants at ≤ 18 weeks gestation to an intervention (1-2 HEPA cleaners in homes from early pregnancy until childbirth) or control (no HEPA cleaners) group. We collected exposure, health, and demographic data through home and clinic visits and from clinic records. We measured one-week indoor PM2.5 concentrations in early (~11 weeks gestation) and late (~31 weeks gestation) pregnancy, collected blood samples in late pregnancy for analysis of cadmium, and obtained birth data at delivery. We evaluated the effect of the intervention on our primary outcome, birth weight, and other fetal growth indicators using unadjusted linear and logistic regression and time-to-event analysis, in intention-to-treat analyses. We also used multiple linear and logistic regression to assess the relationships between log2-transformed blood cadmium and fetal growth. Results: HEPA cleaners reduced indoor PM2.5 and blood cadmium concentrations by 29% (95% CI: 21, 37%) and 14% (95% CI: 4, 23%), respectively. Among 463 live births, the median (25th, 75th percentile) birth weights for control and intervention participants were 3450 g (3150, 3800 g) and 3550 g (3200, 3800 g), respectively, but the intervention was not associated with an increase in birth weight (18 g; 95% CI: -84, 120 g). In a pre-specified subgroup analysis of 429 term births the intervention was associated with an 85 g (95% CI: 3, 167 g) increase in mean birth weight. A doubling of blood cadmium was associated with an 86 g (95% CI: 26, 145 g) reduction in birth weight. Conclusions: Our findings provide further evidence that PM2.5 and cadmium exposures during pregnancy impair fetal growth and that exposure reduction during pregnancy can reduce these effects. Portable HEPA cleaners are an effective household-level intervention but reductions in air pollution emissions are needed to realize the largest public health benefits.

Document type: 
Thesis
File(s): 
Senior supervisor: 
Ryan Allen
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) Ph.D.

An institutional ethnography of substance-use practices among nurses and related management intervention practices in a province in Western Canada

Author: 
Date created: 
2018-12-05
Abstract: 

When nurses have problems with substance use and are reluctant to seek treatment, their health and wellness are put at risk and their care provision to the public is potentially compromised. Nurses’ substance-use problems and their management through professional organizations’ treatment programs are underresearched and poorly understood overall, and particularly from a Canadian perspective. The disjuncture I experienced between my own embodied experiential knowledge as a nurse and the conceptually based, decontextualized, individuated “official accounts” of the issue I found in the professional and scholarly literature became the problematic that I explored in a multiphase, manuscript-based doctoral study. I carried out a critical integrative review of the literature on nurses’ substance-use problems, followed by an institutional ethnographic inquiry, in which I aimed to discover (a) how dominant discourses in nurses’ talk about their everyday worlds organized their substance-use practices and (b) how nurses’ experiences were managed in a regulatory treatment program. I utilized data from interviews with 12 standpoint informants (nurses in a regulatory program for substance-use problems) and six secondary informants from different standpoints in the institution, as well as analyses of relevant institutional texts. This work yielded significant original findings. Dominant individuated, moralistic, decontextualized discourses in nurses’ talk about their everyday worlds and in professional and scholarly texts silenced nurses’ experiences of work stress. Employers’ roles in nurses’ working conditions were obscured. Nurses’ substance-use practices, particularly alcohol, were organized in ways that enabled them to silently manage their distress and keep working. Nurses gaining capacities to self-advocate for improved working conditions was linked to their recovery from substance-use problems. The standardized regulatory treatment program studied was not based on current norms of practice; did not afford nurses the right to choose treatments; privileged physicians while silencing and subordinating nurses; and was rife with conflicts of interest, power imbalances, and private corporate benefits—all acritically accepted by the regulatory body. The important new nursing knowledge gained informs prevention, treatment, regulatory, and education processes aimed to address nurses’ substance-use problems. It does so from nurses’ everyday knowledge and standpoint, furthering their interests and those of other disciplines concerned with professional power and domination.

Document type: 
Thesis
File(s): 
Senior supervisor: 
Nicole S. Berry
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) Ph.D.

Understanding a public bicycle share program in Vancouver, Canada: program uptake and impacts on bicycling

Author: 
Date created: 
2018-09-25
Abstract: 

Public bicycle share programs have the potential for positive health and environmental benefits. In order for these benefits to be realized, the programs need to be well used at the population level and contribute to increases in bicycling. This thesis aimed to understand demand for the Vancouver public bicycle share program among residents and the impact of the program on bicycling. We used data from a public bicycle share member survey and a repeat cross-sectional survey of Vancouver residents. As of Fall 2017, approximately 6.2% of Vancouver residents have used the public bicycle share program, and amongst non-users, nearly 1 in 4 indicate they are likely to use the program. However, we did not observe an increase in bicycling for those living and/or working inside the bicycle share service area relative to those outside the service area in the second season of program operation.

Document type: 
Thesis
File(s): 
Senior supervisor: 
Meghan Winters
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) M.Sc.

A randomized controlled trial of prenatal air pollution exposure and the development of allergic sensitization in infancy

Author: 
Date created: 
2018-07-12
Abstract: 

Background: Prenatal exposure to PM2.5 has been associated with the development of allergic sensitization in children. We conducted a single-blind, randomized controlled trial in Ulaanbaatar, Mongolia to test the effectiveness of HEPA filter air cleaner use during pregnancy on the risk of allergic symptoms in the first year of life. Methods: We enrolled 540 pregnant women at 10.3 weeks’ gestation, on average, and randomly assigned them to the intervention group (N = 217), which received one or two air cleaners (depending on home size) to use from enrollment until childbirth, or the control group (N = 187). We measured indoor PM2.5 concentrations over 7-days at ~11 weeks’ gestation and again at ~31 weeks’ gestation. We surveyed mothers about eczema, wheeze, respiratory infections and otitis media in the first year of life. The effectiveness of the intervention was analyzed using logistic regression in intention-to-treat analyses. Results: Baseline characteristics were similar between the two groups. PM2.5 concentrations were 29% lower, on average, in intervention homes than control homes (95% CI: 21-37%). The prevalence of outcomes ranged from 8.2% for wheeze to 54% for eczema. The intervention was significantly associated with a reduction in wheeze (OR: 0.47, 95% CI: 0.22 – 0.97). For eczema (OR: 1.12, 95% CI: 0.76 – 1.66), otitis media (OR: 1.07, 95% CI: 0.64 – 1.76) and chest infections (OR: 0.91, 95% CI: 0.58 – 1.43), the 95% confidence intervals indicated both potential harmful and beneficial effects of the intervention. Conclusion: The use of HEPA filter air cleaners during pregnancy reduced the odds of parent-reported wheeze in the first year of life.

Document type: 
Thesis
File(s): 
Senior supervisor: 
Ryan Allen
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) M.Sc.

Assessing the relation between plasma PCB concentrations and elevated autistic behaviours using Bayesian predictive odds ratios

Author: 
Date created: 
2018-07-11
Abstract: 

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by impaired social communication and repetitive or stereotypic behaviours. In utero exposure to environmental chemicals, such as polychlorinated biphenyls (PCBs), may play a role in the etiology of ASD. We examined the relation between plasma PCB concentrations measured during pregnancy and autistic behaviours in children aged 3-4 years old in the Maternal-Infant Research on Environmental Chemicals (MIREC) Study. We calculated Bayesian predictive odds ratios for more autistic behaviours based on a latent variable model with a threshold of SRS >60. We found small and imprecise increases in the mean SRS score for the highest quartile of plasma PCB concentrations compared with the lowest quartile; these were accompanied by larger increases in the odds of more autistic behaviour. In conclusion, we found some evidence that plasma PCB concentrations during pregnancy may be associated with small increases in autistic behaviours in this cohort.

Document type: 
Thesis
File(s): 
Senior supervisor: 
Lawrence McCandless
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) M.Sc.

Potential barriers and facilitators to small businesses adopting a psychological health and safety management system

Author: 
Date created: 
2018-07-24
Abstract: 

In recent years, the importance of identifying and managing psychological risk factors in the workplace has received increasing recognition due to significant evidence that suggests that workplace factors can adversely impact the onset and duration of mental health problems among workers. This has led to the development of the National Standard of Canada for Psychological Health and Safety in the Workplace (The National Standard). Some organizations, especially large ones, have implemented, or are starting to implement, the National Standard. Notwithstanding that, there is still a lack of understanding of the facilitators and barriers to the effective implementation of a psychological health and safety management system (PHSMS). Thus, the challenges and opportunities of how small organizations put the National Standard into practice needs further study. This paper aims to examine the relevant literature and perform a search to identify potential facilitators and barriers that may affect small businesses in the process of implementing a PHSMS. In addition, some recommendations have been provided to assist small business in overcoming these barriers.

Document type: 
Graduating extended essay / Research project
File(s): 
Senior supervisor: 
Merv Gilbert
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Project) M.P.H.