Public Health Sciences (School of)

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This is the collection for the University of Waterloo's School of Public Health Sciences. The School was known as the Department of Public Health and Health Systems until January 2021.

Research outputs are organized by type (eg. Master Thesis, Article, Conference Paper).

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Breast cancer risk associated with phosphate toxicity
(University of Waterloo, 2024-07-18) Brown, Ronald B
Background - The essential dietary mineral phosphorus in the form of inorganic phosphate (PO43-) is regulated in the blood serum by a sensitive network of endocrine hormones released from bone, kidneys, parathyroid glands, and intestines. Western dietary patterns are high in phosphorus-rich foods, including dairy, meats, grain products, and foods processed with phosphate additives. Consequently, average phosphate intake is far above the U.S. dietary reference intake of 700 mg for adults. Phosphate toxicity, the accumulation of excess inorganic phosphate throughout the body from dysregulated phosphate metabolism, is associated with tumorigenesis as high levels of inorganic phosphate within the tumor microenvironment stimulate cell signaling pathways and promote cancer cell proliferation. Breast cancer in women is projected to increase to 3-million new cases globally by 2040, yet much of the public remains unaware that breast cancer is associated with alcohol consumption, and phosphate toxicity may play a mediating role in the association of alcohol with breast cancer. Phosphate toxicity is also associated with osteolytic loss of bone mineral density and abnormal osteoblastic bone mineral deposition. Methods - This thesis presents three studies investigating the association of phosphate toxicity with risk of breast cancer in women related to alcohol consumption, high dietary phosphate intake, and disorders of spinal bone mineral density. A grounded theory literature-review method was used in the first study to retrieve research findings from the literature on alcohol, kidney function, phosphate metabolism, rhabdomyolysis, and breast cancer. Findings were compared and categorized into concepts and themes and were synthesized into a theory positing a mechanism by which the association of breast cancer with alcohol consumption is mediated by phosphate toxicity. The second study used a nested case-control design to measure the relative risk of breast cancer incidence associated with dietary phosphate intake levels in a cohort of middle-aged women from the Study of Women’s Health Across the Nation. The lowest level of 800 to 1000 mg phosphorus per day, based on recommendations from the United States National Kidney Foundation, was used as the reference level to calculate the relative risk of breast cancer in the higher levels of phosphorus intake. The third study used a mixed-methods grounded theory design to synthesize a theory relating phosphate toxicity with breast cancer and spinal bone mineral disorders. Based on the theory, the study used a mixed-effects model to test the hypothesis that changes in spinal bone mineral density are associated with incidence of breast cancer in women from the Study of Women’s Health Across the Nation. Results - Results of the first study found that alcohol burdens renal function, which can impair the regulation of inorganic phosphate, reduce excretion of excess serum phosphate, and increase phosphate toxicity, a potential mediating factor in breast cancer risk. Alcohol can also cause nontraumatic rhabdomyolysis which ruptures cell membranes and releases inorganic phosphate, contributing to hyperphosphatemia (blood serum phosphate levels above 4.5 mg/dL) with increased breast cancer risk. Furthermore, phosphate toxicity potentially mediates the risk of cancer associated with kidney disease in the medical specialty of onco-nephrology. In the second study, the highest daily intake of dietary phosphorus in the cohort from the Study of Women’s Health Across the Nation, >1800 mg, is approximately equivalent to menus promoted by the United States Department of Agriculture. This level of dietary phosphorus was associated with a 2.3-fold increase in the risk of breast cancer incidence compared to the reference level of 800 to 1000 mg (RR: 2.30, 95% CI: 0.94–5.61, p = 0.07). The study’s clinically significant effect size, specificity, biological gradient, and other findings meet Bradford Hill’s criteria for causative inference from epidemiological associations. Randomized trials are warranted to test epidemiological associations of dietary components with reduced risk of cancer, as recommended by the National Cancer Institute The analysis of findings from the reviewed literature in the third study confirmed an association of phosphate toxicity with bone mineral disorders and tumorigenesis. In the follow-up study to test the hypothesis that bone mineral disorders are associated with tumorigenesis, women in the Study of Women’s Health Across the Nation who self-reported breast cancer were found to have higher bone mineral density at baseline. But these women also had more rapid losses in bone mineral density during follow-up visits compared to women in the control group who remained cancer free. These findings are consistent with osteolytic and osteoblastic bone mineral changes associated with breast cancer. Conclusions - Thesis findings provide the rationale for further clinical studies to test dietary phosphate as a modifiable cause of breast cancer and bone mineral disorders. The effect of alcohol associated with phosphate toxicity can also be disseminated to the public to increase awareness of the risk of breast cancer associated with alcohol consumption.
Exploring Young Women’s Conceptualization of Sexuality: A Narrative Inquiry
(University of Waterloo, 2024-07-15) McCorriston, Jennifer
Sexual health is an important part of public health’s mandate, especially when working with young adults who are experiencing great physiological and psycho-social development and change. The World Health’s Organization’s (2024) definition of sexual health encompasses physical, emotional and social wellbeing, yet is best understood within the larger definition of sexuality. Hence, sexuality is conceptualized as an individual’s attitudes, thoughts, behaviors, identities and relationships as shaped and influenced by biological, psychological, social, political, cultural and religious factors. Using this definition therefore means that how sexuality is defined and enacted will vary based on time, place and social context. Quantitative research has traditionally dominated public health’s examination and assessment of sexuality, with a concentration on individual behaviors and risk outcome measures. Much less public health research has focused on how individuals and groups subjectively experience their sexuality, including positive aspects of sexual wellbeing. Notably, women’s subjective experience of sexuality has been underrepresented given the long-standing history of gender inequality. Traditional social norms and practices for women have resulted in inadequate access to sexual health information and services, limited decision-making power in their sexual behavior and increased vulnerability in sexual violence. Due to the stark reality of these health inequalities, it is important to capture diverse women’s voices in sexuality research so that institutional programs and policies meet their needs and do not contribute to gender bias, stigmatization and discrimination. Utilizing a social constructionist theoretical lens, the overarching purpose of this dissertation research is to develop an understanding of how young women conceptualize sexuality in Ontario, Canada. This dissertation is separated into three papers, each drawing from the same study and research questions but having their own distinct aim. Paper one examines the constructed meanings and lived experiences of young women’s sexuality as situated within gender roles, norms, identities and scripts. Paper two understands how young women construct, negotiate and/or challenge a dominant risk narrative of sexuality. Paper three takes a methodological focus to explore the use of photo-elicitation for the construction of sexuality narratives. Taken together, these papers make empirical, theoretical and methodological contributions. The study employed a qualitative approach to sexuality research through narrative methodology. Purposive sampling recruited thirteen young women from Ontario, aged 18-24 years. The women participated in 1-2 virtual interviews, in addition to incorporating a visual method known as photo-elicitation. Using a broad definition of ‘photo’, participants used self-chosen pictures, art, advertisements, memes or online images as prompts to elicit memory recall and/or more detailed stories of their sexuality. Data collection, analysis and interpretation was an iterative process to co-construct narratives between researcher and participant. Employing thematic analysis of narratives, the focus was on content of narratives to identify common categories and characteristics. In paper 1 and 2, themes were interpreted across young women to understand what their personal stories revealed about current socio-cultural context. Paper 3 examined themes within only one participant’s narratives, as a case-study example for methodological discussion. Narratives in paper one revealed five themes about how young women gave meaning to and experienced their sexuality within current gender norms, identities and scripts, which included: 1) imposed identity labels, 2) expected feminine presentation, 3) submission and servitude, 4) objectification and victimization, and 5) pleasure. These themes constructed an overall narrative across young women that their sexuality was often not seen as their own. In paper two, young women narrated physical and psychosocial risks of sexuality, with four themes emerging: 1) experiencing slut-shaming, 2) disappointing parents, 3) responding to sexual violence (feared or realized), and 4) not measuring up to peers. Across young women, sexuality continues to be situated within a discourse of risk, as constructed through social institutions including family, education, healthcare and media. The third paper summarized my journey, as the researcher, utilizing photo-elicitation (PE) for the co-construction of sexuality narratives. Highlighted are research considerations, including practical and ethical issues of collecting photos of a sensitive nature and using photos when considering anonymity and confidentiality. Findings demonstrate that PE can be used to explore and make meaning of contradictory and complex narratives that are reflections of societal and cultural norms and assumptions. Overall, PE is a useful visual methodology when working with underrepresented groups and creating a collaborative participant-researcher relationship. The present research study demonstrated that young women conceptualized their sexuality as something that was predominantly defined and judged by others, and not always experienced as something they control or enjoy for themselves. This reflects prominent historical, social and cultural gender norms, expectations and scripts for women that perpetuate gendered sexual stereotypes and oppression. Additionally, young women conceptualized sexuality predominantly through its negative outcomes (e.g. sexual violence), with much less focus on positive aspects (e.g. pleasure). Some women countered dominant narratives of risk through stories of resistance, however many more women normalized the gendered nature of risk and often felt powerless against the status quo. Conclusions drawn from this study feel troubling given the WHO’s definition of sexuality stresses autonomy and pleasurable sexual experiences. As a primary site that socially constructs and reconstructs gender and sexuality, educational institutions including school curriculum, have a pivotal role to play in countering gender ideologies in order to support diversity, equality and acceptance. Within public health and health care, a focus on pleasure as a sexual right for all, is imperative to advancing gender equality and promoting sexual behaviors that are respectful, safe and non-coercive. Future research should continue to explore meanings and experiences of sexuality not only for women, but also men and gender-diverse individuals, as this will help assess whether progress is being made towards deconstructing traditional gender norms and expectations. Additional research should use an intersectional analysis approach to understand not only gender, but the intersections of gender with other social identities and the role of power relations in health inequalities.
Characterizing water-health pathways and perceptions among diverse system actors in a rural Western Highlands community of Guatemala
(University of Waterloo, 2024-07-02) Garcia-Barrios, Joshua
Background: Rural livelihoods in Latin America are disproportionately vulnerable to poor health outcomes from water risks. In the Western Highlands of Guatemala, rural communities face compounding issues such as geography related challenges, population growth, and poverty that increase vulnerability to water-health risks. To inform water-health interventions, there is a need for research that considers and examines the proximal, intermediate, and distal water-health pathways influencing rural community health and wellbeing. This study aimed to characterize these pathways for a Westen Highland community of Guatemala and to examine how these pathways were perceived among local system actors. Methods: Semi-structured qualitative interviews were conducted across two data collection phases during May-June 2023 and October-December 2023 in Tojchoc Grande, Guatemala. Interviews were conducted with local farming and non-farming community members, water managers, and health workers. Interviews were audio recorded, transcribed verbatim using Sonix transcription software, and thematically analyzed using an inductive approach. Following data analysis, an adapted three-level water-health framework was used to categorize major themes under proximal, intermediate, and distal pathways. Results: Diverse and multi-scalar water-health pathways were characterized in the community, with similarities and differences in perceptions of these pathways across actor groups. Proximal water-health pathways included issues related to geographic proximity to water system infrastructure, climate and weather variability, and risky water use, sanitation, and hygiene issues. Intermediate water-health pathways related to population growth, water withdrawals for agriculture, and administration challenges decreasing community water levels. Distal water-health pathways related to broader socio-economic factors such as poverty and migration influencing healthcare and water access, as well as broader institutional factors like state-absence shaping challenges for local water administration and public health delivery. Conclusion: This study highlighted the complexity of water-health pathways among diverse actors in a rural community in the Western Highlands of Guatemala. The results demonstrate the intricate interplay of proximal, intermediate, and distal pathways shaping health and wellbeing at local level. Crucially, it was observed that intermediate and distal pathways played a substantial role in shaping reported health outcomes, highlighting their importance alongside proximal factors. By highlighting the differential perceptions among local actors, this research emphasizes the need for context-specific interventions that address the multi-scalar and multi-faceted nature of water-health challenges facing rural communities. Understanding and addressing these pathways are crucial for designing effective water-health interventions that can mitigate risks and support rural public health and wellbeing.
The Association between Social Isolation, Functional Social Support, and Memory: A Moderated Mediation Analysis of the Canadian Longitudinal Study on Aging
(University of Waterloo, 2024-06-20) Endresz, Nicole
Social support is a widely investigated, modifiable factor thought to promote memory function and successful aging. However, the intertwined effects of the two components of social support – objective social isolation and subjective functional social support – on memory are less understood. Therefore, we explored whether social isolation was associated with memory function in middle-aged and older adults, and whether this association was mediated by functional social support. We also examined moderated mediation by age group and sex. We analyzed data from the baseline and first follow-up waves of the Tracking Cohort of the Canadian Longitudinal Study on Aging. These data included a derived variable for social isolation, a standardized instrument for self-reported functional social support, and a combined immediate and delayed recall memory score from a modified version of the Rey Auditory Visual Learning Test. Using multiple linear regression and an analytical sample of 12,834, we regressed memory scores at follow-up onto baseline social isolation status, controlling for baseline sociodemographic, health, and lifestyle covariates, baseline memory, and baseline and follow-up functional social support. We further assessed whether functional social support at follow-up mediated the association between baseline social isolation and follow-up memory. To assess moderated mediation, each path of the mediation analysis was stratified by age group and sex The independent and direct effect of social isolation on memory controlling for covariates showed a non-statistically significant, inverse association. Social isolation predicted lower levels of functional social support, whereas high functional social support was associated with higher memory scores. Memory scores decreased on average by 0.03 points in socially isolated participants versus non-isolated participants, when mediated by functional social support. Lastly, some evidence of effect modification was found by the oldest age group on the “a” path of the mediation analysis. This thesis provides novel findings on the mediating effect of functional social support on the relationship between social isolation and memory. Our findings suggest the association between social isolation and memory operates through, not independently of, functional social support. Health professionals working with socially isolated individuals at risk of, or experiencing, memory problems should pay particular attention to these individuals' levels of functional social support.
Exploring the Determinants That Contribute to and Promote the Wellbeing of Immigrant and Refugee Children in Canada
(University of Waterloo, 2024-06-18) Herati, Hoda
In 2023, Canada’s new Immigrant Levels Plan was introduced to support Canada’s economic recovery and growth, reunite families, and respond to humanitarian crises. As a result, Canada will welcome over 480,000 new immigrants annually during 2024-2026 including many families with children and youth. To date, most research with immigrant and refugee children has focused on the negative impacts of migration stressors over the factors that can support their wellbeing. Further, few studies include children as research participants despite the fact that children can play an active role in studies that examine issues affecting them. Rather, studies focused on children’s experiences are based on the perspective of institutions and adults. As such, the overall aim of this dissertation is to examine the determinants that contribute to and promote the wellbeing of immigrant and refugee children in Canada, considering their perceptions and subjective experiences. To meet this aim, this dissertation includes four papers, described below. Paper I is a scoping review, following Arksey and O’Malley’s methodology, that aimed to understand the psychosocial needs of resettled immigrant and refugee children and youth in Canada in the context of their school and community, and to identify the characteristics of school-/community-based mental health programs for this group. The findings of this review make contributions to the literature in terms of identifying approaches, particularly collaborative care models, school-community-family partnerships, and school-based creative expression programs, to addressing mental health issues in immigrant and refugee children and youth. Furthermore, this scoping review informed the methodology used in Paper II as it highlighted the value of using creative expression methods when working with immigrant and refugee children. Paper II, the empirical paper of this dissertation, used a multi-method qualitative approach, namely the Mosaic methodology, to explore and identify the determinants that contribute to and promote the wellbeing of immigrant and refugee children aged 6-13 settled in Canada. In this paper, I focused on immigrant and refugee children from the Middle East and North Africa (MENA) region, taking into account that Canada has resettled a large number of refugees from this region in recent years (over 120,000 from 2015 to 2023). Considering the multi-method approach of the Mosaic methodology, I used a visual method (drawing) combined with a verbal method (interviews) to collect data from children (n=16) and their parents (n=9). This study was informed by the social-ecological framework that considers a child within the context of family, community, and broader society. Accordingly, the findings of this study suggested that immigrant and refugee children’s wellbeing is influenced by individual characteristics, relationships with their surroundings, and organizational/community factors. Further, the results showed that wider societal policy and practice changes are necessary to enhance the wellbeing of this group. Drawing upon the findings of Paper II, Paper III examined and demonstrated the use of a multi-method approach in research with immigrant and refugee children in a virtual setting, making a methodological contribution to the literature. This methodological paper emphasized the importance of listening to children and involving them as active participants in research studies by using creative visual combined with traditional verbal methods to collect data from this group. This paper provides practical guidance for using a multi-method approach in research with immigrant and refugee children in a virtual setting. Given the findings of Paper II, the conceptual paper of my dissertation (Paper IV) aimed to extend the PERMA model of wellbeing, a framework developed within a Western context and has five constructs: Positive emotions, Engagement, Relationships, Meaning, and Accomplishment, to respond to the needs of immigrant and refugee children of colour from the MENA region. This framework has been used to study and evaluate individuals’ wellbeing, however, its current constructs may not adequately represent the views and experiences of people with marginalized identities, such as racialized children and newcomers from non-Western nations. The findings of Paper IV contribute to the existing literature on wellbeing by identifying two new components, C for cultural and religious identity and S for safe and peaceful environment, to be added to the PERMA model of wellbeing (titled the PERMA-CS). The extended model can be used as a framework for research with immigrant and refugee children from the MENA region who resettled in a Western context, a novel population for this model. In summary, through conducting a scoping review and a qualitative study that used a multi-method approach, I provide empirical, methodological, and conceptual contributions that will support the promotion of wellbeing of immigrant and refugee children in Canada. In particular, this thesis contributes to the literature by empirically identifying the factors that influence and promote the wellbeing of immigrant and refugee children in Canada. Moreover, the methodological approach of this thesis furthers our understanding of the use of a multi-method approach in research with immigrant and refugee children in a virtual setting. Additionally, my thesis makes conceptual contributions to the literature by proposing a framework of wellbeing that builds on a previously defined model.
Depressive Symptoms as a Mediator of the Association Between Functional Social Support and Executive Function: A Moderated Mediation Analysis of the Canadian Longitudinal Study on Aging’s Comprehensive Cohort
(University of Waterloo, 2024-06-17) Lupoi, Laura
BACKGROUND: Social support and depression are modifiable factors that can affect cognition. Social support and depression may be related through the influence of close relationships on emotional regulation; however, few studies have investigated whether depression mediates the relationship between social support and key domains of cognition, such as executive function. OBJECTIVES: To explore whether depressive symptoms mediate the association between functional social support and executive function, and to ascertain if age and sex moderate this mediation. METHODS: Analyses were based on baseline and three-year follow-up data (n=16,421) from the Comprehensive cohort of the Canadian Longitudinal Study on Aging, a population-based study of adults aged 45–85 years at baseline. Baseline functional social support was measured with the Medical Outcomes Survey-Social Support Survey, follow-up executive function with a combined z-score of five cognitive tests, and follow-up depressive symptoms with the 10-item Centre for Epidemiological Studies Depression Scale. Conditional process analysis, a robust strategy based on a linear regression framework, was used to evaluate moderated mediation. RESULTS: After adjusting for sociodemographic, health, and lifestyle covariates, depressive symptoms at baseline significantly mediated the association between functional social support and executive function. This mediated effect was significant across most age and sex subgroups, with the exception of males and females 65–74 years old. CONCLUSION: At least some of the benefits of social support on executive function depend on the positive effects of social support on depressive symptoms. Social support interventions with components addressing depression may be effective at promoting executive function in middle-aged and older adults.
Transitions in Mood Among Residents of Canadian Long-Term Care Facilities: The Effects of COVID-19 Individual Risk Factors and Regional Characteristics
(University of Waterloo, 2024-05-31) Mulla, Reem
Long-term care home residents are among the most vulnerable populations due to their advanced age. Their health and well-being can be influenced by physical and psychosocial factors, the surrounding physical environment, and practice patterns that make them more susceptible to increased morbidity, disability, and mortality. Mental health disorders are particularly common among residents of long-term care (LTC) homes affecting between 27% and 40% of all LTC residents in Canada. The COVID-19 pandemic had a substantial impact on the physical and mental health and well-being of residents of long-term care (LTC) homes. The increased vulnerability of older adults combined with essential preventive and infection control measures led to a challenging environment in these care facilities. The COVID-19 pandemic highlighted and magnified pre-existing challenges in the LTC system, emphasizing the importance of comprehensive strategies to safeguard the mental health of LTC residents. Study 1 is a scoping review that investigates the effect of isolation and loneliness on the mood of long-term care (LTC) home residents, both before and during the COVID-19 pandemic. It provides an overview of existing literature to understand the effects of family and friends’ visits or loneliness and of COVID-19 restrictions on residents’ mood. The review shows a diversity of findings highlighting the complexity of factors influencing residents' mood during a global health crisis such as that of COVID-19. It suggests a need for a nuanced understanding of the interplay between social interactions, pandemic-induced restrictions, and individual coping mechanisms. It also highlights the need to use a standardized measure for depressive symptoms globally to prevent biases and inconsistencies that might arise from research based on different measures. Study 2 is a longitudinal study evaluating the effect of COVID-19 pandemic on incident mood disturbance among Canadian long-term care home residents. It also examines the effects of COVID-19 in stratified models using resident and facility-level variables. This study shows that a variety of factors contributed to an increase in mental health challenges during the initial waves of the pandemic including, but not limited to, the potential effects of lockdown procedures. Our findings highlight the importance of implementing broad-based multidimensional interventions to ensure the mental well-being of all individuals during outbreaks. Study 3 is a pan-Canadian retrospective longitudinal analysis of residents in long-term care homes. It examines the complex transition between the different mood states and absorbing states out of LTC settings using a one-step multistate Markov transition analysis. Study 2 reports incident mood disturbance among Canadian long-term care home residents; however, it does not address the multidirectional changes or the absorbing states that act as competing risks. This study can inform decisions on programs that can enhance the mood of long-term care residents by examining predictors of worsening or improving mood as well as factors predicting transition to the absorbing states. Study 4 expands on our knowledge from study 3 by treating COVID-19 as a covariate to examine the effects of COVID-19 on transitions between the transient mood states and the absorbing states in comparison to the pre-pandemic period. A one-step multistate Markov transition analysis was used in a pan-Canadian retrospective longitudinal analysis. The findings suggest further knowledge on the effects of COVID-19 on mood and inform decisions on the effective programs that can improve mood during periods of outbreaks. The importance of this thesis lies in its comprehensive examination of the multifaceted complex interplay between social interactions, pandemic-related measures, as well as individual and facility-level variables pre-pandemic and during the COVID-19 pandemic. The included studies provide important insights for developing targeted interventions to support positive mood of LTC residents. In conclusion, this thesis not only advances our understanding of the mental health implications for LTC residents but also informs the development of evidence-based strategies to mitigate the adverse effects of isolation and pandemic-related stressors on this vulnerable population.
Assessing the implementation and outcomes of a food prescription program in Ontario, Canada: A realist evaluation
(University of Waterloo, 2024-04-30) Delamere, Megan
Background: Social prescribing has grown in popularity around the world as a method for health care practitioners to address the social determinants of health. Social prescribing is the process of a practitioner identifying a non-medical, social need in a patient, and then developing a non-medical prescription to connect them to community services. A subset of social prescribing is food prescribing, in which patients who are typically identified as food insecure are connected with services to provide access to nutritious foods. The Fresh Food Prescription Program (FFRx) was implemented beginning in 2021 by the SEED, a working group of the Guelph Community Health Centre (GCHC). Clients of the GCHC who were identified as food insecure and experiencing a cardiometabolic health condition were provided weekly vouchers for fruits and vegetables at the SEED’s online grocery store. Research question: The objectives of this research were 1) to describe the experiences of participants with FFRx 2) to evaluate impacts of FFRx on household food security, diet patterns, health, and well-being and 3) to identify how various contexts and mechanisms shaped differential program experiences and outcomes among FFRx participants. Methods: Semi-structured interviews (n=23) were conducted with FFRx participants along with follow-up focus groups and individual discussions (n=10). Guided by realist evaluation, a hybrid thematic analysis was utilized to identify context, mechanisms, and outcomes in the data. Results: Three key program outcomes were identified: 1) increased food access; 2) improved physical health and diet quality; and 3) improved mental health. Participants shared that they enjoyed having more food available to them and were able to purchase produce that was previously inaccessible due to financial constraints. Participants also noted that they consumed more fruits and vegetables during the program, as well as less nutrient poor foods. As a consequence, many participants associated their increased consumption of fruits and vegetables with improved physical health symptoms, more energy, and better sleep. Participants highlighted that they felt less stress throughout the program due to the stability of food access, increased social connections, and improved self-esteem. Discussion and conclusion: This study builds on current understandings of food prescribing, through demonstrating how these program can benefit participants through enhancing food access as well as self-reported physical and mental health. Importantly, this study also acknowledges the need for long-term, sustainable programming and funding to support food prescribing initiatives. The research elucidated the importance of developing programs that are context-aware and include supportive mechanisms that foster agency among participants. Further, this research serves as a starting point for future realist evaluations to be conducted, and highlights program design elements that could be implemented in future food prescribing programs.
Modifiable behavioural factors and their association with depression and anxiety in Canadian undergraduate post-secondary students
(University of Waterloo, 2024-04-30) Gibson, Sandra
Background: The mental health of post-secondary students is important for academic success and overall wellness. If post-secondary students are struggling with mental health concerns, these concerns can affect various aspects of university life including transitioning to post-secondary education, socialization and making connections, physical health, academic success, and student retention. Certain lifestyle behaviours identified as modifiable behavioural factors, or behaviours that are within the students’ control, such as sleep, physical activity, and substance use, may be valuable commodities to explore to proactively and positively improve the mental health and academic achievements of post-secondary students. Objective: This thesis explored the associations between depression and anxiety, and six modifiable behavioural factors (sleep, physical activity, cigarette smoking, e-cigarette use, marijuana use, and alcohol consumption) among female and male Canadian undergraduate post-secondary students. Method: Data from the 2019 National College Health Assessment (NCHA) Canadian Reference Group was analyzed using logistic regression models. Models, stratified by sex at birth, explored the association between depression as a mental health indicator and six modifiable behavioural factors (sleep, physical activity, cigarette smoking, e-cigarette use, marijuana use, and alcohol consumption) while controlling for relevant covariates. The same approach, also stratified by sex at birth, explored the association between anxiety as a mental health indicator and the six modifiable behavioural factors and covariates. Results: In this sample of Canadian undergraduate students, 53% of students reported depression and 71% of students reported anxiety. The main predictors of depression for female and male students were insufficient sleep, cigarette use, and marijuana use, but insufficient physical activity predicted depression only for female students. The main predictors of anxiety for female and male students were insufficient sleep, insufficient physical activity, cigarette use, and marijuana use. Alcohol consumption including binge drinking was either not significant or was found to have an inverse association with depression and anxiety for both sexes. Conclusion: Mental health is a serious problem among Canadian undergraduate post-secondary students. Both depression and anxiety are linked to several modifiable behaviours: sleep, physical activity, cigarette use, and marijuana use. These finding warrant the need for effective health campaigns, programming, and institutional policies that support student well-being and decrease mental health prevalence at post-secondary institutions.
Evaluation of the Capacity Building Model for the Tremplin Santé Program: A Mixed Methods Study
(University of Waterloo, 2024-04-25) Chen, Melvin, Chih-Shing
Introduction: Fewer than 1 in 5 Canadian children/youth met national guidelines for physical activity and sedentary behaviours in 2022 (ParticipAction, 2022). Summer camp environments provide a structured opportunity for children and youth outside of a school-setting to meet these guidelines and can foster emotional intelligence and independence, builds social skills and develops resiliency and confidence. Currently in Canada, there is no clear approach for summer day camps to follow that would serve to maximize the potential benefits that the camp experience has to offer camp staff and campers. Power Up is an intervention that aims to support the development of environments that are conducive to the promotion of healthy habits through the training and tools they offer to participating camps. The purpose of this research study is to evaluate: (1) how camp staff (administrators, coordinators and counsellors) implement the activities promoted by Power Up in summer day camps and (2) how the training and supports provided by La Fondation Tremplin Santé shape the environment of the camps through the leadership of counsellors and the physical activity of campers. Methods: This study involves mixed methods including interviews and structured observations in the camps. Semi-structured interviews were conducted with camp administrators, coordinators and counsellors to understand how they implemented the intervention in the camp setting. This study also included observations using two validated time-sampling tools: System for Observing Play and Leisure Activity in Youth (SOPLAY) and System for Observing Staff Promotion of Activity and Nutrition (SOSPAN) for assessing physical activity and promotion of healthy behaviours by counsellors. Results: The results of the direct observations and interview themes indicate that the training and resources provided by Power Up supported camp staff in the promotion of healthy habits and shaped the camp environment in a positive direction. Through the Power Up training, camp staff were able to learn and familiarize themselves with the available tools and resources to help with daily activity programming. However, there are challenges and barriers to implementing the Power Up intervention that requires further research. Conclusion: These results of this study will inform an understanding of program implementation and the way camp environments support physical activity and healthy eating in campers and counsellors for insight into program outcomes. This information will assist La Fondation Tremplin Santé in future iterations of the program and add to growing evidence regarding capacity building interventions to enhance healthy habits.
Unmet Mental Health Needs and Barriers to Mental Health Treatment Among Persons with Multiple Sclerosis in the NARCOMS Registry
(University of Waterloo, 2024-04-09) Lundenberg, Lucie
Background – Multiple sclerosis (MS) is a chronic, neurological disease. Mental health comorbidities, such as depression, anxiety and bipolar disorder, are highly prevalent in persons with MS, and their presence is associated with adverse health and economic consequences. Unfortunately, these conditions are frequently underdiagnosed and undertreated. To better meet the mental health needs of MS patients, it is important to identify the correlates, barriers and consequences associated with untreated mental health comorbidities. Previous studies have generally found socioeconomic factors (e.g., inadequate health insurance, low education) to limit access to mental health care; however, the findings for sociodemographic (i.e., age, race, ethnicity) and clinical factors (i.e., severity of mental health symptoms and level of physical impairment) have been less consistent. While qualitative investigations of MS patients have identified common barriers to mental health treatment, these barriers have been poorly investigated in larger samples of MS patients. Further research is needed to identify disparities in the use of mental health services for the treatment of mental health comorbidities in persons with MS. Research Aims – Cross-sectionally, this thesis aimed to assess the prevalence and correlates of untreated mental health comorbidities in persons with MS. This thesis also explored the prevalence and correlates of treatment barriers (in those not receiving treatment) and treatment modalities (in those receiving treatment). Longitudinally, this thesis aimed to assess the temporal association between baseline mental health non-treatment and depressive symptoms and health-related quality of life outcomes (mental and physical domains) at one-year follow-up. Methods – To address these aims, this thesis utilized cross-sectional (2011) and longitudinal (2011 to 2012) data captured by the North American Research Committee on Multiple Sclerosis (NARCOMS) Registry. The NARCOMS Spring 2011 Survey had a total of 9765 respondents; 3928 of whom were diagnosed with one or more of depression, anxiety or bipolar disorder. Mental health comorbidities were explored separately for all our analyses, resulting in three non-mutually exclusive baseline samples: depression (n=3589), anxiety (n=1487), and bipolar disorder (n=196). Other than initial descriptive data, statistical analyses were restricted to the depression and anxiety cohorts due to the small number of participants with bipolar disorder. Baseline respondents who responded to key outcomes (depressive symptoms, HRQOL scores) on the NARCOMS Spring 2012 Survey were included in follow-up analyses. Cross-sectionally, bivariate and logistic regression analyses were conducted to assess the associations between participant characteristics (with a focus on sociodemographic characteristics) and mental health non-treatment. The barriers to mental health treatment were explored in bivariate analyses through the lens of Andersen’s Behavioural Model of Health Service Utilization. Longitudinally, bivariate and logistic regression analyses were conducted to assess the temporal association between baseline mental health non-treatment and depressive symptoms (NARCOMS Depression Scale) and HRQOL quality of life outcomes (MCS-12 and PCS-12 scores on the RAND-12) at one-year follow-up. Multivariable regression analyses adjusted for baseline scores (NARCOMS Depression Scale and RAND-12 scores) and relevant baseline sociodemographic and clinical confounders. Results – In 2011, NARCOMS participants were more commonly untreated for anxiety (26.1%; 95%CI=23.9, 28.3) and bipolar disorder (23.5%; 95%CI=17.5, 29.4), followed by depression (15.2%; 95%CI=14.0, 16.4). In adjusted analyses, participants with younger and older ages (vs. 45 to 64 years; the former significant for depression cohort only), racialized participants (significant for depression cohort only), and those with low SES (health insurance for depression cohort, education for anxiety cohort) had significantly higher odds of mental health non-treatment. Participants with clinically meaningful depressive symptoms and those with more severe levels of disability had significantly lower odds of non-treatment. Of those not receiving treatment, participants were most commonly untreated due to need factors (i.e., “not having symptoms now”) (depression cohort: 57.4%, 313/545; anxiety cohort: 65.2%, 253/388), followed by predisposing factors (depression cohort: 43.1%, 235/545; anxiety cohort: 32.5%, 126/388) and enabling factors (depression cohort: 19.5%, 106/545; anxiety cohort: 22.2%, 86/388). Participants with low SES were significantly more likely to report enabling factors but less likely to report need factors as barriers to mental health treatment. Of those receiving treatment, less than one-third of participants were treated with both psychotherapy and medication (depression cohort: 20.1%, 611/3044; anxiety cohort: 27.7%, 304/1099). Participants with low education were less likely to receive the recommended treatment combination of psychotherapy and medication. Approximately two-thirds of treated participants reported clinically meaningful depressive symptoms (depression cohort: 63.3%, 1927/3044; anxiety cohort: 65.1%, 715/1099). After adjusting for key confounders (baseline scores, as well as other sociodemographic and clinical factors), baseline mental health non-treatment was not associated with the presence of clinically meaningful depressive symptoms or a clinically meaningful decline in mental or physical HRQOL at one-year follow-up. Conclusion – The findings of this thesis add to the literature by identifying important sociodemographic and clinical correlates of mental health service use and later health outcomes in MS patients to be considered in future research. Targeting the barriers identified in this thesis may improve access to mental health care for disadvantaged MS patients. To build upon the results of this thesis, future investigations could utilize multiple data sources (administrative, clinical and registry data) to assess the prevalence and correlates of mental health treatment barriers in a more diverse and representative sample of persons with MS.
University Students’ Gynecology Care Experiences in the US and Canada: Implications for Equitable Access to Person-Centered Care
(University of Waterloo, 2024-03-18) Richards, Nicole Karen
Introduction: The United States (US) and Canada (CA) have differing healthcare systems that play a central role in how reproductive care is accessed and delivered. Yet, their shared patriarchal history and culture contribute to the underdevelopment of medical reproductive knowledge and appropriate healthcare for uterus-having individuals of various intersecting identities. Medical literature lacks uterus-having individuals’ lived experiences of navigating reproductive services, and perspectives on how social factors, healthcare structure, and clinical practice can better support equitable access to person-centered reproductive care within both countries. As university students reflect diverse individuals transitioning to autonomous roles and changing reproductive health needs, their voices are critical to uncovering social and structural influences of person-centered access. The overall goal of this research was to identify what the US and CA system stakeholders can learn from uterus-having university students to improve reproductive healthcare delivery. I investigated how university students navigate gynecology care within divergent healthcare delivery models to address the following aims. Aim 1: Identify university students’ barriers to accessing gynecology care. Aim 2: Document factors influencing students’ person-centered gynecology care experiences. Methodology: This study was operationalized from the transformative-intersectional perspective that knowledge is created through individual experiences of reality, power, and oppression. Twenty-two university students who have used reproductive health services (CA: n = 11, US: n = 11) participated in semi-structured interviews and surveys (Nov 2019 – Jan 2021). Five reproductive health experts (CA: n = 3, US: n = 2) were interviewed to further situate students’ experiences within existing policy and practice standards. Student data collection tools were guided by intersectionality theory, the equitable access model (EAM), person-centered care frameworks, and American College of Gynecology clinical recommendations. Qualitative analysis occurred in three coding steps: inductive, identity, and deductive, allowing a broad look at raw data, intersectional identity discovery, and equitable healthcare access framework application. To supplement qualitative clinical-level findings, I analyzed surveys to show descriptive frequencies of students’ reported experiences of person-centered care indicators. I used abduction to connect qualitative and descriptive findings to existing concepts (e.g., theories, models, literature), identifying themes within and beyond existing knowledge and standards. To conclude my analysis, I used retroductive reasoning to extend the EAM model as it applies to gynecology care, illustrating social, policy, and practice opportunities to promote accessible person-centered care in both health systems. Results: Each participant self-reported uniquely intersecting identities (e.g., races, ethnicities, genders, sexualities, socioeconomic statuses, and cultures), which contributed to specific reproductive needs that played a role in their healthcare navigation and clinical experiences. These reports determined the scope of my thematic investigation, establishing a focus on access to and quality of preventive gynecology care and treatment for chronic reproductive issues in CA and the US. Aim 1: University students’ gynecology care access was determined by intersecting influences of structural health system nuances and personal cues to accessing reproductive care. CA’s health system provided students in this study with simplified reproductive healthcare navigation, but it limited reproductive health options and prolonged waits to specialist services. The US health system theoretically provided participants with reproductive care choices, but access to these choices was logistically complicated by healthcare fragmentation. Healthcare structure shaped the clinical setting, determining protocols and care provisions that students identified as negatively impacting care options and experiences such as inaccessible preferred contraception methods, short appointment durations, and a narrowed scope of health services. Students reported the importance of providers’ health system knowledge and clinical strategies to mitigate negative impacts of their respective health models. Personal influences to seeking care existed at various steps, including identifying when to seek care, knowing how to access care, preparing for clinical interactions, and physically attending appointments. Personal influences of how and when to access care stemmed from participants’ life experience and social networks, which they developed over time. Students reported that universities’ social and built environments further shaped reproductive health efficacy by providing proximate support, resources, and confidential services. Aim 2: I noted discrepancies between current reproductive care standards, participants’ clinical experiences, and students’ perceptions and values of what person-centered care means. Students reported frustration with the wording, intention, and interpretation of some standard clinical screening questions. Most students were not asked questions related to sexuality, mental health, and abuse. With participants’ frequent reference to the relationship between mental, sexual, and reproductive wellbeing, failure to ask these questions sometimes limited providers’ ability to address students’ needs. While most students were offered STI testing and reported STI services as a key reproductive health value, students infrequently reported blood tests, possibly indicating incomplete or insufficient STI testing. Students’ discussions about clinical experiences focused on perceived quality of provider interactions. While most survey responses showed satisfaction with providers’ shared decision-making approach, interviews revealed nuanced experiences of students feeling unengaged in their care, reporting providers did not offer adequate support to enable them to make informed, autonomous decisions. Conclusion: Students in both countries expressed the need for reproductive service navigation support within systems that provided timely options to care that centered on their specific intersectional identities and health needs. In addition to policy and practice mitigation opportunities for identified structural barriers within health systems, I found that comprehensive education policy and social support may improve students’ access to person-centered reproductive care, allowing for knowledge and skills to identify reproductive needs, navigate health systems, self-advocate, and ultimately make informed decisions. These findings suggest that providers can play a crucial clinical role in mitigating some structural and personal barriers to person-centered care by maintaining and applying proficiencies in reproductive health literature, health policy, and cultural safety as it relates to their patient populations. Overall, this work situates reproductive healthcare access within the EAM, extends this framework to better integrate person-centeredness as a care quality mediator, and connects concepts identified in this study to opportunities for improvement.
Understanding Longitudinal Changes in The Performance of Activities of Daily Living in Long-Term Care Settings: Trajectories, Transition Patterns, Predictors and Associated Health Outcomes
(University of Waterloo, 2024-01-26) Egbujie, Bonaventure Amandi
Abstract: With rapid global growth of the aging population and the associated “expansion of morbidity”, more people live to experience challenges with performing the usual daily living activities resulting in an increasing need for long-term care (LTC). Understanding the complexities of changes in physical function is essential for the planning and delivery of person-level care that would promote healthy aging and enhance quality of life. This thesis explores the diverse trajectories of change in functional level that occur among LTC. It examines the role of individual-level factors in these complex changes, with a view to identifying early markers of adverse trajectories and enablers of beneficial trajectories. The ultimate goal of this is to generate evidence that could be used for person-level care planning, health management, and policy development. The thesis is comprised of five empirical studies representing different steps toward the main goal. Study 1 is a scoping review of existing literature for approaches used to examine longitudinal trajectories of change in physical function. It summarizes evidence of how trajectories of physical function have been modeled over the past 20 years, showing the most frequently applied methods and their outputs. This chapter presents an easy-to-use, concise summary of the existing functional change modeling approach, highlighting the benefits of each method and the situations where they would most likely be more appropriate. It contributes to our understanding of how physical function trajectory modeling evolved over the years and highlights current gaps in research. Study 2 provides evidence based on generalized estimating equations to quantify the marginal effect of the COVID-19 pandemic on ADL performance in LTC settings in Canada. This chapter which has already been published with the title, “Functional Decline in Long-Term Care Homes in the First Wave of the COVID-19 Pandemic: A Population-based Longitudinal Study in Five Canadian Provinces”, provides an aggregate level comparative analysis of functional decline between the pandemic and pre-pandemic periods. It contributes to the literature on the actual “additional” functional decline that occurred during the pandemic, differentiating this effect from the decline that usually occurs among residents in the setting. Study 3 presents an analysis of three-year longitudinal trajectories of functional decline in LTC settings using Group Based Trajectory Modelling (GBTM) technique, which is a form of latent class growth analysis. GBTM was identified through the scoping review in Study 1 to be the most appropriate method for answering the research question addressed in this chapter. Four distinct functional decline trajectory subgroups were identified with this modeling approach for the overall population and the sub-analytic samples are presented in the associated chapter. Predictors of trajectory group membership were determined as well using binary logistic regression. The study also highlights the value of identifying functional decline trajectory by showing that it predicts future health outcomes like mortality and resource utilization. Prior to this study, there has not been any characterization of the pattern and predictors of longitudinal trajectory of functional decline among LTC residents in Canada. This study therefore contributes new knowledge about the multiyear trajectory of functional change followed by residents upon entry into care homes. Study 4 highlights the multifaceted and complex transition between the different ADL functional levels and transitions out of LTC settings. Study 2 of this thesis provides the aggregate analysis of functional changes associated with a widespread health crisis and, study 3 reports trajectory patterns. However, both do not address the complex dynamic multidirectional changes that occur among residents. This study fills this gap by using multistate Markov transition analysis to capture the complex multidirectional transition between different functional levels (including improvement, decline, and remaining unchanged), and transition out of the setting observed during each assessment. The novel contribution of this study is in expanding our knowledge about the transient and terminal transitions that occur concurrently between ADL functional levels and other health outcomes in LTC setting. Last, the 5th study further deepens our understanding of COVID-19’s effect on LTC settings. Multistate Markov transition analysis was used to produce evidence of the transitions between ADL functional levels and out of the LTC setting that occurred during COVID-19 pandemic compared to similar transitions in the pre-pandemic period. It advances our previous chapter on Functional Decline in Long-Term Care Homes in the First Wave of the COVID-19 Pandemic, by providing a disaggregated, multidirectional analysis. The study therefore improves existing knowledge by providing a more granular analysis of the complex effect of the COVID-19 pandemic on the physical function of LTC home residents. Through evidence generated from this comprehensive series of studies, this thesis expands existing knowledge about changes in the performance of activities of daily living in LTC settings. It adds a nuanced understanding of the complex multidirectional transitions between ADL functional levels and transitions out of the setting. By examining both aggregated and disaggregated measures of functional status, the thesis provides various perspectives with evidence that would allow care providers, health administrators, and policymakers to make better decisions about care planning and service provision in LTC. Further, by generating evidence of ADL and other health outcome changes during the COVID-19 pandemic, the thesis contributes additional knowledge that would be useful in planning for future pandemics or similar widespread health crises. Future work should focus on utilizing this evidence to develop decision-support tools to inform personalized care planning, promote healthy aging and enhance the quality of life of older adults.
“Even if we want help, there is no help”: Exploring Perceptions and Barriers in Home Care Services within the South Asian Communities
(University of Waterloo, 2024-01-23) Subbiah, Krithika
Abstract Background: In Canada, the demand for home care services continues to increase due to the ongoing growth of the aging population. This aging population is marked not only by the increase in the number of older adults but also by its significant diversity (National Advisory Council on Aging, 2005). There is a growing need to address disparities in the utilization of home care services among immigrant older adults (Wellesley Institute, 2016). Despite the importance of home care services, little is known about how ethnic minorities perceive home care services in Ontario, specifically South Asian communities – who are the largest minority in Canada. Therefore, recognizing this overarching context, my research aimed to explore South Asian communities’ nuanced perceptions about home care services in Ontario, barriers they face when accessing these services and recommendations on how home care services in Ontario can be structured to address their unique needs. Specific Aims: The study aimed to explore South Asian communities' nuanced perceptions about home care services in Ontario and the barriers they experience when they access home care services. Additionally, it sought recommendations from these communities on how to enhance home care services for older adults, aiming to improve the provision of culturally aligned home care services for South Asian communities in Ontario. Methods: This study employed an exploratory qualitative research design to investigate the nuanced perceptions about home care services in Ontario, barriers they face when accessing these services and recommendations on how home care services in Ontario can be structured to address their unique needs. Thirteen participants, including seven care partners, three South Asian older adults, and three social workers who engaged with South Asian older adults, contributed to the study. A Reflexive Thematic Analysis was utilized to engage with the data and generate themes for the study. This method facilitated a rigorous and reflexive examination of participants' narratives, enhancing the depth and richness of the study findings. Results: The participants emphasized a significant demand for home care services within South Asian communities. In shedding light on the barriers faced by these communities in accessing home care services, various challenges experienced by care partners and older adults in Ontario were revealed. The findings also revealed the impact of duration of residency in Canada on openness to formal home care, the presence of stigma hindering care-seeking, and a lack of awareness about available home care services. Evolving gender roles and care partner burdens were discussed, emphasizing the necessity of culturally tailored support services. Preferences for culturally competent and humble care, language concordance, and alignment with care providers' gender and ethnicity emerged as significant themes. Additionally, the study participants offered valuable recommendations to improve home care services for South Asian communities. These suggestions, ranging from enhancing accessibility to customizing services, aim to align with the cultural needs of the South Asian communities. Discussion: The study reinforced the notion that the South Asian communities are a diverse and heterogeneous group. Perceptions of home care services differed based on the extent of Western cultural adaptation and lived experiences. The research also underscored that while the general population faces obstacles in accessing home care, these challenges are more pronounced within the South Asian communities due to factors like cultural expectations, language barriers, and financial constraints. Additionally, it highlighted the need for culturally tailored home care services to meet the specific needs of an increasingly diverse aging population. Conclusion: This study significantly contributed to ethnogerontological knowledge by examining South Asian communities' nuanced perceptions about home care services in Ontario, barriers they face when accessing these services and recommendations on how home care services in Ontario can be structured to address their unique needs. Recommendations included targeted awareness strategies and culturally sensitive services for South Asian communities. The study advocated for a holistic home care model, patient-centered care, and cautioning against reliance on cultural stereotypes. Future research suggestions included exploring perceptions among recent immigrants, those with dementia, and an intersectional analysis. Additionally, investigating cultural factors like filial piety and their impact on long-term care decisions within the South Asian communities is recommended.
COVID-19, Mental Health, and Chronic Illnesses: A Syndemic Perspective
(University of Waterloo, 2024-01-12) Saqib, Kiran
Introduction: The term "syndemic" refers to the interaction between two or more coexisting epidemics, where the interactions amplify the negative health outcomes. The COVID-19 pandemic can be considered a syndemic because it involves the convergence of multiple factors: the direct impact of the SARS-CoV-2 virus causing COVID-19, the exacerbation of pre-existing chronic health conditions, and the associated mental health challenges. These factors interact in complex ways, creating a situation where the combined effect is greater than the sum of its parts. The COVID-19 pandemic has triggered a surge in mental health challenges worldwide. The connection between COVID-19, mental health, and non-communicable diseases is bidirectional. Mental health issues can exacerbate existing chronic conditions, while pre-existing chronic conditions can increase the vulnerability to severe COVID-19 outcomes and also contribute to poor mental health. Recognizing the syndemic nature of the COVID-19 pandemic is crucial for holistic understanding and effective response. Approaches that solely focus on the virus itself or individual health conditions may overlook the complex interactions of other factors. A syndemic perspective not only highlights the synergy between COVID-19, chronic diseases, and mental health, but also emphasizes the need for comprehensive public health strategies that address not only the virus's spread but also consider the broader social, economic, and health implications. Methods: This dissertation utilized secondary data acquired from the Ontario Health Database Platform (OHDP) through the Institute for Clinical Evaluation Sciences (ICES) with adult Ontarians aged 18 years and above as the study population. The exclusion of individuals under 18 years old in the research was driven by the specific emphasis on chronic illnesses, which are typically more widespread in the 18+ age group. Despite the occurrence of COVID-19 in those under 18, the research focuses on individuals aged 18 and above, considering that younger individuals generally face milder complications compared to their older counterparts. Consequently, the inclusion of minors was deemed irrelevant to the research specific objectives. Various administrative health databases including the Discharge Abstract Database (DAD), National Ambulatory Care Reporting System (NACRS), Ontario Health Insurance Plan (OHIP), Ontario Mental Health Reporting System (OMHRS), and ICES-derived cohorts were used to identify variables of interest and address specific research objectives. The primary aim of this analysis was to evaluate the syndemic impact of COVID-19 and related anxiety and depression on health outcomes in the Ontario population. In Study I, Cox proportional hazards regression was utilized to assess the association of factors with time to anxiety and depression related health services utilization, and results were summarized using hazard ratios (HRs) with corresponding 95% confidence intervals (CIs). For comparison of morbidity and mortality before and during the pandemic, an interrupted time series study design was adopted in study II, using a segmented regression model to assess the monthly impact of COVID-19 on overall morbidity and mortality in the Ontario population. For every assessment period (defined as month), we determined the total number of morbidity episodes and mortality per month for each year. For Study III, multiple logistic regression analysis was utilized to identify important risk factors associated with the syndemic impact of COVID-19 and co-occurring anxiety or depression on morbidity, among the adult Ontario population Results: In the adjusted Cox proportional hazards model (Study I) for the sample, the individuals who had PCR tests had a higher risk of utilizing health services for anxiety and depression during the pandemic, (aHR, 6.37; 95% CI, 6.25-6.50 and aHR, 5.91; 95% CI, 5.87-5.95) for COVID-19 positive and COVID-19 negative respectively, as compared to those who had no PCR testing done for COVID-19. Study II noted that in the early stages of the COVID-19 pandemic's first wave in Ontario, there was a decrease in physician visits and hospitalizations among those with chronic conditions, possibly due to infection fears and disruption of health services. As time passed, there were later phases marked by significant rises in medical visits and hospitalizations. In the final adjusted regression model (Study III) for the sample, the individuals who were COVID-19 positive and had either anxiety or depression were more likely to utilize health services for chronic conditions of interest during the pandemic, as compared to those who were COVID-19 negative with mental health issues (ORs, 1.33; 95% CI, 1.12-1.58). A higher risk of morbidity was observed among males (ORs 1.28; CI,1.16-1.41), as well as in individuals with diverse ethnic backgrounds and low socioeconomic status. Conclusion; The individuals who had COVID-19 testing exhibited greater utilization of healthcare resources for anxiety and depression in comparison to those who were not tested, irrespective of COVID-19 disease status. Investigating the causes of psychological distress related to COVID-19, especially among individuals undergoing PCR testing, is essential for addressing its mental health impacts and improving readiness for future pandemics. We also noted the complex trajectory of healthcare utilization during the pandemic's waves. While the initial decline in physician visits and hospitalizations could be attributed to fear and healthcare system adjustments, subsequent periods witnessed increases in healthcare utilization and mortality rates, highlighting the evolving dynamics of the pandemic's impact. The shifts in healthcare utilization brought about by the pandemic carry significant clinical and public health implications. These include potential consequences such as missed diagnoses, delayed treatment, higher morbidity, and increased mortality. These challenges highlight the importance of healthcare system adjustments and preparedness for future pandemics. It is vital to tackle barriers to health care, ensuring that individuals, particularly those with chronic conditions, can access essential medical services, even when resources are constrained. Moreover, the individuals diagnosed with COVID-19 and co-occurring mental health issues of anxiety and depression exhibited increased healthcare service utilization. This points towards the interconnectedness of physical and mental health and emphasizes the importance of addressing both aspects for individuals' overall well-being, especially within the context of the COVID-19 pandemic. The impact of COVID-19 on mental health can be seen as a "syndemic," wherein its effects on susceptible individuals with chronic illnesses are exacerbated through synergistic interactions. This interplay underscores the significance of comprehensive public health strategies. Acknowledging this syndemic enables policymakers to develop focused measures aimed at mitigating adverse health effects among vulnerable groups.
The Maternal Health Literacy of South Asian Newcomer Mothers and Canadian-born Mothers
(University of Waterloo, 2024-01-09) Khajeei, Dahlia
Research suggests newcomer mothers score lower than Canadian-born mothers on health literacy (HL) and health numeracy (HN) assessments and have difficulty accessing maternal health services. This dissertation explored the nexus between language, language competencies, and the comprehension of health information by English-speaking, South Asian newcomer mothers (SANMs) and English-speaking, Canadian-born mothers, with a focus on learning. First, we conducted a scoping review using a systematic search strategy to identify conceptualizations of maternal health literacy (MHL) and HN according to the empirical research. Second, we employed narrative inquiry and used thematic analysis in conjunction with propositional analysis to explicate the verbalizations of mothers who shared stories about their comprehension of ultrasound examination preparation, health-risk information, and shared decision making. Third, we determined the accuracy of an explanatory model of qualities of MHL through an observation-oriented investigation of data from an online survey and used a non-parametric procedure to perform comparative analysis of responses. In study one, the final themes of the scoping review of MHL and HN conceptualizations were (i) sociocultural demographics, (ii) self-efficacy, (iii) communication, (iv) information seeking and operationalization, (v) health status, and (vi) reasoning. In study two, the results of the narrative inquiry suggested mothers demonstrate MHL through reifying, posturing, and volition. In study three, the results of the post-hoc analysis of survey data showed SANMs mothers are limited in their functional health literacy (FHL) compared to Canadian-born mothers. The collective contribution of the papers advocates for greater sociocultural linguistic measures of MHL in public health research to account for individual learning behavior.
Seeking the Source: Dioxin Exposure Levels and Determinants and Fluoroalkyl Substance Determinants in Arctic and Subarctic Communities within Canada
(University of Waterloo, 2023-11-27) Simpson, Ashlyn
Abstract Background Dioxins, furans, and non-ortho dioxin-like polychlorinated biphenyls (PCBs), and per- and poly- fluoroalkyls (PFAS) are persistent toxic chemicals that have been detected in areas far from known emission sources. Following biomonitoring projects conducted in the Dehcho Region, Northwest Territories (2016-2018) and Old Crow, Yukon Territory (2019), elevated levels of PFNA were detected, and dioxins, and like-congeners were yet to be investigated. This thesis reports on dioxin exposure levels and identifies determinants that may influence dioxin and PFAS exposures in the study areas. Research Questions To assess dioxin, furan, and non-ortho dioxin-like PCB exposures, two research questions are raised: What are the levels of dioxins in blood plasma samples from Old Crow and how do these compare to the general population of Canada? and are there specific demographic variables that are associated with higher or lower exposure? The determinants of exposure are then explored among the participating communities with dioxin and PFAS exposure measures: Are there lifestyle factors or traditional foods consumption patterns that are associated with biomarkers of these analytes? Methods Biobanked plasma samples (n=54) from Old Crow were analyzed for dioxins, furans, and non-ortho dioxin-like PCBs. Data from surveys on traditional food consumption and lifestyle factors were collected in Old Crow and the Dehcho Region. Descriptive statistics were used to quantify differences in exposure between the Old Crow and Canadian Health Measures Survey (CHMS) data, then simple linear regression and multiple variable regression was used to identify the traditional foods and lifestyle factors that may influence PFAS, and dioxin and dioxin-like congener exposures. Results Most dioxins, furans, and non-ortho dioxin-like PCB exposures were lower, or similar in the study areas in comparison to the respective levels in the general population of Canada. Like the previous findings with PFNA, PCB 169 levels appeared to be approximately two fold elevated in Old Crow participants aged 20 to 39 years and 60 to 79 years when compared to the general population of Canada. The investigation of exposure determinants revealed that traditional foods were generally negatively associated with PFAS exposures, indicating that those who consumed traditional foods may have eaten fewer processed and packaged foods. However, some exceptions to this were observed. For example, PFNA exposure was positively associated with consumption of some moose tissues in Old Crow, while whitefish eggs, Canada goose meat, lake trout, and ptarmigan showed similar directionality and significances of association in the Dehcho Region. Unexpectedly, height was positively associated with PFOA, PFOS, and PFHxS levels in the Dehcho Region, but this association was not consistent with the same variable in Old Crow. Determinants analysis among dioxins and dioxin-like congeners showed different trends; PCB 126 was positively associated with multiple foods across categories. Coho salmon was significantly positively associated with exposures to 1,2,3,6,7,8-HxCDD, 2,3,4,7,8-PeCDF, and PCB 126. PCB 169 exposure was significantly positively associated with employment in an occupation of risk. It is notable that some traditional foods appeared to be associated with some persistent organic pollutant exposures; however other aspects of health, such as culture, social, and nutritional benefits were also considered in the interpretation of the results. The processes that surround the harvesting, preparation, consumption, and sharing of traditional foods promote physical activity, spiritual well-being, and socialization. It is concluded that the benefits of eating traditional foods continue to outweigh the risks of environmental contaminant exposures in the researched communities. Contribution Regional partners and community representatives were included in developing the contextualization, interpretation, and communication of the results synthesized in this thesis. The results from these investigations were provided to the respective study participants, participating communities, and governments through an in-community meeting (e.g., Vuntut Gwitchin Research Round-up), personalized biomarker results letters, and infographic flyers. Knowledge sharing in Old Crow led to continued development of community questions surrounding local sources of contamination, and knowledge that may be applied to further investigate the sources of persistent organic pollutant (POP) exposures, potentially empowering communities to enact local policy, and reduce population exposures to contaminants. Aggregate results have been shared with researchers (e.g., the International Society of Exposure Science Conference (Chicago, 2023) and publications, according to processes outlined in community research agreements. Research on POP exposures in inland First Nations across the territories has been limited. Nationally, these results help to inform peoples’ exposures to POPs and the exposure sources among Indigenous communities located in Arctic and subarctic areas within Canada. These results are in alignment with the research priorities of the Northern Contaminants Program (Canada), Arctic Monitoring and Assessment Programme (AMAP), and Stockholm Convention which continue to monitor the levels and exposure patterns of persistent organic pollutants. This thesis has analyzed data and information from Indigenous communities that have not been represented in national biomonitoring studies. Through the biomonitoring studies and analyses conducted prior to, and in parallel with this thesis, several data gaps regarding environmental exposures in northern Indigenous populations have been filled, addressing inequities in baseline exposure information, and understanding of the potential determinants of exposure. This approach aims to enhance understandings of environmental contaminant exposures among First Nations living in participating regions while also empowering communities with local environmental health data that complements Traditional Knowledge.
Widening the View: A Standardized Approach to Capturing Family Members’ Perspectives on Quality of Life in Long-term Care
(University of Waterloo, 2023-11-20) Norman, Kathleen
Background and Rationale: Family members provide important functional and socio-emotional support to residents living in Long-Term Care (LTC). With high rates of cognitive impairment among residents, family member input is increasingly valued in new LTC standards provided by Health Standards Organization (HSO), given their unique perspectives, knowledge, and role in the resident’s circle of care. A standardized instrument to collect this input is lacking in the current literature. Methods: A scoping review was conducted to gather and evaluate the existing literature studying the instruments used to evaluate family perspectives on Quality of Life (QoL) in LTC. This and retrospective analyses of secondary data collected from 3 previous studies using the interRAI Family QoL LTCF instrument (FamQoL V1), informed the development of a new instrument, the interRAI Family QoL LTCF Version 2 (FamQoL V2). An expert panel participated in the Delphi method to gather expert input into the development of a Version 2 interRAI Family QoL-LTCF (FamQoL V2) Instrument, through the Seniors Quality Leap Initiative (SQLI). Primary data were then collected from 38 LTC homes in Canada and the US with a total of 716 unique family members responding. These data were used to examine the psychometric properties of the instrument, develop summary scales, and examine distributions of Family QoL perspectives in North American LTC homes. Results: The previously published instruments varied considerably with item counts ranging from 21 to 104 and 4 to 15 summary domains. While several common item themes were identified (e.g., living environment, resident care, autonomy, security, global recommendations), others were less consistent among the instruments (e.g., administration, admission process, therapies). Family members had lower positive response rates on the items with higher missing or non-response rates (e.g., bath/shower when wish, affection and romance, social activities). They scored higher than residents on items related to staff responsiveness and trust and lower than residents on items related to social life and personal control. Several Delphi rounds were conducted to build consensus, resulting in a 25-item FamQoL V2 instrument with 12 shared QoL-LTCF and 13 unique FamQoL V2 items. The instrument had strong performance. Five summary scales were developed through factor analysis, with Cronbach’s alpha ranging from 0.88 to 0.92. Conclusion: This dissertation provides actionable evidence that supports the Quadruple Aim of Healthcare Improvement, meeting new national LTC standards, and assisting LTC homes in their quality improvement efforts. Through an extensive scoping review, analysis of a large and multi-study secondary dataset, expert Delphi input, multi-country primary data collection and psychometric testing, and family member feedback, a FamQoL V2 instrument was developed and accepted by a large consortium of LTC providers and researchers (SQLI). The instrument is operationally feasible, with a shorter number of items compared to other surveys and interoperability with other interRAI instruments. The scientific work underlying this instrument’s development has been reviewed and approved by interRAI’s Instrument and Systems Development (ISD) Committee and the FamQoL V2 is now included in interRAI’s published manual for QoL measures. An evidence-informed, reliable instrument is now available for jurisdictions to standardize how this important perspective is collected and measured in LTC.
Considerations regarding Incorporating a Cash-for-care Program in Ontario's Approach to Care for Older Adults
(University of Waterloo, 2023-11-13) Andrews, Douglas
Ontario, like Canada more generally, has an aging population, which will exert further pressures on the approaches to providing care to older persons. Certain of these pressures are outlined, with the aid of population projections. Many developed countries, most of which have aging populations, have adopted various approaches to care provision for older adults, which differ from Ontario’s approach in certain ways. Ariaans et al. (2021) developed a typology based on the approaches used in 25 OECD countries but did not include Canada or Ontario in the analysis. This thesis analyzes the care approach used in Ontario along the dimensions developed by Ariaans et al. (2021) to place it within the typology used by Ariaans et al. (2021). A measure used by Ariaans et al. (2021) is whether a cash-for-care program is included. Ontario’s approach does not incorporate a cash-for-care program, whereas some other countries’ approaches do include a cash-for-care program. A scoping review was performed to identify and report on the benefits and disbenefits of a cash-for-care program, identified in the literature, and five themes were revealed. A form of framework analysis was used for more detailed exploration of the gender engraining aspects of cash-for-care programs. The discussion has special relevance to any proposed intervention, such as introduction of a cash-for-care program, because women play a disproportionately large role as carers, both paid and unpaid, and as care recipients in long-term care homes, and may be adversely affected.
Examining the Connection: Traumatic Life Events, Substance Use, and Service Utilization Among Persons Admitted to Inpatient Psychiatry in Ontario
(University of Waterloo, 2023-11-06) Fearon, Danielle Olivia
Background Experiencing traumatic life events and the symptoms that follow have been associated with an increased risk for other mental health conditions. Among individuals who have experienced traumatic life events, comorbidities such as substance use disorder are particularly common. Individuals with co-morbid trauma and substance use may be less responsive to treatment, are prone to relapses, and increased hospitalizations. Gaps in care for individuals with co-occurring trauma and substance use reflect the growing need to understand associations between trauma experiences and substance use to identify opportunities for improving care and outcomes. Using data from persons who experienced trauma prior to admission to inpatient psychiatry, the purposes of this dissertation are to (1) identify the classifications of both trauma and substance use, (2) examine the service complexity received by persons with trauma, and (3) examine whether trauma classifications, and the presence of social relationships are associated with early leaves from inpatient care. Methods A population based retrospective cohort was developed using interRAI Mental Health (RAI-MH) assessment data from all inpatient psychiatric assessments in Ontario, Canada between January 1, 2015, to December 31, 2019. The RAI-MH is a comprehensive assessment tool completed by clinical staff overseeing the care of the person. Completion of the assessment draws on multiple sources of information such as a review of the patient’s clinical records, interviews and observations, consultation with other clinical staff, family, and first responders (CIHI, 2023). The cohort included all persons in non-forensic and non-geriatric beds who were over the age of 18, and who had experienced a traumatic life event at some point prior to admission. Modelling and analyses were all conducted using SAS 9.4. Study 1: Data were included for individuals with an index admission stay of 72 hours or longer during the observational window. Patients were excluded if they were admitted from another psychiatric hospital or if their first episode was not an admission assessment. Patients were included if they triggered the Traumatic Life events CAP of the RAI-MH (N=10,125). Latent class analysis was used to determine underlying subgroups of patients based on their patterns of traumatic life events and substance use behaviour. An 8-class solution was selected based on comparisons of Akaike information criteria, Bayesian information criteria, adjusted Bayesian criteria, and entropy values. Study 2: Data from the Ontario Mental Health Reporting System were included for patients who triggered the Traumatic Life events CAP with no recent psychiatric assessments (i.e., no admissions within the last two years) (N=7,871). A service complexity variable was created based on length of stay (from date of admission to date of discharge, measured in days), the frequency of non-nursing formal care use, and nursing interventions in the prior 7 days. Descriptive statistics and bivariate associations between all demographic characteristics and level of service complexity were conducted. Logistic regression modelling was then used to assess the association between latent classes and the outcome (i.e., service complexity: low/moderate versus high service complexity). Odds ratios (unadjusted and adjusted), and 95% confidence intervals were reported for the initial and final models. Study 3: All records for individuals who triggered the Traumatic Life events CAP with an index admission over 72 hours between January 1, 2015 and December 31, 2019 were included (N=11,043). Early leaves were defined based on discharge status. The variable was coded into three different levels including unplanned leaves (patients who were discharged due to an absence without an approved leave, and persons discharged against medical advice), early leave (patients with short length of stays), and no early leave. Chi-squared tests were used to understand associations between demographic and clinical characteristics, and early leaves from inpatient stays. Multinomial logistic regression modelling was then used to assess the association between latent classifications of trauma and substance use, Clinical Assessment Protocols, demographic and clinical characteristics, the multi-level outcome of early leaves (i.e., unplanned, or short length of stay), and those who did not discharge prematurely. Results Study 1: Using latent class analysis, eight classifications of trauma and substance use were identified, ranging from low (i.e., Class 1: Interpersonal Issues, Without Substance use) to high (i.e., Class 8: Widespread Trauma, Alcohol & Cannabis Addiction) complexity patterns of traumatic life events and substance use indicators. Classes with similar profiles of trauma were differentiated by variations in substances use patterns. Furthermore, substance use patterns ranged from use of specific substances to widespread use and show variation in the presence of indicators of problematic use. Multinomial logistic regression models highlighted additional factors associated with class membership such as homelessness, where those who were homeless were estimated to be 1.71-3.02 more likely to be in Class 3: Safety & Relationship Issues, Alcohol & Cannabis use, and 2.09-4.02 times more likely to be in Class 6: Widespread Trauma & Substance Addiction. Study 2: Service complexity ranged from 1 to 13, with the most common services being psychiatrist (84.3%), nurse practitioners or medical doctors (non-psychiatrists) (64.1%), and social workers (59.7%). High service complexity, defined as the upper quintile of formal care service use (scores of greater than or equal to 9), nursing interventions, and longer length of stay was observed in 18.1% of individuals with trauma. Compared to patients with few trauma experiences and no substance use, patients with more widespread trauma experiences and indicators of alcohol and cannabis addiction were 2.1 times (95% CI: 1.68-2.50) more likely to have high service complexity. Patients with safety and relationship traumas with alcohol and cannabis use, were less likely to have high service complexity compared to patients with interpersonal issues, without substance use (adj. OR: 0.70, 95% CI: 0.54-0.91). Characteristics such being female, having greater education, and being employed were associated with higher service complexity. Study 3: Multinomial logistic regression revealed that individuals in latent classes with patterns of substance use (e.g., Class 6: Widespread Trauma & Substance Addiction) were more likely to have unplanned early leaves compared to those without substance use (adj. OR: 4.17, 95% CI: 2.72-6.39). Individuals with interpersonal conflict (i.e., conflict in relationships and widespread interpersonal conflict) had increased odds of having early leaves that were unplanned. Persons in Class 4: Immigration with Interpersonal Issues, Alcohol & Cannabis Addiction (adj. OR: 0.68, 95% CI:0.56-0.83), and Class 8: Widespread Trauma, Alcohol & Cannabis Addiction (adj. OR:0.73, 95% CIL 0.60-0.89) were less likely to have early leaves that were short length of stays compared to all other classes. Discussion The findings highlight multi-dimensional experiences of both trauma and substance use. That is, experiences of trauma and patterns of substance use vary among patients with trauma admitted to inpatient psychiatry. Patterns of service use, and discharge status also varied. Differences identified suggest the need to consider the nuances of trauma to support patients, consider ongoing prevention of substance use, and address barriers in maintaining treatment. Study 1: When considering traumatic life events across the latent classes, experiences of trauma were diverse among inpatients: from those with a few traumatic life experiences centered around health and loss (Class 1) to those with widespread experiences that include accidents, health challenges, grief and loss, and other social circumstances (Class 8). In Ontario, there are few specialized programs in place for supporting trauma, except for several tertiary hospitals. Advances in publicly funded services outlined in provincial strategic plans may hold promise, such as the introduction of structured psychotherapy programs and specific resources to support the military and first responders (Ministry of Health, 2022). Increasingly, dual treatment options for both trauma and substance use (e.g., Concurrent Treatment of PTSD and Substance Use Disorders (COPE)) should be further explored (Persson et al., 2017). Further research should explore patterns of trauma and substance use in community mental health settings, and supporting clinician confidence in discussing traumatic life events with patients. Study 2: Nuances were observed when considering the relationship between latent classes of trauma and level of service complexity. Patients with indicators of substance addiction were more likely to have high service complexity. Findings highlight the importance of ensuring funding is allocated to public services for the continuation of care post-discharge. The RAI-MH can identify specific experiences and needs of persons with trauma that may be useful for informing further analyses on resource utilization and service planning. Given that economic costs data were not available, future research may consider the use of resource measurement and cost data to validate observed differences in service complexity. Study 3: The results of study 3 point to differences between early leaves that are unplanned versus short length of stays. Both discharge statuses reflect an important period for providing treatment and recognizing substance use. Latent classes with the highest likelihood of unplanned early leaves generally included indicators of substance use. An eagerness to return to the community to utilize substances may reflect early unplanned discharges in this study. Inpatient admissions highlight an important timeframe to intervene in ongoing substance use. Unplanned early leaves may also reflect individuals with complex trauma that would better be supported in longer-term specialized treatment programs. Other factors such as interpersonal conflict, and eating disorders were associated with early discharge status. Future studies should assess the association between social relationships, formal supports, and early leaves.

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