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

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Increased risk of severe infections and mortality in patients with newly diagnosed systemic lupus erythematosus: A population-based study

Author: 
Date created: 
2021-01-25
Abstract: 

Systemic lupus erythematosus (SLE) is a chronic disease with a broad spectrum of clinical manifestations and infections are a leading cause of morbidity and premature mortality in patients with SLE. Findings from previous studies may be limited because of small sample sizes and using prevalent cohorts. To evaluate the risk of severe infection and infection-related mortality among patients with newly diagnosed SLE. We conducted an age- and gender- matched cohort study of all patients with incident SLE using administrative health data from British Columbia, Canada. Primary outcome was the first severe infection after SLE onset. Secondary outcomes were total number of severe infections and infection-related mortality. Multivariable Cox proportional hazard and Poisson models were used to evaluate the association of SLE with the outcomes, adjusting for confounders. The findings suggest SLE is associated with increased risks of first severe infection, a greater total number of severe infections and infection-related mortality.

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

Patterns of health service use among people experiencing homelessness and mental illness in British Columbia

Author: 
Date created: 
2021-04-16
Abstract: 

Background: The burden of illness faced by people experiencing both homelessness and mental illness is staggering. When the needs of this population go unmet, it is often the healthcare system that is criticized. The aim of this thesis was to examine patterns of medical service use among people experiencing homelessness and mental illness, and to identify factors associated with high-levels of use, health outcomes and opportunities for intervention. It was hypothesized that people with the highest objective needs would access more medical services and that those who access care in a timely and continuous fashion would have better outcomes, including lower risk of hospitalization. Methods: Data were drawn from both the baseline interviews of Vancouver At Home (VAH) study participants and the Inter-Ministry Research Initiative database. All analyses were retrospective using both self-report and administrative data to examine factors associated with low vs. high health service use, continuity of care following hospitalization, and timeliness of community-based medical service use following detention in provincial custody. Results: Among VAH participants, we found that those with lower assessed need were accessing more health services that those with higher needs (i.e., schizophrenia). When continuity of care was examined, we found that our sample was accessing community-based outpatient services in both a timely and ongoing manner, however, it was not conferring a protective benefit against rehospitalization. Finally, when studying the impact of timely community medical service use following release from provincial custody, we found that those who accessed services in both a timely and continuous manner were more likely to be hospitalized than those not using services in this manner. Discussion: These findings highlighted the overwhelming burden of illness among people experiencing homelessness and mental illness. Contrary to our hypotheses, those with the greatest needs were not accessing the most health services, and for those who did access services frequently, these contacts did not offer protection against further negative health outcomes including hospitalization. Collectively these findings suggest looking beyond the healthcare system and underscore the importance of structural and systemic failings within our social, justice and healthcare systems as perpetuating the morbidity within this population.

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

Factors associated with housing stability and criminal convictions among people experiencing homelessness and serious mental illness: Results from a Housing First study

Date created: 
2021-05-25
Abstract: 

Background: Housing First (HF) facilitates immediate access to independent housing with community-based supports for people experiencing homelessness and serious mental illness (PEHSMI). Despite positive outcomes associated with HF, studies have infrequently investigated factors that are associated with adverse outcomes once in HF. This thesis investigates factors which hinder housing stability following randomization to HF and factors associated with criminal convictions prior to and following randomization to HF. Methods: Three investigations were conducted using data from the Vancouver At Home study, which contains two randomized controlled trials each involving randomization to HF vs. treatment as usual (TAU) among PEHSMI. Using self-reported data, the first investigation examined the effect of experiencing homelessness in childhood or youth on housing stability (≥90% of days stably housed) after receiving HF (TAU excluded). The second investigation retrospectively examined factors associated with criminal convictions during the five-year period preceding baseline. The third investigation examined factors associated with criminal convictions after receiving HF (TAU excluded). Provincial administrative data were combined with self-reported baseline data for the second and third investigations. Results: 1) Among participants randomized to HF (n=297), those who had experienced homelessness in childhood or youth had significantly lower odds of housing stability. 2) Prior to study baseline, seven variables were significantly associated with criminal convictions among participants (n=425), such as drug dependence, psychiatric hospitalization, and irregular frequency of social assistance payments (vs. regular). 3) Following receipt of HF (n=255), five variables were significantly associated with criminal convictions, including daily drug use, daily alcohol use, and having received addictions counselling among others. Conclusions: Results underscore social marginalization as contributing to poorer housing stability in HF and criminal convictions while in HF and prior to enrollment among PEHSMI. Further supports are needed to facilitate improvements for a greater proportion of HF clients. HF providers may be able to identify clients with additional support needs related to housing stability and criminal convictions by asking about the factors found to be significant in analyses.

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

Discrimination at work and symptoms of mental disorders among nurses in British Columbia

Date created: 
2020-10-14
Abstract: 

Nurses belonging to equity-seeking groups, including people of colour, Indigenous people, people with disabilities, and people identifying as 2SLGBTQIA+, face barriers to opportunities and resources, and might more frequently experience workplace discrimination. Whether these experiences are associated with adverse mental health outcomes is unknown. This study examines factors associated with workplace discrimination and relationships between discrimination and mental health outcomes, using survey data from nurses in British Columbia, Canada. Using logistic regression, I investigated relationships between workplace discrimination and symptoms of mental disorders, adjusting for personal and work/role characteristics. Of 4545 respondents, 12.5% reported experiencing discrimination, rising to between 19.6% and 24.4% among those who identify with equity-seeking groups. Overall, 45.8% of nurses reported symptoms of post-traumatic stress disorder, 28.1% reported symptoms of anxiety, and 31.1% reported symptoms of depression. Nurses reporting workplace discrimination were more than twice as likely to report symptoms of mental disorders, with similar results across mental disorders. Experiences of discrimination in the workplace are common for nurses in BC, and symptoms of post-traumatic stress disorder, anxiety, and depression are prevalent in this population. Worker psychological health and safety is often treated as an individual issue and responsibility, but we must instead consider how it is related to working conditions both embedded in, and reflecting, societal inequalities.

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

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.