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

Medical tourists, persons traveling across international borders with the intention of accessing medical care, are often unaware of safety and ethical concerns related to the practice of medical tourism. Accessing medical care as a medical tourist may result in risks to the health of the patient, as well as negative impacts to both destination and departure country health care systems and global health equity. These ethical considerations are not provided in sources of information commonly accessed by Canadian medical tourists. This interview-based study affirms the usefulness of an iterative process for designing an information sheet for Canadians considering engaging in medical tourism and for communicating ethical considerations to consumers of other services. Perceptions from former Canadian medical tourists indicate that this information sheet is useful in raising awareness of the ethical concerns of medical tourism, which may impact medical tourists’ decision-making given adequate additional sources of information and support.

The hypoxia-inducible factor 1 (HIF1) complex, comprised of a HIF1α and aryl hydrocarbon receptor translocator (ARNT/HIF1β) heterodimer, regulates the transcription of genes promoting tumour progression under hypoxia. Preliminary data suggests that the retinoblastoma protein (RB) attenuates HIF1-mediated transcription directly through interaction with the co-activator thyroid hormone receptor/retinoblastoma interacting protein 230 (TRIP230) to inhibit invasiveness of MCF7 human breast cancer cells. The objective of this study was to further characterize the invasive phenotype in MCF7 cells following loss of RB. Loss of RB resulted in a hypoxic-dependent increase in expression of HIF1 target genes involved in tumour progression. Protein-protein interaction analysis demonstrated that RB exists in complex with ARNT and TRIP230. Moreover, this complex dissociated in the presence of an ARNT-interacting peptide. Lastly, the C-terminal region of the TRIP230 RB-interaction domain has been identified as the minimal interaction domain. Altogether, these results further establish RB as an attenuator of HIF1-mediated transcription.

Homeless individuals represent a disadvantaged and marginalized group who experience increased rates of physical illness, mental and substance use disorders. Compared to housed individuals, homeless adults use emergency departments (ED) and other acute healthcare services at a higher frequency. Housing First (HF) has been identified as an effective means of facilitating acute health service reductions among homeless populations. The present analysis is based on (n=297) participants enrolled in the Vancouver At Home Study (VAH) randomized to one of three intervention arms: HF in a congregate setting (CONG), HF in scattered site apartments (SS), or to treatment as usual (TAU), and incorporates linked data from a regional database representing six urban ED’s. Compared to TAU, significantly lower ED utilization was observed during the post-randomization period in the SS arm. Our results suggest that HF, particularly the SS model, produces significantly lower ED visits among homeless adults with a mental disorder.

Noncommunicable diseases (NCDs) are an emerging health problem and result in considerable economic burdens at national, regional, and global levels. Mongolia, as is the case in many other developing and developed countries, has experienced a shift in the burden of disease from infectious to NCDs. The prevention and management of NCDs are now an essential responsibility of the health care system in Mongolia. Improved and a better performing primary health care system is one of the important aspects of NCD prevention and management in Mongolia. The goals of the study were to: 1) measure the relationship between the characteristics of the physicians and the residential populations they serve, and the NCD prevention practices (i.e. risk factor assessment, behaviour modification recommendation, treatment plan, and follow-up practice) of health care providers; 2) explore the reasons/underlying the determinants of current NCD prevention practices; and 3) identify areas for possible improvement of NCD prevention practices at the primary health care level through the collection and analysis of both quantitative and qualitative data from the six main urban districts of Ulaanbaatar. 200 surveys were completed by family doctors and 21 key informant interviews, 4 focus group discussions, and 6 participant observation sessions were conducted. The results showed that physicians’ medical specialties, experiences working in primary care, year of graduation from university, number of family doctors working in a family clinic, and the relative poverty level of the community were predictive of elements of NCD prevention practice among family doctors. Doctors specialized in family medicine, who worked with four or five colleagues, and had more experience in primary health care offer better prevention activities. Several significant barriers (e.g. doctors’ inadequate practice skills, workload at family clinics, and poor health-seeking behavior of patients) and facilitators (e.g. prevention activity and policy toward NCD prevention) of NCD prevention practices were identified at physician, family clinic, population, and policy/health system levels. Improvements to organizational activities, and resources and services such as increasing funding and reorienting primary health care, were recommended to develop the practice of NCD prevention and management at the primary health care level in urban areas of Mongolia.

In Ugandan, the social expectation that women should bear children competes with HIV clinic expectation that HIV-positive women should bear few or none. This contradiction undergirds this thesis, which examines how access to ART, social expectations and clinical expectations all combine to influence how HIV-positive women approach pregnancy in southwestern Uganda. From August to December 2011, ethnographic fieldwork was conducted in Mbarara, Uganda. Semi-structured interviews were conducted with 25 pregnant HIV-positive women accessing ART. The main themes that emerged were that: 1) HIV-positive women reported new optimism about pregnancy since being on ART, 2) adherence to ART and family support helped women manage social expectations placed upon them, and 3) clinic counselling about pregnancy beyond adherence to ART was not common. Thus, ART is an important link between managing social and clinical expectations for HIV-positive women since it improves women’s health and decreases risks of childbearing.

Utilizing helicopter emergency medical services (HEMS) to minimize the time from injury to definitive trauma care is increasingly popular in North America. Through a combination of improved access, expeditious transport, and superior preclinical therapy, multiple studies have demonstrated that direct transfer by HEMS from the emergency scene to a level-1 trauma center significantly reduces mortality. Early activation of HEMS, or Autolaunch, to emergency scenes prior to the arrival of ground ambulances based on information provided by 9-1-1 callers is an innovative way of reducing response times further. Information extracted from these callers enables the dispatcher to simultaneously send HEMS and ground-EMS directly to the scene. This work presents a study that examined the changes in response times to major trauma patients in southwestern British Columbia since the Autolaunch strategy came into effect in 2004. This study highlights significant reductions in response times when Autolaunch is used.

According to the World Health Organization (WHO), cardiovascular disease (CVD), which sits under the chronic disease umbrella, is the number one cause of death globally. Over time, we have witnessed different trends that have influenced the prevalence of CVD. One of the ways of decreasing CVD and its social costs and global fatalities is through influencing preventable CVD risk factors. Though many risk factors such as age and gender are not preventable, there are several effective behaviours that reduce the risk of CVD. To estimate the potential impact of various interventions on CVD, such as reducing blood pressure as a result of lowering sodium intake, or increasing awareness regarding healthy eating behaviour, we have used descriptive statistics and modelling. We estimated the impact of a gradual decrease in sodium intake on CVD mortality and morbidity in Canada (CA), United States (US), and Latin American (LA) countries. Our analysis shows that small changes in sodium intake at the population level can make an important difference in the total number of CVD events that can be prevented. Using data in Canada and France we also explored the potential role of individual decision making on daily sodium consumption. Our analysis showed that the main obstacle to consumers making healthier choices appears to be neither the availability of products, nor the price. Consumers may be more hampered by the difficulty of comparing food labels than by the availability of lower sodium products. Using Canadian data, we also examined the potential impact of having a positive family history of CVD on CVD mortality. Based on our analysis, father stroke before the age of 60 was a strong predictor for CVD mortality. Following this analysis, we used mathematical models, to improve our understanding of the impact on CVD of changes in the trend of CVD risk factors such as obesity, social and environmental influences. We investigated each of these risk factors separately, in order to have a clear foundation for more complex models. We also used a Fuzzy Cognitive Map (FCM) that considered a wide range of interactions and interrelationships between different CVD risk factors.

The limited neutralizing activity of V3 antibodies is typically attributed to V3 masking. While relatively much effort has been devoted to exploring V3 accessibility on subtype B viruses, V3 exposure and mechanism(s) that might restrict V3 exposure on non-subtype B viruses have yet to be understood. I have focused on exploring the significance of the conserved V3 tip motifs GPGR and GPGQ of subtype B and nonsubtype B viruses for antibody recognition. Position 315 in representative subtype B and subtype C viruses was mutated to Gln and Arg respectively to assess the effect of the conserved Arg/Gln at position 315 on V3-specific neutralization. The Q315R subtype C viruses became sensitive to anti-V3 mAb B4e8 neutralization whereas the R315Q switched subtype B virus became resistant to V3 neutralization, even to V3 antibodies that do no contact the residue at position 315. These observations suggest that at least the tip of V3 is antibody accessible on the surface of some non-B viruses but it is the presence of Gln315 residue that modulates V3 antibody recognition. As such, engineering V3 tip antibodies to make high affinity interactions with a Gln315 residue could broaden V3 neutralization of non-subtype B viruses. To attempt to improve B4e8’s neutralizing activity, targeted mutagenesis of B4e8 complementarity determining region residues was done to generate antibody libraries using yeast and phage display. The libraries were subjected to multiple rounds of selection on subtype C gp120s, however B4e8 variants with enhanced affinity for subtype C gp120 were not recovered after the final rounds of selection. This suggests that the residues targeted here were not sufficient for enhancing B4e8 affinity for non-subtype B HIV.

Chronic beryllium disease (CBD), a lung disease caused by exposure to beryllium, is a serious occupational health issue. Despite the presence of industries within British Columbia with possible beryllium exposure, many workers are not aware of their risk of developing CBD. The objective of this study was to assess the utility of risk communication to raise awareness of CBD and to promote screening in aerospace workers and dental technicians in BC. Online surveys conducted before and after risk communication evaluated the effectiveness of the communication based on the Precaution Adoption Process Model (PAPM). The recruitment of aircraft maintenance workers was unsuccessful. Fifty completed survey responses were collected from dental technicians. There was a significant tendency for subjects to become concerned about their risk and to consider taking a screening test after the risk communication. Subjects’ levels of knowledge, perceived severity, perceived benefits, and self-efficacy were associated with the PAPM stages.

Most Canadians receive basic health services from family physicians who play an important role in chronic disease management. Canada, however, has an endemic shortage of family physicians and consequently, a large population of unattached patients. Physician scarcity is particularly acute in rural regions, leaving patients transitioning between family physicians at risk for not readily finding a new doctor. To ensure patient-centred solutions to this barrier to care, policymakers need to inform their responses with an understanding of the patient experience. This qualitative study explores the experiences of chronically ill, rurally situated Canadian women transitioning between family physicians with the goal of providing insight into how the system supports these patients. The study reveals the presence of a multi-phase transitioning trajectory. Participants’ accounts indicate that efforts to attach to a regular family physician were hindered by the lack of available doctors and by gaps in system support within each transitioning phase.