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

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Privacy concerns, HIV care provider trust, and clinical care engagement among women living with HIV in response to the criminalization of HIV non-disclosure in Canada

Author: 
Date created: 
2020-01-13
Abstract: 

In 2012, the Supreme Court of Canada ruled that people with HIV have a legal obligation to disclose their serostatus to partners prior to sex that poses a “realistic possibility” of HIV transmission. This study used Wave 2 survey data from 1422 women living with HIV (WLWH) enrolled in the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study to examine (1) the proportion and socio-demographic characteristics of WLWH who perceived privacy concerns due to the law; (2) the association between WLWH’s privacy concerns and trust of HIV care providers; and (3) the association between WLWH’s privacy concerns and HIV clinical care engagement. Results showed that a majority of participants reported privacy concerns, and that the socio-economically vulnerable women had significantly higher odds of privacy concerns. WLWH with lower provider trust had higher odds of privacy concerns. There was no significant association between privacy concerns and HIV care engagement.

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

Evaluating and utilizing crowdsourced data and population surveys in bicycling safety research

Date created: 
2020-04-14
Abstract: 

Increased population level bicycling would benefit society by improving health outcomes and reducing fossil fuel emissions. A main factor preventing increased bicycling is concerns regarding safety. Traditional sources of bicycling safety data (police, hospital or insurance data) underreport incidents and are biased. Alternative sources of bicycling safety data, including crowdsourcing and population surveys, are untested and rarely utilized. Crowdsourced data will include incidents that go unreported to traditional sources, but the nature of any systematic biases in these data are poorly understood. Population surveys represent the only means of collecting detailed individual-level information regarding road users, but there is little consideration by researchers of how survey design choices may affect measured outcomes. When combined with spatial data, population surveys can contribute to understanding associations between rarely studied characteristics of road users and perceived or objective safety. In this thesis, I evaluate alternative sources of bicycling safety data, and contribute to different dimensions of bicycling safety knowledge, by evaluating bicycling safety data collection methods and identifying correlates of perceived and objective bicycling safety. Specifically, the chapters in this thesis address gaps in our understanding of (i) biases in crowdsourced bicycling safety data, (ii) the relationship between personal characteristics, infrastructure, and overall perceived bicycling safety, (iii) the impacts of survey design on measurements of bicycling behaviour, and (iv) bicycling crash risk for different sociodemographic characteristics, social environments (including attitudes and social norms), and neighbourhood-built environment features. In this thesis I provide two broad contributions: (i) showcasing the potential for crowdsourced data and population surveys to compliment traditional bicycling safety data and, provide answers to applied question in bicycling safety research; (ii) underscoring the value of linking a-spatial survey data to a geographic location to be able to assign measurements of a participants built environment and, be able to consider different scales of influence on the outcome. Future research in this area should focus on creating a linked crash database of self-report, crowdsourced, police, hospital and insurance data, as well as on the collection and integration of spatially resolved exposure estimates in travel surveys.

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

Economic evaluation in the context of schizophrenia and related psychotic conditions: A systematic review and cost-consequence analysis

Author: 
Date created: 
2020-04-15
Abstract: 

Psychosis is a symptom that presents in mental health disorders including schizophrenia, major depression, and bipolar disorder. How best to capture the benefits of interventions in the broader context of mental health is an area of debate in health economics, particularly the suitability of generic quality of life measures. Specific to psychosis, these issues are explored through a systematic review and cost-consequence analysis. Findings from the review show the array of outcomes that have been used to quantify benefit in economic evaluations, with most studies using condition-specific (rather than generic) measures. Given this deviation from ‘standard’ approaches, cost-consequence analysis provides an appropriate way to assess the cost-effectiveness of interventions in this clinical context – the illustrative example in this thesis comprises an assessment of a supported employment model. Understanding the reasons for the infrequent use of widely-accepted economic evaluation techniques is an important area for further health economics and policy research.

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

Health economic modeling to optimize the HIV care continuum: methods and applications

Author: 
Date created: 
2020-01-30
Abstract: 

Despite over $20B of annual federal funding directed towards domestic HIV efforts, 38,000 new cases were diagnosed in 2017 in the US. The recently announced “Ending the HIV Epidemic: A Plan for America” initiative set ambitious goals to reduce new HIV infections by 90% within 10 years. Achieving these ambitious goals necessitates a resource-intensive response consisting of targeted, context-specific combination implementation strategies. Economic models play a critical role in informing resource allocations for the care and prevention of HIV/AIDS, providing a unified framework to quantify the health and economic value of different strategies. A diversity of modelling designs and approaches exist, each requiring different forms of data. Input data are rarely known with certainty. This in turn might propagate into result uncertainty and lead to suboptimal decisions. However, presently there is a paucity of standardized guidelines on model structural design, evidence selection and methods to address decision uncertainty. The objective of this thesis is to provide methodological advances in decision-analytic modeling in HIV/AIDS, with a focus on model design, the quality of supporting evidence, calibration, validation and analysis of uncertainty. The design of a model and input data are two central factors in ensuring credible inferences. We executed a narrative review of a set of dynamic HIV transmission models to comprehensively synthesize and compare the structural design and the quality of evidence used to support each model parameter (Study 1). Model complexity and uncertainty surrounding its inputs can diminish our confidence in a model. We provided a comprehensive description of the calibration and validation of a dynamic HIV transmission model for six US cities with diverse microepidemics, detailing key methodological innovations and efforts to increase rigorousness in the process. The resulting projections will provide a basis for assessing the incremental value of further investments in HIV combination implementation strategies (Study 2). Value of information analysis quantifies the value of collecting more information to reduce decision uncertainty and helps guide efforts for future data collection. Using the developed HIV model, we performed probabilistic sensitivity analysis on the highest-valued combination strategies and applied metamodels to estimate the value of collecting additional information to eliminate decision uncertainty (Study 3). Findings of this study will make substantial methodological and public health contributions, providing implications for health decision-makers and scientists alike. This methodological approach can serve as a means of optimizing HIV strategies and be applied to diverse settings across North America and internationally.

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

Discovery and mechanistic study of HIV-1 transcriptional inhibitors from natural and synthetic products

Author: 
Date created: 
2019-12-17
Abstract: 

There is currently no safe, scalable cure for HIV-1 infection due to the persistence of a latent viral reservoir. The Block-and-Lock strategy to achieve drug-free HIV remission requires promotion of a durable, deep latent state from which dormant HIV does not reactivate. However, there are currently no licensed HIV inhibitors that target expression from the latent reservoir. Factors that are required for efficient viral transcription, such as the HIV protein Tat and the host factor CDK9, are potential targets for Block-and-Lock approaches. My thesis describes an effort to discover novel antivirals that prevent expression from latently infected cells and inhibit viral replication. I describe the identification of natural and synthetic inhibitors of HIV Tat-mediated transcription, the investigation of their molecular mechanisms, and their potential as Block-and-Lock agents. The work presented here informs the development of future HIV drug-free remission strategies and identifies CDK9 as a potential target for Block-and-Lock strategies.

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

Thesis on the association of vaginal practices to bacterial vaginosis among adolescent girls and young women in South Africa: A risk for HIV

Author: 
Date created: 
2019-12-17
Abstract: 

South Africa has one of the highest prevalence of HIV globally with adolescent girls and young women (AGYW) being mostly affected. Increased vulnerability to HIV acquisition among adolescent girls and young women in South Africa is due to a combination of behavioral, socio-structural, demographic, clinical, and biological factors. Some of these factors are prevalent in South Africa and they are inclusive of bacterial vaginosis (BV), an effect in part of vaginal practices (VPs). VPs comprise a variety of behaviors used by women for cleanliness, health, and sexuality of the vagina and they’re practices that have been shown to have associations with BV. Major pathogenic organisms involved in presentations of BV have been found to encourage the replication of HIV and therefore, its acquisition. This project aimed to measure the prevalence of VPs and to assess the varying types of VPs among HIV-uninfected or HIV-unknown dis-gender AGYW aged 16-24 years. It also measured the prevalence of BV in this population and its association to VPs .We used a cross sectional study design to assess baseline data of the AYAZAZI, a prospective cohort study whose longitudinal design analyses varying aspects of the sexual and reproductive health of adolescents and youth in South Africa. We employed the estimation Framework to evaluate VPs and their relationship to BV. For both our analyses (Chapters 2 and 3) we create a directed acyclic graph (DAG) to help establish the interrelationship of covariates and to determine the adjustment variables for each model. We then assessed VPs before measuring their prevalence and association to BV. Seventy seven percent of AGYW use VPs and this is mostly by washing with water only inside the vagina (66%). Bacterial vaginosis was reported in 47% of AGYW compared to symptoms of GTI in only 15%, supporting the notion that syndromic BV management offers substantial under-diagnosis for the effective management of implications to BV. Through multivariable logistic regression, we found 1.7 (0.7-3.8) odds of BV among VP users. Vaginal practices are highly prevalent among AGYW. An association between vaginal practices (VPs) and bacterial vaginosis (BV), a risk for HIV acquisition, has been previously reported. This study provides further evidence to this relationship and suggests that VPs are a likely determinant to BV; a plausible cause to increased HIV acquisition among AGYW. This information is important for the inferential management of the sexual and reproductive health of AGYW. The inconclusive findings call for a need to study and understand predisposing factors to HIV infection among AGYW for development of effective interventions.

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

A case study of integrated knowledge translation in the context of en masse interinstitutional relocation of a long-term care home in Canada

Author: 
Date created: 
2019-09-27
Abstract: 

The knowledge translation (KT) literature continues to grow but a gap persists in our understanding of the utility and application of the numerous KT models due to limited reporting and analysis in the literature. To address this gap, a case study of an integrated KT (iKT) project that applied the Knowledge to Action (KtoA) model (Graham et al., 2006) in the development of a guiding framework to support en masse interinstitutional relocations of long-term care (LTC) homes was completed. Specifically, the research questions were 1) what was the relevance and utility of applying the KtoA model to an iKT project, and 2) what approaches used provided new insight and how could that be applied to other projects? Central to KT is knowledge synthesis and central to iKT is stakeholder engagement, the evidence and processes used detailed in this case study include: in-depth interviews with residents, staff and families; World Café dialogues with experienced LTC informants; and a research literature synthesis. The use of the KtoA model and its limitations are explored, including the lack of emphasis on relationality and context within the model. In addition, the challenges and lessons learned with the World Café approach to deliberative dialogues are explored including the pitfalls of biased method selection and the richness of interactive conversations. The findings of this case study contributes to the KT literature through the detailed reporting and analysis of the use of the KtoA model and engagement methods that can inform further KT model and methods development.

Document type: 
Thesis
Supervisor(s): 
Marina Morrow
Department: 
Health Sciences: Faculty of Health Sciences
Thesis type: 
(Thesis) Ph.D.

Epidemiological evaluations of methadone adherence in opioid dependent offenders: Implications for public health and public safety

Author: 
Date created: 
2019-08-13
Abstract: 

Background: Opioid use is associated with elevated rates of morbidity and mortality and has a significant impact on public health and public order. Justice involved individuals are disproportionately affected by opioid related harms but effective interventions are underutilized. Methadone maintenance treatment is the best researched and mostly widely implemented pharmacotherapy option for the treatment of opioid dependence. Despite its demonstrated efficacy in general populations, few studies have examined its effectiveness among patients with criminal justice histories and complex health and social challenges. This thesis aims to address the deficits in existing extant literature through three unique research studies described herein. Methods: All studies were conducted using a retrospective cohort design involving linked population-level administrative data. Participants comprised a cohort of individuals from British Columbia, Canada with histories of convictions and who filled a methadone prescription. Three independent analyses estimated the effect of methadone on crime, mortality and hospitalization. Methadone was divided into medicated (methadone was dispensed) and nonmedicated (methadone was not dispensed) periods and analyzed as a time-varying exposure. Cox regression was used in all three analyses and hazard ratios with 95% confidence intervals were reported as an effect size. In all instances additional subgroup and sensitivity analyses were performed. Results: Over a mean follow-up time of eight years, findings from the sample (n=14, 530) revealed a significant association between dispensed methadone and lower rates of violent and non-violent crime; all-cause and cause-specific mortality; and any-cause hospitalization (n=11, 401) even after controlling for a number of covariates. Findings for crime and hospitalization analyses demonstrated the magnitude of protective effect for methadone was greatest during the initial years following methadone treatment initiation but decayed in periods exceeding a decade. Subgroup and sensitivity analyses demonstrated a similar pattern of results. Conclusions: Adherence to methadone is associated with lower rates of opioid related harms among justice involved patients with opioid dependence. Results consistently point to the need for increased access to methadone and higher rates of adherence for offenders and similarly marginalized groups. Implementation of evidence-based policies and programs are required to improve adherence and promote recovery in this vulnerable population.

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

Improving patients’ understanding of their rights under British Columbia’s Mental Health Act

Author: 
Date created: 
2019-07-02
Abstract: 

In a 2011 survey of mental health patients in BC, 43% of respondents who had been involuntarily hospitalized said that their rights under the Mental Health Act were not explained to them in a way they could understand. One possible reason for this lack of understanding is that the document used to give rights information to involuntary patients, the statutory Form 13, may not be an effective communication tool. Another possible reason is that the rights-information process doesn’t meet patients’ information needs. Using a qualitative approach anchored in a transformative research paradigm, which seeks to redress power differences by involving the community of interest in designing and implementing solutions, I aimed to identify key features of a patient-centred rights-information process. First, I user tested Form 13 with people who had experienced involuntary hospitalization. The main findings were that the form’s content was unclear and had an intimidating and disempowering tone. Armed with this feedback, I coordinated a patient-oriented research team to develop a new suite of rights-communication tools to supplement Form 13. I user tested the tools with people who had experienced involuntary hospitalization. Participants found the suite of tools friendlier to use compared with Form 13. They appreciated that the many formats within the suite would accommodate different communication preferences and would give patients several opportunities to learn about their rights. I did a thematic analysis of the full set of user-testing interviews to learn more about involuntary patients’ experiences with the rights-information process. A key theme was that patients wanted more transparency and open communication about every aspect of their hospitalization. They also wanted clinicians to foster a culture where patients could feel safe talking about rights. The uncertainty from a lack of information exacerbated participants’ mental distress and made some fearful of hospitalization. A better understanding of what they could do under the legislation and how much they could participate in treatment decisions would reduce feelings of powerlessness and could help involuntary patients engage in their own recovery.

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

What is a First Nation person's wellness journey?

Author: 
Date created: 
2019-06-20
Abstract: 

To address the health disparities for First Nation people it is important to understand what their wellness journey encompasses and how primary care services can support their individual journeys. Current health care structures focus on illness and what is wrong with an individual. It is coming to light more that the four aspects of a human being are important to promote wellness throughout an individual’s life journey. Historically, First Nation wellness encompassed spiritual, emotional, mental and physical components of each individual. The analysis of information, gathered through observation and interview methods in this research project, utilized the First Nation Health Authority’s First Nation Perspective of Wellness as a framework to ensure all components of an individual were honoured. Honouring the information shared by each of the research participants, their voices are heard through direct participant quotes. Participants related their mental wellness journeys, what worked and what didn’t, who they considered important in their journeys and times in their lives where they identified a change occurring. Instrumental to this was the support provided by their community. This research project was supported by the community of Seabird Island and portrays how their current health and cultural programs and services are supporting their client’s wellness journeys. Key priorities identified from observations of community cultural workshops and semi-structured interviews include health services considering each individual’s needs, access to culturally safe services, the importance of belonging and purpose in life, as well as how spirituality and gratitude support an individual’s wellness journeys.

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