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

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Social and structural contexts of the overdose crisis: An ethnography of overdose risk among structurally vulnerable women who use drugs in Vancouver, Canada

Author: 
Date created: 
2020-01-08
Abstract: 

Background: North America’s overdose crisis is driven by illicitly-manufactured fentanyl and fentanyl-adulterated drugs. Vancouver’s Downtown Eastside neighborhood in Canada is one of North America’s overdose epicenters. Notably, the majority of overdose deaths in Vancouver are occurring in indoor environments, including single room accommodations (SRA) housing. While there is an awareness of the role social, structural, and environmental factors in producing harm among people who use drugs (PWUD), we do not fully understand how social-structural forces (e.g. housing models, social norms) shape overdose risk for women who use drugs (WWUD). This dissertation seeks to address this gap by examining how contextual factors operating in a street-based drug scene create variegated overdose risk for WWUD. Methods: This dissertation draws on ethnographic research conducted with WWUD living in SRAs in Vancouver’s Downtown Eastside from May 2017 to December 2018. Data include in-depth baseline and follow-up interviews, and approximately 100 hours of observational fieldwork in SRAs and neighborhood areas. Analysis drew on an intersectional risk environment approach that was developed and then applied to the data to characterize social-structural dynamics shaping overdose risk for WWUD. Results: Findings underscored how normalized violence against WWUD in the drug scene shaped the social and spatial relations of women, and acted as a driver of overdose risk. First, women challenged gendered power dynamics through embodied drug use practices and using drugs alone. Second, WWUD experienced operational and social environmental barriers that minimized their utilization of low-threshold overdose-related interventions in SRAs, thereby increasing risk of fatal overdose. Finally, WWUD experienced burnout related to care-taking and paid labor responsibilities (e.g. peer overdose response), which led them to use drugs alone to cope. Conclusion: These findings demonstrate how gendered power dynamics operating within a drug scene setting overlapped with social (e.g. stigmatization, gender inequities), structural (e.g. prohibition of smoking in overdose-related interventions), and environmental factors to shape fatal overdose risk for WWUD. These findings underscore the need for wider structural transformations to mitigate morbidity and mortality for WWUD. Modifying and scaling up overdose prevention interventions in the community and within SRAs to make them more accessible to women is also imperative.

Document type: 
Thesis
File(s): 
Supervisor(s): 
Kanna Hayashi
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) Ph.D.

The whole systems approach to obesity and non-communicable diseases: Implications for research, policy and practice

Author: 
Date created: 
2019-12-10
Abstract: 

Obesity and non-communicable diseases (NCDs), significant threats to population health, are widely understood to be embedded in complex systems of interdependent causal factors. As such, researchers, policymakers and practitioners have become increasingly interested in systems-wide approaches that have the potential to reduce the burden of these diseases. Outcomes of this trend include the development and application of new systems science methods, and a turn towards multi-sectoral collaborative engagement as a key directive for influencing systems. This dissertation explores these aspects of the whole systems approach to obesity and NCDs through three original research papers. In the first, a novel systems science framework is employed to analyze recommendations drawn from 12 documents aimed at influencing obesity planning. Results show that many of the documents focus on changing the determinants of energy imbalance and lack planning at higher levels of system function, such as interconnections between system elements and goal setting. This paper demonstrates the utility of systems science frameworks for introducing systems thinking into policy-level planning in a manner accessible to public health stakeholders. The second and third papers turn to the subject of multi-sectoral partnerships. The first of these represents a review of the role of public health partnerships with the private sector in addressing obesity and NCDs. Contemporary challenges around working with the food and beverage sector are considered through a systems-informed lens that pushes traditional thinking about conflict of interest and the role of monitoring and evaluation activities related to partnership engagement. The following chapter presents an exploratory qualitative study of federal governmental public health staff’s experiences working to develop co-funded multi-sectoral partnerships. Findings highlight the opportunities and challenges that emerge from government efforts to shift relations with traditional and novel partners in an effort to leverage partnerships for system change. Suggestions for how program implementers can take dynamic system attributes such as capacity, trust, and power relations into account when implementing multi-sectoral partnership programs are also offered. Finally, this dissertation concludes with a critical reflection on the research findings in light of the whole systems imperative and its implications for the public health response to obesity and NCDs.

Document type: 
Thesis
File(s): 
Supervisor(s): 
Diane Finegood
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) Ph.D.

Getting from here to there: Boosting women’s participation in bicycling through adult bicycle skills training.

Author: 
Date created: 
2020-09-30
Abstract: 

Increasing bicycling in cities is a public health and sustainability goal. Although supportive infrastructure is a necessary precondition for most people to begin riding, other forms of encouragement are also needed to spur uptake across populations. Women are an important target group as they participate in bicycling at roughly one-third the rate of men. While much is known on the importance of a safe, dense, and well- connected bikeway network, there are knowledge gaps on ‘soft’ interventions related to training or education. Questions remain on the effectiveness of bicycle skills training, how trainings interact with the bikeway network, and, given the bicycling gender disparity, the role training has on supporting women’s participation. To address these gaps, this dissertation assessed the impact of a bicycle training course in encouraging participation among new and returning bicyclists, and the broader processes that enabled bicycling for women of diverse backgrounds. Weaving together behaviour change theory and gender frameworks, the longitudinal mixed methods study drew on questionnaire and interview data from Metro Vancouver, Canada—a region promoting bicycling and extending its bicycle infrastructure. The dissertation found that training facilitated only modest short-term increases in leisure bicycling. Other elements of the social and physical environment did not support a full variety of journeys to be made by bicycle, and these elements were more influential than individual attributes such as skill or knowledge. Nevertheless, training provided a safe environment to improve handling skill, learn traffic rules and safety, or reinforce pre-existing knowledge. Training enabled some participants to bicycle in more challenging conditions, thus enhancing their bicycling mobility. Policy recommendations derived from this work include: bold expansion of the bikeway network; more intensive training and practice sessions for new and returning riders; broader outreach to clarify bicycling norms and etiquette; education for drivers; and integrating a gender lens into bicycle planning. By applying a novel integration of gender and social practice theoretical frameworks to examine the impact of an intervention on an under-studied population of new and returning bicyclists, this dissertation contributes both new evidence and new conceptual insights to theory and practice of bicycling in cities.

Document type: 
Thesis
File(s): 
Supervisor(s): 
Meghan Winters
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) Ph.D.

Cotinine, tobacco smoke, and diet: Strengthening our understanding of this biomarker in early life

Author: 
Date created: 
2020-08-26
Abstract: 

There are concerns about the usefulness of cotinine and trans-3’-hydroxycotinine (3HC), as biomarkers of risk in populations with light tobacco smoke exposure. Using CHILD cohort study data, multiple linear and logistic regression was used to determine how well questionnaire responses explained urinary concentrations of cotinine and 3HC in infants, whether these concentrations predicted childhood asthmatic and allergic disease risk, and whether breastmilk facilitated nicotine exposure. Predictive models explained 31% and 41% of the variation in cotinine and 3HC, respectively. Only 23% of the infants had urinary concentrations consistent with second-hand smoke (SHS) exposure. The majority (92%) of household smoking occurred outdoors. While smokers breastfed less often, breastmilk did facilitate nicotine intake. The implications of dietary nicotine sources through breastmilk were inconclusive. Subclinical impacts and the pervasiveness of thirdhand smoke pose a challenge for public health and we should re-evaluate our use and interpretation of nicotine biomarkers in low-smoke exposure settings.

Document type: 
Thesis
File(s): 
Supervisor(s): 
Tim Takaro
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) M.Sc.

“This is what labels you”: Examining the structural context of how limited English proficiency and experiences with interpretation services interact to shape health and health access for im/migrant women in Metro Vancouver, British Columbia

Date created: 
2020-10-20
Abstract: 

Considerable research has documented negative health outcomes of ‘language barriers’ for im/migrants in destination countries. There is a crucial need for research underpinned by structural and intersectional frameworks that center im/migrant women’s lived experiences to inform interventions that move beyond the individual-level towards systemic, equity-oriented change. This study analyzed qualitative data from focus groups (4, N=29) and individual interviews with im/migrant women (N=49) and providers (N=10) conducted from July 2018 – February 2020 in Metro Vancouver, British Columbia. Moving beyond conceptualizations of language as a ‘barrier’, narratives revealed how unmet communication needs for im/migrant women operated as a form of systemic discrimination. Responsibility for communication often rested on im/migrant women, relegating them to a second tier of care. Best practices for interpretation included a holistic approach that went beyond availability of language-concordant options towards im/migrant-sensitive models that accommodate converging effects of language, im/migration status, systemic racism, and gender.

Document type: 
Thesis
File(s): 
Supervisor(s): 
Shira Goldenberg
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) M.Sc.

Chronic inflammation and the onset and pace of reproductive maturation in Mayan girls

Date created: 
2020-07-14
Abstract: 

Life History Theory proposes that, when metabolic energy availability is limited, trade-offs ensue amongst growth, maintenance, development, and reproductive tasks. Thus, we hypothesize that limited energy availability resulting from chronic inflammation should create a trade-off between immune function and reproductive maturation, leading to a delay in the maturation of the female reproductive system. We assessed reproductive hormone profiles (follicle-stimulating hormone, estrogen, and progesterone) and inflammation status (using C-reactive protein and interleukin-1β as biomarkers) of 20 Guatemalan girls in 2013 (before menarche) and in 2017 (after menarche). We observed an average delay of 15 months (95% confidence interval [5.8, 24.1]) of menarche in girls with chronic inflammation compared to girls with no inflammation. However, our results did not provide evidence that chronic inflammation affected cycle length or ovulation frequency. This study aims to contribute to filling the gap in our understanding of the biological effects of low-grade immunological challenges, such as chronic inflammation, on girls’ reproductive maturation process.

Document type: 
Thesis
File(s): 
Supervisor(s): 
Pablo Nepomnaschy
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) M.Sc.

Social and cultural aspects of living with type 2 diabetes for ethnic minorities in Canada

Date created: 
2020-04-30
Abstract: 

Diabetes is a chronic progressive disease that affects one in three Canadians and ethnicity is one of its risk factors in Canada. Type 2 diabetes (T2DM) which constitutes the vast majority of the cases, is highly impacted by social and cultural factors. However, we know very little about how social and cultural factors impact living with T2DM in for ethnic minorities in Canada. A systematic review of the existing literature and survey-based assessment of patient perceptions were conducted. The most important social and cultural determinants of health for patients were diabetes education, social support, cultural competency of institutions (e.g. healthcare system, the government), patient trust for institutions, perceptions of self, and the perception of financial barriers. The social and cultural factors of importance can be understood in three categories of (1) diabetes education, (2) perceptions of self and perceived relations with others, (3) perceived financial constraints.

Document type: 
Thesis
File(s): 
Supervisor(s): 
Scott Lear
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) M.Sc.

The knowledge and effect of a drug-related good samaritan law among people who use drugs in Vancouver, Canada

Author: 
Date created: 
2020-08-04
Abstract: 

In response to the drug poisoning crisis in Canada and the US, some jurisdictions have enacted drug-related Good Samaritan laws (GSLs) to encourage observers of acute poisoning events to call emergency medical services (EMS) during times of overdose. To date, the effectiveness of GSLs are indeterminate. This thesis undertook a literature review on the effectiveness of GSLs, evaluated the working knowledge of a GSL, and the impact of this law among participants of three large prospective cohort studies of community-recruited people who use illicit drugs (PWUD) in Vancouver, a full year after the enactment of a GSL in Canada. Overall, the literature review demonstrated mixed evidence with regard to the effectiveness of GSLs. Only about a third of our sample had accurate knowledge of the GSL and the GSL did not appear to have changed EMS-calling rates. Additional measures are urgently needed to support the aims of GSLs.

Document type: 
Thesis
File(s): 
Supervisor(s): 
Kanna Hayashi
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) M.Sc.

Fairness under fire: Environmental justice, mental health, and natural disasters

Author: 
Date created: 
2020-08-10
Abstract: 

Natural disasters are increasing due to climate change, bringing with them substantial increases in disaster-associated mental illnesses, such as depression, PTSD, and anxiety. Previous evidence has shown that after a natural disaster, these mental heath outcomes are not distributed equally throughout the population, but tend to affect certain groups of people more than others. Yet, inequality does not necessarily constitute an inequity. Currently, there is no established way of determining the fairness of mental health outcomes post-disaster, which is a necessary component of determining whether policies or guidelines ought to change in order to remedy an injustice. In this project, I use an environmental justice framework to assess the justness of mental health outcomes after natural disasters, using the Fort McMurray fire of 2016, known as The Beast, as a case study. Environmental justice theories have not previously been used to determine justness of mental health outcomes after natural disasters, therefore I begin by determining whether this the correct type of theory to use for this endeavour by examining certain critical components of the theory against what would be required for its application in this particular context. I end this ethical analysis by suggesting particular elements for inclusion in an environmental justice theory, to accommodate its usage for mental health outcomes post-natural disaster. The Beast caused the largest mandatory evacuation and was the costliest disaster in Canadian history. It therefore serves as a highly relevant case study to examine the question of equity in mental health outcomes in a Canadian context. Using aggregated data from Alberta Health, academic articles, newspaper articles, and published reports, I attempt to determine what the mental health outcomes of the Beast were, and if they affected the members of the population equally. In my final chapter, I applied the findings from my ethical analysis to the case study. This iterative process highlighted gaps and strengths in the approach. I conclude this thesis by reflecting on the learnings from this application process and offer thoughts on how we can move forward.

Document type: 
Thesis
File(s): 
Supervisor(s): 
Jeremy Snyder
Diego Silva
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) M.Sc.

A study of mindfulness-informed group process: Towards burnout prevention and treatment

Author: 
Date created: 
2020-07-02
Abstract: 

Background: Chronic work-related stress, known as burnout, is damaging to patient’s recovery, healthcare professional’s health and the organization’s functioning. Burnout increases medical errors and healthcare costs through a cascade of effects, including a decrease in work quality, job satisfaction, and retention. Prevention and treatment strategies have focused on the improvement of the organizational environment or building individual resiliency. While important, these have not adequately addressed the vital role groups play in the management of stress. I posit the need for new approaches inclusive of innovative group strategies that bring about the co-regulation of stress in work groups. Mindfulness-informed group process is one such approach that appears to improve group functioning through a combination of safe group development infused with mindfulness. Methodology: To better understand the principles of mindfulness-informed group process, this research used a constructivist grounded theory methodology to develop a mindfulness-informed group theory. Data was collected using semi-structured interviews, relevant scholarly literature collated through systematic reviews, and additional related published materials. Interviews were conducted with mindfulness-informed group leaders, each with extensive training in a mindfulness-informed practice and group therapy. Results: Findings detailed an interlocking process whereby the leader’s mindfulness and the form of the group infuse the interpersonal mindfulness of the group. This creates an interpersonal field where mindfulness is practiced and trained as a skill. Mindfulness-informed group leaders play a vital role in the development of mindfulness-awareness in the group through their openness, genuineness and skillful communication. Interpersonal mindfulness allows for enhanced communication as member’s signal safety facilitated by the skillful articulation of feelings and thoughts in-the-moment within workplace constraints. Members create connections and social support, which appears to allow for increased self-regulation of stress through mindfulness and co-regulation through interpersonal mindfulness. Discussion: Mindfulness-informed group theory offers insights into the regulation of stress and burnout for healthcare leaders and professionals in small group environments. It does so by highlighting the development of safe group environments through the practice of interpersonal mindfulness in work interactions. Burnout is best addressed through improving individual resilience, the development of safe interpersonal environments and organizational efforts to support professionals in healthcare delivery.

Document type: 
Thesis
File(s): 
Supervisor(s): 
Daniel Vigo
Heesoon Bai
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) Ph.D.