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.

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Trajectories of Psychopathology and Mental Health Service Use Among Youth with A Physical Illness
(University of Waterloo, 2025-03-04) Dol, Megan; Ferro, Mark
Youth with chronic physical illness (CPI) are at an increased risk of developing co-occurring mental disorders (i.e., multimorbidity). About 40% of youth with CPI receive a mental disorder diagnosis. The relatively high multimorbidity prevalence suggests this is a pressing public health issue—youth with multimorbidity experience greater symptom severity and functional impairment. In addition, multimorbidity negatively impacts psychosocial outcomes, including health-related quality of life, self-esteem, and academic functioning. Although these children experience poorer outcomes and use a greater amount of mental health services, there is limited understanding of how specific trajectories of mental disorder symptoms (i.e., psychopathology) influence service use over time. By examining the course of psychopathology and its association with mental health service use (MHSU), we can identify critical intervention points aiming to improve the effectiveness of care and allocation of resources. In Canada, the financial burden of mental illness is approximately $51 billion annually, including costs arising from healthcare services, lost productivity, and poor quality of life. Compounding on these burdens, there is an acute shortage of youth-specific mental health services in Canada, where up to 70% of youth with mental health concerns do not receive the specialized services they need. Understanding MHSU in youth with CPI may help efficiently use resources, identify unmet needs, improve the timing of interventions, support families in predicting care needs, and inform policies for targeted and integrated services. This dissertation addresses critical gaps in research on youth psychopathology among you with CPI. While previous studies have explored youth MHSU, few have examined the unique trajectories of psychopathology in this population or how these trajectories affect mental health service use over time. Additionally, limited research has investigated the interplay between parent psychological distress, youth psychopathology, and healthcare use, particularly using longitudinal models. Focusing on these areas, this dissertation provides insights into the complex needs of youth with CPI. It highlights opportunities for improving integrated mental health and healthcare support for this at-risk group. To address these gaps, this dissertation examined youth psychopathology trajectories and transitions and whether psychopathology trajectories impact the association between family factors and MHSU. Specifically, the objectives were to: 1) identify distinct trajectories of psychopathology among youth with a CPI; 2) validate these trajectories by comparing with categorical classifications produced by a diagnostic interview tool; 3) examine predictors of the trajectory groups; 4) identify distinct subgroups of youth psychopathology; 5) examine transitions across these subgroups of psychopathology; 6) identify predictors of such transitions; 7) explore if youth psychopathology trajectories mediate the association between family factors and MHSU. The first study developed a trajectory model using latent class growth analysis (LCGA) to examine the optimal number of trajectories of youth psychopathology and predictors of the different trajectories. Results indicated a three-trajectory model characterized as low-stable, moderate-decreasing, and high-decreasing trajectories. Older age, higher disability, greater parent psychological distress, and higher household income were associated with less favourable trajectories. Results demonstrate that youth with CPI exhibit different courses of psychopathology, and that different individual and family characteristics are associated with trajectory group membership. The second study used latent profile analysis to identify four profiles of youth psychopathology: low psychopathology, primarily internalizing, primarily externalizing, and high psychopathology. Additionally, latent transition analysis was used to track transitions between these profiles over time. Many youths in the primarily internalizing subgroup transitioned to the low psychopathology subgroup over time. Further, youth classified in the high psychopathology subgroup from six to 24 months were more likely to have persistent psychopathology. These findings suggest that youth with CPI exhibit distinct profiles of psychopathology, with unique symptom combinations and patterns of change over time, emphasizing the potential for different mental health needs and trajectories within this population. Youth with CPI do not all experience psychopathology in the same way, and they may shift between profiles, suggesting dynamic changes in symptom patterns. The third study conducted a path analysis to determine if youth psychopathology trajectories mediate the association between family factors (parent psychological distress and family functioning) and MHSU (i.e., contact with a healthcare professional). Results demonstrated that youth psychopathology trajectories (subclinical vs. low) mediate the association between parent psychological distress and contact with a healthcare professional. These findings support using a family-centred care approach to youth healthcare to minimize the burden on families and promote well-being and positive health outcomes. This dissertation fills a critical gap in terms of knowledge of psychopathology and MHSU among youth with CPI. Taken together, these findings can be distilled into four themes: (1) call for integrated physical and mental healthcare; (2) early identification of psychopathology among youth with CPI; (3) adaptive treatment approaches to care; and (4) the need for family-centred care in youth mental health settings. Future longitudinal research should investigate transitions across psychopathology profiles over longer periods and investigate other potential mediators that facilitate or impede the use of mental health services for youth with CPI.
Evaluating the impact of participation in school-based physical education lessons on adolescent health and wellbeing in Ontario: Findings from the COMPASS study
(University of Waterloo, 2025-01-30) Buchan, Marisa Claire; Leatherdale, Scott
Physical activity rates among adolescents in Canada are critically low; only about one in every three grade 9 students are meeting the recommended 60 minutes per day of moderate to vigorous physical activity (MVPA). These high rates of physical inactivity among youth are alarming, as physical activity is essential for both physical and mental wellbeing, and it sets the foundation for healthy habits in adulthood. School-based physical activities including physical education (PE) classes, and intramural and varsity sport programs are ideally situated for the promotion of physical activity as they can reach a large number of youth and overcome many of the barriers associated with extracurricular activities. PE is designed to provide opportunity for youth of all ages to engage in physical activity that is structured into their weekly routine. However, in secondary school, a period that is critical for establishing healthy behaviour patterns for later in life, PE becomes non-mandatory for students in many provinces and territories across Canada, resulting in a missed opportunity to engage adolescents in regular physical activity. Ontario currently has the most lenient PE policy in Canada, with students only required to complete one secondary school-level PE course. To date, only four studies have examined the impact of PE programming in Canada on physical activity levels, only one of which included students from the province of Ontario. No published studies to date have explored the impact of PE participation on mental health outcomes among adolescents in Canada. The lack of evidence in this domain renders it challenging to determine the effectiveness of PE or make recommendations to enhance PE programs to maximize their impact on student health and wellbeing. This dissertation aimed to provide a deeper understanding of the patterns of physical activity behaviours and the impacts of participating in non-mandatory secondary school PE on physical activity and mental health outcomes among adolescents in Ontario. Specifically, Study 1 characterized longitudinal physical activity profiles of non-mandatory PE participation, adherence to physical activity guidelines, and sport participation throughout secondary school. Study 2 quantified the impact of participation in PE on physical activity levels, over time. Study 3 quantified the impact of PE participation on student mental health, over time. This dissertation utilized linked longitudinal data from students in Ontario who participated in four consecutive years of the COMPASS Study (Time 1: 2015-16; Time 2: 2016-17; Time 3: 2017-18; Time 4: 2018-19). The COMPASS Study is a school-based prospective cohort study (2012-2027) that collects demographic, behavioural, and mental health data from students annually across Canada. Study 1 utilized a repeated measures latent class analysis to identify longitudinal physical activity profiles of adolescents in Ontario. Studies 2 and 3 utilized linear mixed models to estimate the average effect of PE participation on (a) minutes of MVPA (Study 2) and (b) symptoms of anxiety, (c) symptoms of depression, and (d) psychological wellbeing (Study 3), over time. Models in Studies 2 and 3 were adjusted using doubly robust propensity score methodology to account for self-selection biases that may influence PE participation. Findings from Study 1 illustrated that there are distinct, clustered physical activity profiles among adolescents which vary by sex; three physical activity profiles were identified among both female and male students: Guidelines, PE & Sports, and Guidelines & Sports. A fourth profile was identified among male students only: Inactive. Study 2 demonstrated that participation in secondary school PE had a significant positive impact on MVPA levels over time, and effects were most pronounced for male students and during the semester of PE participation. Study 2 also illustrated that the benefits of PE remained present in the semester opposite to PE participation, suggesting that the benefits of PE extended beyond the MVPA accumulated during class-time. In Study 3, PE participation was not associated with symptoms of anxiety or depression, over time. Study 3 also found that male students enrolled (but not currently participating) in PE were found to have higher psychological wellbeing compared to those not enrolled in PE within the academic year. This dissertation fills an important gap with respect to our understanding of PE programming in Ontario secondary schools. Findings from this dissertation revealed that many students are choosing not to enroll in PE, with a particularly high-risk subgroup of male adolescents showing low participation across several physical activity behaviours during secondary school. Among male students who elect to participate, PE was found to positively impact time spent in MVPA and psychological wellbeing. These results highlight the potential of PE for improving the health and wellbeing of adolescents, although low participation rates limit these benefits being experienced at the population-level. Importantly, all three studies identified sex-based differences in the physical activity profiles and the impact of PE on health outcomes; female students were found to have lower PE participation rates and experienced reduced benefits compared to male students. These result underscore the importance of promoting inclusive environments in PE to ensure health benefits are experienced by all adolescents, regardless of sex and other key characteristics. Findings from this dissertation offer valuable insights for public health programming, particularly within the school context; decision-makers in Canada should explore ways to increase PE participation across secondary schools, paying particular attention to female students and those not participating in other forms of physical activity.
Exploring the Wellbeing and Food Security of Ethical Vegans through the Human and More-than-Human World
(University of Waterloo, 2025-01-27) Russell, Julia; Skinner, Kelly
Background: Health and environmental data reveal significant challenges faced by populations around the word in relationship to food. Complex choices and constraints shape people’s dietary patterns. While there is often debate about which eating patterns people should follow, for vegans ethical motivations are paramount. Vegan diets can be healthy diets, but there remains a gap in the literature surrounding veganism and overall wellbeing, including food security and connection to nature. Objectives: Taking into consideration both human and more-than-human factors this research explored how vegans live their lives embedded within the complex circumstances that shape their wellbeing. This exploration was informed by the application of a holistic model of health (the Revised Mandala of Health) and the use of an ecofeminist lens. Through a series of three studies and one methodological reflection, this research addressed the following objectives: (1) To investigate how ethical veganism influences a person’s experience and conceptualization of food security; (2) To explore the success and challenges faced by ethical vegans, how they may resist these challenges, and the implications for wellbeing; and (3) To explore ethical vegans’ experiences with the more-than-human world, and the implications for their wellbeing and coping strategies. Methods: The first study (Chapter 2) used focus groups to learn about vegans’ experiences and ideas related to food security at the individual, household and community levels. Four focus groups were held, of which three were comprised of vegans who in the year prior had experienced food security, with the final focus group being reserved for vegans who had experienced food insecurity. The focus groups’ data were analysed using Tracy’s phronetic iterative analysis approach. The second study (Chapter 3) used semi-structured interviews to collect data on veganism and wellbeing from 26 participants. The data from these semi-structured interviews were analysed using reflexive thematic analysis (RTA). The third study (Chapter 4) had six participants who took part in both a 2-day, group, body-map storytelling (BMST) workshop and then a follow-up individual, semi-structured interview. Data collected over the course of the body-map storytelling workshop included each participant’s presentation of their body-map to the group, as well as a written ‘testimonio’, two end of day reflective exercises, and one focus group. All data from this third study were analysed together using RTA. Finally, a fourth component was generated for this dissertation (Chapter 5). This methodological reflection was written based on the lead researcher’s impressions of the BMST workshop and comments about this workshop that were shared by the participants during data collection for the third study. Results: The results of Study 1 indicated that responsibility was a prominent feeling experienced by the participants both in relationship to their veganism and their experiences of food (in)security. The participants believed they should be informed about the food system, know how to shop frugally, and have cooking skills. Feelings of personal responsibility for food security may have been amplified by the perception of the absence of a vegan-friendly social safety net. The participants noted vegan foods could be nutritious, convenient, and inexpensive but not generally all these things at once. Therefore, compromising on at least one feature of their food was often needed. Participants in both the food secure and food insecure groups explained how at times they experienced difficulty accessing vegan-friendly foods. The results of Study 2 demonstrated that veganism is regarded as a positive way of living that though challenging at times, especially early on in one’s experience and in relation to social relationships, was of overall net benefit to the vegan participants. This benefit contributed to enhanced wellbeing. The areas of wellbeing the participants identified most often as being influenced by veganism were the mental and emotional realms. The participants’ identities influenced their experiences of veganism. In navigating life as vegans the participants eschewed the belief in a ‘perfect’ veganism, which may have contributed to the longevity of their veganism. The results of Study 3 showed the participants were ecologically embedded. Being ecologically embedded meant that when the participants perceived harm to the more-than-human world they subsequently felt a negative effect on their own wellbeing, including as solastalgia. However, being ecologically embedded also meant that participants experienced enhanced wellbeing through their connection to the more-than-human world. In the methodological reflection, the researchers argue that while BMST requires significant participant involvement it can be a rewarding approach for both participants and researchers, and a safe method of data collection if careful attention is paid to the social location of potential participants and the sensitivity of the research topic. The researchers found different data collection approaches were more and less effective during the BMST workshop and they offer practical considerations for the design and undertaking of future BMST workshops. Conclusions: Through the completion of three studies and one methodological reflection this research found that veganism was a positive force that enhanced wellbeing in the lives of the participants. As veganism is outside of the norm in Western cultures, being vegan did lead to challenges for the participants, but the challenges were not with veganism itself, rather the challenges lay in the social ramifications and accessibility of foods suitable for vegans. Participants felt the benefits of veganism outweighed the challenges. Considering the results via their alignment with the Revised Mandala of Health suggests that veganism can have health promoting properties for vegans and the more-than-human world. As plant-based diets are increasingly considered a way to address issues of health and sustainability, this study adds important understandings about the personal value and maintenance of veganism.
Impacts of Alternative Policing on Officer Health: The Community Engagement Unit (CEU)
(University of Waterloo, 2025-01-21) Fenton, Arden; Mielke, John; Anthony, Kelly
Created by the Waterloo Regional Police Service (Ontario-Canada), the Community Engagement Unit (CEU) links high-needs community members with specially trained police and to appropriate social services. Whether living with homelessness, poor mental health, domestic violence, or substance use, and often with several of these challenges simultaneously, high-needs community members often require greater police attention. Indeed, CEU officers act as a “911 calls diversion centre” by redirecting high-needs individuals away from traditional law enforcement approaches and towards relevant social service agencies. However, due to their unique work environment, CEU officers likely experience additional/unique stressors that may impact their health. As a result, when developing alternative policing units like the CEU, recognizing the potential stressors of such work and their impact on the police service is essential. This mixed methods study utilizes semi-structured interviews and surveys to assess the work environment of CEU officers relative to traditional police officers to improve our understanding of stress-related health risk factors within alternative policing units. Five CEU officers were recruited via email to participate in a 1-hour semi-structured interview. Thematic analysis of semi-structured interviews developed the CEU ‘phenotype’ by assessing the unique work environment, roles, and responsibilities of CEU officers. The CEU officers were asked to reflect on these aspects of their work compared to previous units (primarily patrol). The experience of stress in CEU is more prolonged and chronic, given the continuous nature of their interactions with high-needs individuals, as opposed to the fast-paced, case-to-case stress nature of patrol units. This ‘slow-burn’ stress, combined with the frustration of navigating under-resourced community social support systems and moral distress when cases lack resolution, is likely to present unique challenges to the officers' health and well-being. Surveys collected standard demographic information and included validated scales to measure self-reported health, health-risk behaviours, given and received social support, and varying levels and types of police-specific stressors using the operational and organizational police stress questionnaires (PSQ-Op, PSQ-Org). Seven CEU officers (14.0%) and 43 traditional (TRAD) officers (86.0%) were recruited via e-mail to participate in the survey. CEU officers had lower levels of fatigue (-42.5%), shiftwork (-57.6%), working alone at night (-58.3%) and internal investigations (-63.3%) compared to TRAD officers. This study reveals distinct differences between CEU and TRAD officers. CEU officers report lower fatigue and less shiftwork but experience prolonged "slow-burn" stress due to ongoing interactions with high-needs individuals and frustrations with under-resourced support systems. These findings emphasize the need for tailored support systems in alternative policing units like the CEU. Improved mental health resources, decompression opportunities, and clear mandates can help reduce health risks associated with their unique stressors. This study adds to the research on alternative policing, highlighting the importance of understanding occupational health in non-traditional police roles.
Understanding the Individual and Combined Impacts of Social Isolation and Loneliness on Memory: A Sequential Explanatory Mixed Methods Study
(University of Waterloo, 2025-01-14) Kang, Ji Won; Oremus, Mark
Social isolation (SI) and loneliness (LON) are important risk factors for cognitive health; however, their combined effects on memory, a key cognitive domain, are under-researched. This thesis is the first sequential, explanatory, mixed methods study to examine how SI and LON individually and together affect memory in middle-aged and older adults. Using three waves of data from the Canadian Longitudinal Study on Aging (CLSA), spread over six years, LON was measured by the loneliness frequency question from the 10-item Center for Epidemiologic Studies Depression Scale. SI was measured by an index based on marital/cohabiting status, retirement status, social activity participation, and number/frequency of social network contacts. Memory was evaluated with combined immediate- and delayed-recall z-scores from the Rey Auditory Verbal Learning Test. Primary analyses utilized all available data across the three waves of CLSA data and retained participants with missing covariate data (n = 14,208). Linear mixed models to account for all three waves of data were used to regress combined memory scores onto SI and LON, adjusting for sociodemographic, health, functional ability, and lifestyle variables. Results showed that combined SI and LON had the greatest negative impact on memory (least-squares mean: -0.80 [95% confidence-interval: -1.22, -0.39]), followed by LON alone (-0.73 [-1.13, -0.34]), then SI alone (-0.69 [1.09, -0.29]), and lastly by experiencing neither (-0.65 [-1.05, -0.25]). Two sensitivity analyses – one excluding participants with missing covariate data from the primary analysis sample and another employing a multiple imputation approach – both confirmed these findings. The qualitative phase involved phenomenological, semi-structured interviews with ten individuals – recruited through purposive and snowball sampling – to explain the quantitative results from the perspective of middle-aged and older adults. Based on thematic analysis, qualitative participants believed that LON has a stronger negative impact on memory than SI because individuals can still engage in mental stimulation while isolated, but are less motivated to do so when feeling lonely. Participants also believed that the combination of SI and LON is most detrimental to memory, as these conditions can exacerbate each other in a feedback loop, leading those who experience both to be more prone to self-destructive behaviours. This research highlights the need for targeted interventions involving multimodal brain health programs, which simultaneously address multiple risk factors for cognitive decline – such as SI and LON – through actionable steps, including staying socially connected, finding meaning in life, engaging in cognitively stimulating physical/leisure activities, managing medical conditions, and adopting healthy lifestyle choices.
Perceived Differential Parenting and Childhood Physical-Mental Multimorbidity
(University of Waterloo, 2025-01-02) Barclay, Christopher; Ferro, Mark
Background: Physical-mental multimorbidity (herein multimorbidity), the co-occurrence of a chronic physical and mental illness, affects a substantial proportion of children, compromising their quality of life, causing hardship for families, and burdening the healthcare system. Research investigating the potential causal mechanisms of childhood multimorbidity is scarce. Child-perceived differences in parenting style within families (i.e., differential parenting) may be one of these mechanisms. Objectives: 1— What is the direction and strength of the association between perceived differential parenting and psychopathology in children with chronic physical illnesses (i.e., multimorbidity)? 2— Do birth order and concordant/discordant child-sibling sex pairs moderate this association? 3— Does child self-concept mediate this association? Methods: Data come from the Multimorbidity in Children and Youth across the Life-course (MY LIFE) study. Perceived differential parenting was assessed using the Sibling Inventory of Differential Experiences (SIDE), and child psychopathology was assessed using the Emotional Behavioural Scale (EBS). linear mixed models were used to determine the directionality and strength of the association between perceived differential parenting and multimorbidity. Stratified models were computed to determine the moderating effect of birth order and child-sibling sex pairs. The product of coefficients approach was used alongside generalized linear modelling to determine the mediating effect of child self-concept. Implications: Health professionals can utilize findings to foster better communication within families and refer those at-risk to appropriate resources. Findings can also inform the integration of physical and mental health services to promote healthy child self-concept and nurturing family environments to reduce the incidence of childhood multimorbidity.
Facing the Heat: Utilizing the Internet of Things (IoT) to Enhance Preparedness Against Extreme Heat Events in Canadian Households
(University of Waterloo, 2025-01-02) Oetomo, Arlene; Morita, Plinio P.
Background: Heat waves pose a severe and growing health risk in Canada, with an estimated 17 million people likely to experience extreme heat in the coming decades. These risks are heightened in urban areas, where the urban heat island effect exacerbates dangerous temperatures. Extreme heat events are increasingly frequent, intense, and widespread, with record-breaking heat waves affecting almost every region globally. Despite increasing awareness, many of the dangers associated with extreme heat are only now being fully realized. This work addresses data gaps related to indoor heat vulnerability needed to create safe indoor conditions. Education and early warnings are critical to protecting the population, especially vulnerable groups. Extreme heat is a climate justice issue, disproportionately affecting marginalized groups with fewer resources to cope. Methods: This study used smart thermostats (ecobee) to collect real-time indoor temperature data, developing a hyperlocal alert system for indoor heat risks. First, we analyzed ecobee's "Donate Your Data" dataset to identify homes without air conditioning and to explore indoor and outdoor temperature differences during the 2018 Quebec heat wave. Next, a scoping review assessed the use of IoT or similar devices, focusing on climate-related impacts. Canadians were surveyed through Google Opinion Rewards to evaluate their understanding of heat waves and preferences for receiving heat-related information. Online discourse about heat waves was analyzed using Latent Dirichlet Allocation (LDA) topic modelling on tweets from Twitter (now X), via natural language processing (NLP), and manually using an inductive approach to observe emerging narratives and themes. Finally, in the summer of 2022, a full-scale deployment of smart thermostats was conducted in community housing without air conditioning in collaboration with housing and public health organizations. Indoor temperature data was collected from 70 British Columbia and Ottawa homes, with results shared via daily emails and an elastic dashboard. Three surveys captured details on building types, resident behaviours, and heat-related habits. Results: The scoping review found that using IoT and low-cost sensors for indoor heat monitoring is an emerging field that could strengthen early warning systems and heat response efforts. The survey results showed that most Canadians preferred to receive heat wave information online, with income correlating to the usage of mobile devices. Older demographics still preferred traditional media like TV, radio, and newspapers. Online discussions centred around activities, personal experiences, advice, and warnings related to heat waves. Emerging trends of climate denial were present in both survey and tweet samples. Indoor temperature data revealed that homes frequently exceeded emerging threshold recommendations of 26°C and 31°C, with some homes recording temperatures as high as 38°C on non-heat wave days. Participants in British Columbia were better prepared and had higher heat safety awareness than other regions. This is the first Canadian study to explore the use of IoT smart thermostats in near-real-time indoor temperature monitoring to protect vulnerable populations from extreme heat. Significant differences were observed between indoor and outdoor temperatures (P <0.001). Discussion and Conclusion: This work shows the potential of IoT devices and social media to improve real-time monitoring and inform evidence-based public health interventions for extreme heat. The widespread adoption of smart thermostats in Canadian homes and the prevalence of social media provide valuable opportunities to address existing data and knowledge gaps. However, the persistence of climate misinformation and denial challenges public health communication efforts. Indoor heat is a public health and equity issue related to poverty, substandard housing, urban planning, and energy access. These interconnected issues must be considered in policy frameworks to protect vulnerable populations. Low-cost sensors and solutions, such as natural ventilation mobile alerts, could support the response to heat health by addressing a data gap. Rapidly analyzing these areas is important as digital spaces evolve to support public health communication. Policymakers must take immediate action to prevent unsafe indoor conditions and protect marginalized communities from the growing threat of extreme heat.
A Community-Based Exploration on the Impacts of Land-Based Learning in an Urban Indigenous Community
(University of Waterloo, 2024-12-20) Bui, Danica; Neufeld, Hannah
Background Connection to the Land is essential for Indigenous Peoples’ health and well-being. Indigenous Food Sovereignty works towards regaining control over traditional food systems. There is a need for sustainable, Indigenous-specific, and accessible urban community Land-based practices. Done in partnership with White Owl Native Ancestry Association (WONAA) and the Wisahkotewinowak Collective (WC), four seasonal Land-based learning events were held. Each event involved a workshop, meal, and gathering at the University of Waterloo’s North Campus Community Gardens. Aims Guided by the interests of project partners, WONAA and WC, the overall purpose of this thesis is to explore and evaluate the impacts of Land-based learning on the local Indigenous and university communities and the PEG project’s effectiveness in establishing networks to facilitate ongoing research and learning to establish a permanent Land-based learning space on campus. The overarching research questions that guided the research are: 1. What are participants’ and facilitators’ perceptions of the Land-based engagement process? 2. What is the effectiveness of Land-based workshops in identifying and prioritizing collaborative Land-based opportunities for learning and research? 3. To what extent can the seasonal workshops establish a local network to facilitate ongoing research and learning in support of the development of an urban Indigenous Land-based learning space on the UW campus? Methods Appreciative Inquiry and Community-Based Participatory Research approaches were used for this thesis. Following each of the events, participants and project collaborators were recruited to participate in interviews. The data for this evaluation was collected through 17 semi-structured interviews with project collaborators and community partners (n=6), urban Indigenous community members (n=6), Indigenous youth and students (n=2), and UW staff (n=3), two focus groups with WONAA and WC staff members (n=5) that were involved with the workshops, and a document review. Reflexive thematic analysis was completed using NVivo for the interview and focus group transcripts, and the documents were analyzed to determine if the budget and timelines were met. Results Overall, participants, collaborators, and facilitators of the Land-based learning events had positive perspectives of establishing a Land-based learning space on campus. The three key themes from the interviews about the Land-based learning events and their potential for building connections to establish a permanent Land-based learning space include: (1) participants’ growing support of Land-based learning (2) creating connections and building relationships and (3) institutional support and project sustainability to support of the development of a permanent urban Indigenous Land-based learning space. The findings from the outcome evaluation, including the interviews, focus group, and documents reflect these themes and include (1) workshop feedback (2) project partners' goals, and (3) identifying opportunities to move forward. These findings show that the community, including project partners, participants, and collaborators, found the Land-based learning events to be a welcoming and positive experience that should become integrated into university curricula to support the university and local community. Conclusion Participants enjoyed the Land-based learning events and supported the establishment of a permanent Land-based learning space at the North Campus Community Gardens. Attending the events and being involved in the project generated ideas for learning and research opportunities, with many participants sharing future workshop ideas and identifying ways to integrate Land-based curricula and research opportunities. The events also connected the local urban- Indigenous community to the university community and helped to strengthen pre-existing relationships between the attendees. Through these connections, the desire for the North Campus Community Garden to become a space for Indigenous learning, teaching, and research, strengthened. Overall, the interview and focus group participants had positive perspectives of the events and the establishment of a permanent Land-based learning space at the North Campus Community Gardens, shared that Land-based learning was a need in the urban Indigenous and university community, and emphasized that further support from UW, longer-term funding, and physical and social infrastructure was needed for the project’s sustainability.
Developing Quality Indicators for Home-based Teleconsultation in Secondary Stroke Prevention
(University of Waterloo, 2024-12-02) Meng, Guangxia; Chen, Helen; McAiney, Carrie
home-based teleconsultation service quality patient satisfaction quality indicators secondary stroke prevention
A psychometric evaluation and application of a measure of food literacy among young adults
(University of Waterloo, 2024-11-11) Holmes, Martin; Kirkpatrick, Sharon
Background: Food literacy is an emerging study area encompassing the knowledge, skills, and attitudes required to navigate dynamic food systems. Food literacy has been suggested as a potential leverage point for improving diet quality and health outcomes. The emerging adult population, facing unique dietary and life transitions, is highlighted as an important group in public health research. Following calls for standard and well-evaluated measures of food literacy, a collaborative working group of public health nutrition practitioners in Ontario, Canada, led the development of a comprehensive food literacy measure, the FLit50, for use with young adults. To support the broad use of the measure in public health practice, assessment of the construct validity of the FLit50 and the development of a shortened version were desired by the public health nutrition practitioners. Objectives: The objectives of this dissertation were to: (1) evaluate the construct validity of the FLit50 measure among post-secondary students (Chapter 5); (2) analyze the characteristics of the FLit50 items to facilitate the development and evaluation of a shortened measure (Chapter 6); and (3) explore the demographic, income adequacy, studentship, and health correlates of food literacy among post-secondary students (Chapter 7). This work was undertaken in collaboration with the public health nutrition practitioners. Methods and results: The first study (Chapter 5) drew upon data from 457 post-secondary students in Ontario, Canada, to evaluate the measure's construct validity by assessing whether it could differentiate between groups hypothesized to have differences in food literacy. The FLit50 showed adequate construct validity, evidenced by higher median food literacy scores among students in food and nutrition programs (KW χ2) = 108, p < 0.001), women (KW χ2= 49.2, p < 0.001), those with adequate health literacy (KW χ2 = 20.6, p < 0.001), those with higher general health (KW χ2 = 49.5, p < 0.001), those with higher mental health (KW χ2 = 17.4, p < 0.001), and those experiencing food security in the past 12 months (KW χ2 = 21.9, p < 0.001), as hypothesized. No differences were observed by age (KW χ2 = 5.24, p = 0.63) or perceived income adequacy (KW χ2 = 4.21, p = 0.38). Differences in group means were observed as hypothesized for scores on items reflecting the underlying domains of food and nutrition knowledge and self-efficacy and confidence, but not food skills or ecological factors. The second study (Chapter 6) involved the application of the 2-parameter Item Response Theory, using data from postsecondary students (n=457) along with data collected from young adults across Canada during the initial development of the measure (n=351). Item difficulty (mean= -1.72 SD from the sample’s average food literacy ability level, range: -3.64 to 3.05 SD) and item discrimination (mean= 1.78, range: 0.33 to 8.43) characteristics were estimated for items on the FLit50. The parameters informed discussions with the public health nutrition practitioner partners to select sixteen items for inclusion in the shortened measure, the FLit16. The correlation coefficient between scores on the FLit50 and the FLit16 was estimated, and whether the FLit16 could differentiate among groups hypothesized to have different levels of food literacy, as per study 1, was examined. Scores from the two versions of the measure were strongly and positively correlated (Rho = 0.87, p < 0.01) and the short measure was able to differentiate among groups, consistent with the full measure. The third study (Chapter 7) drew upon data from the sample of postsecondary students to explore associations between demographic, income, studentship, and health characteristics, identified a priori based on the emerging food literacy literature, and food literacy scores using multiple linear regression analysis. Data from 413 students were included in these analyses after accounting for missing data on the characteristics of interest. Food literacy was assessed using the FLit50 measure, with a mean score of 42 of 49 points. Adjusting for other characteristics, food literacy was higher among women compared to men (β = 2.509, p < 0.001) and those who reported positive or neutral general health (β = 1.743, p < 0.001). Food literacy was lower among individuals identifying as East/Southeast Asian (β = -2.036, p < 0.001), South Asian (β = -2.409, p < 0.001), and other racial/ethnic identities (β = -1.568, p = 0.005) compared to those identifying as White. Food literacy was also lower among those who lived on-campus (β = -1.457, p = 0.073) and those experiencing food insecurity (β = -1.274, p = 0.004). Food literacy scores did not differ by age, income adequacy, domestic or international studentship, whether students attended college or university, household composition, or self-reported mental health status. The regression analysis yielded an R2 of 0.403, indicating that 40% of the variance in food literacy scores was explained by this model, with an overall significance of F(15, 396 DF) = 17.79, p < 0.001. Conclusions: This dissertation continues the work of the collaboration of public health nutritionists by furthering two of its main aims: establishing the construct validity of the FLit50 and developing a shortened measure that demonstrates construct validity. The availability of two well-evaluated measures presents opportunities to better understand and monitor food literacy in emerging adults and assess associations with factors such as diet quality.
Does social rank influence AMPA receptor subunits in the medial prefrontal cortex of adult male and female rats?
(University of Waterloo, 2024-10-21) Solomon, Eden; Mielke, John
Social dominance hierarchies are ubiquitously observed in social species across the animal kingdom. Social interactions, including resource competition and conflict, shape dominance structures, where animals are ranked as dominant, or subordinate to one another. Previous work has implicated the medial prefrontal cortex (mPFC) as a key brain region responsible for controlling social hierarchy through α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPA) function. The trafficking of AMPARs at the synapse plays a key role in synaptic plasticity, and is mediated by interactions between AMPARs and their associated auxiliary proteins. To date, no studies have explored the expression of AMPAR subunits and their auxiliary proteins in the context of a social hierarchy. As a result, the current study aimed to elucidate the effect that social rank might have on the most abundant AMPAR subunits, GluA1 and GluA2, along with their principal auxiliary proteins, GRIP1, PICK1, and stargazin, in both male and female rats.
Machine Learning Approach and Adolescent Health Implementation of Machine Learning Algorithms to Explore Adolescent Health, BMI and Weight Perception Using COMPASS Study
(University of Waterloo, 2024-09-24) Zhang, Qianyu; Leatherdale, Scott; Chen, Helen
Abstract Introduction Adolescence is critical for behaviour formation and physical, social, and psychological changes. The risk related to unhealthy behaviours occurring during this stage can emerge in early adulthood and could lead to adverse outcomes. The COVID-19 pandemic has significantly impacted the youth’s characteristics and the school’s learning environment. Exploring the profile of Canadian youth before and after COVID-19 helps understand the factors that influence student engagement in the multi-domain setting, including school activities, mental health, healthy eating, etc. Among the various aspects of student profile, childhood obesity and weight perceptions are two important topics for Canadian youth's health and well-being. Obesity in children is a complex public health concern in Canada. Almost 1 in 7 children are considered obese, and 75% of obese children are obese in their adulthood when they grow up. Additionally, a youth’s perception of their weight is often connected to their BMI status. Studies have shown that adolescents who are overweight and obese tend to underestimate their true weight, and the ones with normal weight could overestimate their weight status. Both overweight and obese or misperception of body weight are risk factors for developing non-communicable diseases in adulthood and can lead to worse mental health issues, such as lower self-esteem. Therefore, observing these two aspects and related impactful factors is necessary for informing youth obesity preventive intervention. Compared to traditional statistics, machine learning has proven effective in handling the complex relationships between multidomain variables and in detecting nonlinear relationships between the predictor variables and the target outcome. This thesis explores behavioural patterns, specifically BMI and weight perception, among the Canadian youth participating in the COMPASS study. Objective and Methods The dissertation utilized Wave 7 (2018-19) and Wave 9 (2020-21), and linked data from Wave 9 to 11 (2020-23) of the COMPASS study. This ongoing survey-based cohort study includes grade 9-12 students attending secondary schools in Alberta, British Columbia, Ontario, and Quebec in Canada. The survey questions cover multiple aspects of student health behaviours, including eating, sedentary behaviour, alcohol, tobacco, and marijuana use, bullying, academic performance, physical activity, BMI, and school connectedness. Study 1 applied k-means clustering analysis to establish student behaviour profiles, followed by a Random Forest model (RF) to identify the factors associated with the characteristics before and after COVID-19. Among the various student-level behaviour factors, Study 2 focused on self-reported BMI by predicting youth BMI status and identified associated factors using six supervised machine learning classifiers, K-Nearest Neighbour, Logistic Regression, Support Vector Machine, Random Forest, Multinomial Naïve Bayes, and Extreme Gradient Boosting (XGBoost) between Complete Case Analysis (CCA) and multiple imputation (MI) approaches. Since weight perception was identified as the most significant factor associated with BMI prediction in Study 2, Study 3 used weight perception as the outcome variable. This study explored the transition pattern of student weight perception and the associated factors through the Markov Chain, Multinomial Logistic Regression, and time-series deep learning models, including Recurrent Neural Networks (RNN) and Long Short-Term Memory (LSTM). The Shapley Additive Explanations (SHAP) analysis was applied for all three studies to assess the model interpretability. Results Study 1 found that in both pre-COVID (2018-19) and post-COVID (2020-21) cohorts, clusters were distinguished as closely involved with substance use and lower psychological well-being, including personal relationships with their families or unwillingness to discuss their mental health with an adult at school. However, the number of students in these clusters was relatively low compared to the other clusters, comprising only 0.5% of the pre-COVID cohort and 0.2% of the post-COVID cohort. In sub-clusters from the pre-COVID cohort that excluded substance use factors, students who skipped more than 20 classes, did not complete homework, and were involved in bullying were more likely to be grouped together in one sub-cluster compared to students without these behaviours. Additionally, those intending to lose weight, perceiving themselves as overweight,and being less active had higher odds of being in one sub-cluster compared to those without weight change intentions and who perceived their weight as about the right. In the sub-clusters of the post-COVID cohort, students with adverse mental health well-being, higher anxiety scores, self-reported overweight or obese BMI, and those failing to meet the guidelines of at least 60 minutes of physical activity per day were more likely to be grouped together in one sub-cluster compared to the students with the opposite behaviours. Moreover, students with increased cannabis use, less physical activity, lower flourishing scores and higher anxiety scores were more likely to be in one group relative to students who reported no change in cannabis use. Study 2 discovered that, among both CCA and MI approaches, XGBoost achieved the best performance in predicting BMI compared to those using Support Vector Machine (SVM) and Random Forest (RF). In CCA, it achieved an overall accuracy and ROC-AUC value of 0.64 and 0.78. The model performance was similar in MI and yielded an overall accuracy of 0.64 and ROC-AUC value of 0.79. Based on the SHAP summary plot, the most important predictors were weight perception, gender, and weight change intention in all three BMI classes, and the result was consistent in both CCA and MI. According to the SHAP summary plot, the most significant predictors in all three BMI classes were further explained by weight perception, gender and weight change intention. Students who perceived themselves as slightly or very overweight and were trying to lose weight were classified into the overweight and obese class, while model prediction on health weight BMI involved perceiving the right weight and not trying to change their weight. Additionally, gender was emerged as the most significant variable in the unknown BMI class, with model predicting that females and gender minorities were more likely to be categorized in the unknown weight class compared to male students. Study 3 used the MI approaches on the linked dataset. It found that although there was a moderate probability of transitioning from underweight or overweight to about the right weight and a minor probability of changing from underweight to overweight, most youths were more likely to stay in the same weight perception as the previous year. In addition, Study 3 identified predictors associated with weight perception transition over time. Students with underweight BMI, the intention of gaining weight and disagreement with discussing their problems with families in Year 1 had a higher likelihood of perceiving themselves as underweight in Year 2. While overweight and obese or unknown BMI students who had the intention of losing weight and decreased time on social media after COVID-19 in Year 1 were more likely to have an overweight perception in Year 2. Compared to peers who stayed at perceiving about the right weight in Year 2, underweight BMI students had higher odds of remaining underweight perception. In contrast, overweight BMI students with losing weight intention were likely to continue with an overweight perception and transition from about the right weight to an overweight perception. Students who wanted to gain weight were more likely to remain underweight or change from underweight to about the right weight. Notably, students with more participation in muscle-strengthening exercises had a lower likelihood of remaining overweight perception. Both deep learning models have shown the top significant variables in Year 1 and Year 2 were weight change intention, BMI, skipped breakfast for losing weight, and days in muscle training exercises predicting third-year weight perceptions. The intention of losing weight, higher BMI status such as overweight and obese or unknown, and more days in skipping breakfast for losing weight predicted students towards an overweight perception. In contrast, among the right weight perception group, students tended to stay the same weight or not try to do any weight change, had healthy BMI, had a lower number of days skipping breakfast, and had more days in muscle training. These results were consistent with the weight perception transition-associated predictors from the Multinomial logistic regression. Conclusion As the first study that focused on Canadian youth behaviour profiles, prediction of BMI and weight perception incorporating multiple machine learning techniques, the result of the dissertation disseminates key messages to the stakeholders who want to understand student behaviour profiles and focus on the preventive intervention on youth obesity. This research emphasized the importance of the school’s environment on youth’s behaviour and the tri-directional relationships among BMI, weight change intention, and weight perception, suggesting future analysis to emphasize these variables when developing healthy behaviour-related strategies. Overall, it illustrated the necessity of establishing educational programs related to BMI and weight perception at school to raise awareness of self-esteem and body image acceptance.
EXPOSURE TO CANNABIS MARKETING IN THE UNITED STATES: DIFFERENCES BY CANNABIS LAWS AND THE STRENGTH OF RESTRICTIONS IN ‘RECREATIONAL’ CANNABIS MARKETS
(University of Waterloo, 2024-09-23) Winfield-Ward, Lauren Elizabeth; Hammond, David
Background: A growing number of U.S. states have legalized adult “recreational” cannabis. Restrictions on advertising and promotions to prevent marketing exposure among vulnerable populations are a key component of cannabis regulations in legal markets; however, there is little evidence on the impact of restrictions to date. Objectives: To examine differences in exposure to cannabis marketing across U.S. states where cannabis is illegal (‘illegal states’), legal for medical use (‘medical states’), and legal for recreational use (‘recreational states’). This study also examined differences in exposure by the strength of marketing restrictions among recreational states. Methods: Data are from the U.S. component of the International Cannabis Policy Study: repeat cross-sectional data from national surveys conducted with 187,573 respondents aged 16-65 over 6 annual survey waves (2018-2023). Exposure to cannabis marketing was assessed by asking respondents to report whether they have noticed any cannabis marketing across 11 channels in the past 12 months (‘noticing’ of cannabis marketing). The ‘strength’ of marketing restrictions was measured using data sourced from regulatory documents in each recreational state with legal sales and categorized into four strength levels. An index of the strength of marketing restrictions was then created for each recreational state with legal sales. Mixed effects logistic regression models (GLIMMIX) were fitted to analyze differences in self-reported noticing of cannabis marketing across medical and recreational policy changes, as well as by the strength of marketing restrictions in states with legal recreational sales. Analyses also examined exposure measures and associations with sociodemographic factors. Results: Self-reported exposure to cannabis marketing differed across policy changes. Noticing cannabis marketing was lowest in illegal states, with higher levels of noticing in states in the first 12 months following medical legalization (39.24% vs. 35.37%: AOR=1.16; 95% CI=1.01-1.33; p=0.034). Levels of noticing were higher in the first 12 months following recreational legalization relative to established medical markets (49.96% vs. 41.12%: AOR=1.41; 95% CI=1.34-1.48; p<.001), with additional increases 1-3 years and 4 or more years following the policy change (56.21%: AOR=1.20; 95% CI=1.14-1.25; p<.001, and 63.90%: AOR=1.21; 95% CI=1.16-1.27; p<.001, respectively). Noticing cannabis marketing also differed by the strength of restrictions in recreational states. In states with legal recreational sales, jurisdictions with the high (Level 3) restriction strength reported the lowest exposure to cannabis marketing (53.39% noticed), and exposure was similar across Level 1 and Level 2 restriction states. There was insufficient data to examine long-term trends for restriction levels. Conclusions: Self-reported exposure to cannabis marketing increases following medical and recreational cannabis legalization. Overall, stronger marketing regulations may reduce exposure in legal markets; however, underaged people report the greatest noticing of cannabis marketing. Research should continue to monitor trends in marketing exposure over time, as more states begin legal recreational sales and legal markets mature.
Estimating the proportion of hemolytic uremic syndrome cases in Shiga toxin-producing Escherichia coli cases – A systematic review and proportional meta-analysis
(University of Waterloo, 2024-09-23) De Silva, Udani; Majowicz, Shannon
Background: Shiga-toxin producing Escherichia coli (STEC) infection is a foodborne zoonotic infection causing a range of diseases, permanent injury and even death. STEC has been linked to large epidemics globally. While STEC can affect different organs of the human host, the kidneys are the primary site of pathological injury during infection. Hemolytic uremic syndrome (HUS) is a common sequela affecting the kidneys and can affect certain subpopulations disproportionately. This thesis aimed to estimate the cumulative incidence of HUS among symptomatic STEC cases, based on available data. Methods: I conducted a systematic review and meta-analysis to determine the overall and stratified cumulative incidence of HUS. I searched PubMed, Web of Science, Ovid® Embase and Scopus for published literature, followed by five grey literature databases, which were Google Scholar, INASP Journals Online project, OAIster, GreyGuide, and WHO IRIS. The inclusion criteria were human populations of all sociodemographic factors, as either confirmed or probable cases of symptomatic STEC infection. HUS was the condition of interest. Eligible records published in English, between 1 January 1990 and 14 January 2024 from all geographical regions were included. A second screener and I independently identified and included eligible studies in the systematic review. I extracted summary-level data on study information, STEC cases and HUS cases from included studies. A second reviewer and I assessed study quality of included records using tools by the Joanna Briggs Institute. To estimate the pooled cumulative incidence of HUS, I performed a random-effects meta-analysis for single proportions. To estimate the stratified cumulative incidence, I used subgroup analyses and meta-regression models for age, sex, STEC characteristics and study characteristics. Results: I identified 4,906 records from the literature searches, of which 269 studies (comprising 189,350 STEC cases aged 0 – 98 years) from 28 countries were included. The pooled cumulative incidence of HUS was 8.22% (95% CI, 7.82 – 8.61). In subgroup analyses, the cumulative incidence of HUS was highest among children aged between 0 and 4 years at 17.82% (95% CI, 14.57 – 21.07) and among female STEC cases at 13.03% (95% CI, 11.04 – 15.02). STEC O157 and co-infections with multiple serotypes were the most common serogroups among included studies. By study year, the highest cumulative incidence of HUS occurred between 2010 to 2014 at 14.79% (95% CI, 12.74 – 16.84). By study regions, the highest cumulative incidence of HUS was from the WHO European Region at 12.66% (95% CI, 11.47 – 13.85). The included studies were mostly high- quality studies. Age, sex, STEC serogroup, STEC genes, study year range and WHO Regions were significant predictors of cumulative incidence of HUS. Conclusion: The proportion of STEC cases that progress to HUS is relatively low. However, STEC cases are underestimated, and these proportions may overrepresent the true cumulative incidence estimates of the population. Some subpopulations had higher HUS incidence estimates, with age, sex, infecting STEC serogroup, STEC genes, study year range and region being significant predictors of STEC-HUS development. Thereby, these findings support current knowledge of STEC-HUS, provide important insights into STEC-HUS epidemiology, and can be used by clinical specialists and other stakeholders in research, policymaking and clinical guidance.
Understanding Perspectives on Care Manager Competencies: A Multiple-Method Needs Assessment
(University of Waterloo, 2024-09-18) Romano, Leonardo; Paul , Stolee
Background: Home-based primary care may be well situated as an alternative to conventional episodic primary care for chronically ill older adults, potentially delaying and reducing long-term care admissions while improving satisfaction with care and quality of life. Care management, which seeks to assist patients and their support systems in managing their illnesses, could play a key role in providing home-based primary care. However, little is known about the attributes and competencies a care manager should have when working in home-based primary care. Objectives: To identify necessary competencies for care managers who work with older adults, verify competencies in a home-based setting, and gain a deeper understanding of why the competencies are important. Methods: A scoping review following Arksey and O’Malley’s framework was conducted. A search string encompassing care integration, care management, and clinical competence was used to find academic literature on PubMed, CINAHL, and Scopus. The academic search string was adapted to custom Google searches and targeted website searches to identify grey literature. Extracted competencies were organized into similar groups. The sixth step of Arksey and O’Malley’s framework, consultation, was conducted using a quantitative survey to verify the literature review’s findings, and qualitative interviews to gain a greater understanding. The survey used the competencies uncovered in the scoping review and asked care managers and healthcare providers to rank the importance of competency groups with respect to one another, and rate the importance of individual competencies from -3 to +3, with -3 being very unimportant and +3 being very important, in a home-based setting. Results: The literature review identified 125 competencies from 65 academic articles and pieces of grey literature. These were categorized into 13 groups in three audience-facing facets. A total of 20 survey participants rated competencies and ranked competency groups, the averages of which were used to ascertain the degree to which they are important for care managers. The highest-rated competencies were patient-facing relationship and rapport building (2.90) and patient-facing confidentiality (2.90); the highest-ranked competency group was patient care management (2.80). Cronbach’s alpha for the survey was 0.93. A follow-up interview was conducted which provided further endorsement and nuance for some competencies, as well as a test for the feasibility of further qualitative investigation. Discussion and Conclusion: The findings provide support for the importance of competencies for care managers who work in home-based settings with older adults. The review identified competencies beyond those suggested by professional organizations; these included personality traits and caregiver support and communication. Further contextualization is needed to gain a deeper understanding of why the identified competencies are important. Practitioners should be aware of the breadth of competencies a care manager may need to possess when working in home-based settings with older adults and should prioritize training according to their importance.
Using Latent Class Analysis to Create Allostatic Load Profiles to Investigate the Effects of Occupational and Perceived Stress in Firefighters
(University of Waterloo, 2024-09-17) Elliott, Madelyn; Chaurasia, Ashok
Background: Allostatic load is a construct used to assess the sum of the effects of physiological stress across multiple body systems over time. Allostatic load is typically measured using the allostatic load index (ALI); however, this measure does not fully capture the multivariate nature of allostatic load. Using allostatic load profiles as opposed to the commonly used ALI, we hope to explore the multivariate nature of allostatic load and understand its association with perceived stress, since the existing literature exploring the association between perceived and physiological stress is inconclusive. Objectives: The objectives of this thesis are to 1) develop allostatic load profiles using latent class analysis of both study-created and clinical-based thresholds for biomarkers of stress; 2) examine the association between allostatic load profiles and perceived stress in firefighters; 3) assess whether study-based or clinical-based thresholds are more suitable when measuring stress in the firefighters in question. Methods: Using available biomarker data from a sample of 57 male firefighters in Waterloo Fire Rescue, we developed allostatic load profiles using latent class analysis. Biomarkers included systolic blood pressure (SBP), diastolic blood pressure (DBP), hemoglobin A1c (HbA1c), low-density lipoprotein (LDL), high-density lipoprotein (HDL), heart rate variability (HRV), cortisol, waist to hip ratio (WHR) and body mass index (BMI). We then employed logistic regression to assess the association between allostatic load profiles and perceived stress in these firefighters. Results: Our results demonstrated that the use of allostatic load profiles (ALPs), created with study-based thresholds, showed how different biomarkers contribute to elevated or non-elevated physiological stress profiles. In regression models of ALP on Perceived Stress Scale (PSS-10) scores, we saw a consistent positive association such that an increase of 1 unit in PSS-10 score increased the odds of being in the elevated ALP group anywhere between 13.6% (OR = 1.136, 95% C.I. = 1.012, 1.299) in a model with PSS-10 only to 19.2% (OR = 1.192, 95% C.I. = 1.039, 1.400) in a model with PSS-10, length of service (LOS), and the following behavioural confounders: smoking, sleep hours, exercise and alcohol intake frequency. Conclusions: Allostatic load profiles captured the multivariate nature of allostatic load and demonstrated a significant association with the PSS-10, whereas ALI was unable to significantly demonstrate a relationship with perceived stress. The results of this thesis also demonstrated the need for using study-based or study-specific thresholds when examining unique populations with different fitness levels than the general population. Further research can benefit from the use of allostatic load profiles in conjunction with study-based thresholds to accurately and completely address the needs of persons working in high-stress, dangerous occupations.
Assessing the Use of Research Techniques for Supporting the Engagement of People Living with Dementia in Research
(University of Waterloo, 2024-09-04) Conway, Emma; McAiney, Carrie
People with dementia often experience challenges communicating their experiences, which can impact their ability to participate in research. Adapted or modified research methods are needed to better promote the accessibility of research for people with dementia in support of their rights to participate. This manuscript-based thesis employed three studies to examine the use of adapted or modified research methods to engage people with dementia in research and evaluate the use of two techniques for their impact on the engagement of people with dementia in research and on the data produced. First, a scoping review of the current literature was conducted to identify studies that used adapted or modified research methods with people with dementia with the aim of understanding the extent of use of adapted methods with people with dementia in qualitative research. The review identified adapted methods used and examined how impacts on engagement as it relates to meeting accessibility needs were investigated. Two primary qualitative research studies were also conducted to examine two projective interviewing techniques, verbally-prompted storytelling and photo-prompted storytelling, and how these techniques impact the engagement of people with dementia and the data collected in qualitative interviews. Results from the scoping review suggest that a range of adaptations and modifications are made by researchers to their research projects, but limited evidence exists as to the effectiveness of these adaptations on improving engagement of people with dementia in research. The study of verbally-prompted storytelling techniques suggests these methods deepened reflection of impact of dementia on self and others, facilitated conversations when participants experienced challenges recalling a personal example, and enabled conversations about emotional topics. Additionally, the study of the photo-prompted storytelling technique suggests that participants tended to demonstrate deeper reflection of their own and other’s experiences and that the photo-prompted storytelling technique helped overcome challenges with direct questioning and recall. As well, there was a statistically significant difference in observed engagement when participants were interviewed using photo-prompted storytelling techniques but not the verbally-prompted story telling technique. This dissertation contributes to the understanding of adapted and modified methods to engage people with dementia in research and provides preliminary evaluation of projective interviewing techniques for improving the engagement of people with dementia in qualitative research, and how such techniques impact data collected. Improving accessible research opportunities for people with dementia to share their experiences is essential for recognizing the human rights of people with dementia to have equal opportunities to participate. Future research should continue to explore and extend the application of these techniques with particular focus on the impact of the specific prompts used.
The Use of Vaping Products in Attempts to Stop Smoking: Trends Over Time and Possible Substitution for Other Smoking Cessation Aids in Canada, the United States, England, and Australia
(University of Waterloo, 2024-09-04) D'Mello, Kimberly; Hammond, David
Background: E-cigarettes are a popular method of smoking cessation assistance. However, few studies have examined whether e-cigarettes serve as a substitute for other effective smoking cessation assistance, including how population-level changes in the use of e-cigarettes for smoking cessation compare to changes in the use of nicotine replacement therapy (NRT), prescription pharmacological therapies, and other smoking cessation methods. Objectives: To examine changes in the types of cessation assistance used by people trying to quit smoking over time, including: 1) the use of e-cigarettes in a quit attempt and 2) the use of other effective methods of cessation assistance. Methods: The study protocol has been preregistered (https://osf.io/jpnqc). Data are from the 2016, 2018, and 2020 Waves of the ITC Four Country Smoking and Vaping Survey. Respondents were recruited by commercial panel firms in each country who were ≥ 18 years of age and, who currently smoke, recently quit smoking, and/or currently vape. Analyses examined the use of cessation assistance among the 14,551 observations from participants with an attempt to quit smoking in the past 12-months since survey date (CA=4,880; US=2,917; EN= 4,846; AU=1,898). Repeat cross-sectional analyses were conducted using generalized estimating equations stratified by country. Results: Across all countries, e-cigarettes (29.9%) and nicotine replacement therapies (NRT; 29.8%) were the most commonly reported categories of cessation assistance used in a previous quit attempt, followed by self–help services (17.8%), and prescription pharmacological therapies (12.6%). Overall, more than half (59.4%) of respondents used ‘any’ form of effective cessation assistance (including e-cigarettes). E-cigarette use increased in Australia from 2016 (11.1%) to 2020 (25.1%; OR=2.29, 95% CI=1.37-3.82, p=.002). In England, e-cigarette use increased from 2016 (37.1%) to 2018 (46.7%; OR=1.40, 95% CI=1.13-1.73, p=.002), and had no changes over time in Canada or the US. Use of other effective cessation methods (with and without e-cigarettes) had no changes over time in all countries, excluding Canada. In Canada, use of ‘any’ form of effective cessation assistance (including e-cigarettes) decreased from 2016 (64.0%) to 2020 (58.9%; OR=0.75, 95% CI=0.61-0.93, p=.010). Conclusion: Overall, there were strikingly similar rates of effective cessation assistance used across all four countries, despite differences in e-cigarette use and regulatory environments. While e-cigarettes are a popular choice of cessation method, there was little evidence that trends in use of e-cigarettes contributed to changes in the use of ‘any’ effective form of cessation assistance. The extent of ‘substitution’ between individual quit methods at the population-level was not directly assessed in this study; however, there was some evidence consistent with substitution for e-cigarettes and use of prescription therapies such that, the use of prescription therapies increased in England as the use of e-cigarettes as a quit method decreased, with the inverse trend in Australia; and little to no changes in the US and Canada.
Evaluating Synthetic Data as a Proxy for Real Clinical Data in Machine Learning Models: A Comparative Study on Postpartum Hemorrhage Prediction
(University of Waterloo, 2024-08-30) Sharma, Kam; Chen, Helen
Introduction: This thesis investigates the use of synthetic data as a proxy for real clinical data in predictive modeling, focusing on postpartum hemorrhage (PPH). Synthetic data offers a solution to privacy concerns by providing data that mimics real patient data without compromising patient information. The goal is to develop and validate predictive models for PPH using synthetic data and comparing it to the real data, thereby assessing the feasibility and effectiveness of synthetic data in clinical settings. Methods: Synthetic data was generated using Generative Adversarial Networks (GANs) from MDClone to replicate the statistical properties of real clinical data from Ottawa Hospital. The data underwent a thorough cleaning and preparation process, followed by feature selection. Machine learning and statistical models, including logistic regression, decision trees, random forests, and support vector machines, were developed and trained on the synthetic data and then the pipeline was run on the real data at Ottawa Hospital. Model performance was evaluated using precision, recall, F1-score, accuracy, and Area Under the Curve (AUC) of the Receiver Operating Characteristic (ROC) curve. Results: The synthetic data closely mirrored the real data in statistical properties, with low Hellinger distances for most variables. Machine learning models trained on synthetic data demonstrated high performance, with comparable results to those trained on real data. Key predictors for PPH were determined which included the administration of certain medication and clinical parameters. The comparative analysis showed minimal discrepancies between model outputs from synthetic and real data, validating the use of synthetic data for predictive modeling. Discussion: The findings indicate that synthetic data can effectively be used to develop predictive models for PPH, and addressing data accessibility. The study highlights the potential of synthetic data to enhance predictive modeling in healthcare, providing a viable alternative to real data without compromising accuracy. The integration of synthetic data in clinical research can facilitate broader data availability, fostering innovation while adhering to privacy regulations. Conclusion: This research demonstrates the viability of synthetic data in predictive modeling for PPH, with models trained on synthetic data showing high performance comparable to those trained on real data. The study contributes to the theoretical understanding of synthetic data utility and offers practical implications for improving patient outcomes and optimizing healthcare resources. Future research should focus on expanding the use of synthetic data in other clinical areas and further validating its effectiveness in diverse healthcare settings.
Food insecurity among adults and adolescents in Australia, Canada, Chile, Mexico, the United Kingdom, and the United States before and during the Coronavirus Disease 2019 Pandemic
(University of Waterloo, 2024-08-30) Pepetone, Alexandra; Kirkpatrick, Sharon
Background: Household food insecurity is a major public health concern with negative consequences for health and well-being among adults and adolescents. During the Coronavirus disease 2019 (COVID-19) pandemic, shocks and stabilizers may have affected the prevalence and severity of household food insecurity overall and among subgroups of the population. For example, restrictions to reduce the spread of COVID-19 led to loss of employment, potentially increasing risk of food insecurity, whereas policies such as income supplementation for those who lost employment may have had a stabilizing effect. Comparing changes in household food insecurity across multiple countries over time can shed light into how packages of economic and social policy responses implemented or revised by national level governments during the pandemic may have influenced household food insecurity, providing insights into strategies to ameliorate household food insecurity, including in times of crisis. Objectives: The objectives of this thesis were to 1) characterize changes, or lack thereof, in the prevalence and severity of food insecurity among adults and adolescents in Australia, Canada, Chile, Mexico, the United Kingdom, and the United States from before (2019) to during (2020) the pandemic (Chapter 5); 2) examine national level government economic and social policy responses implemented or revised in these countries to, in part, mitigate the impacts of the COVID-19 pandemic and related safety measures (Chapter 6); and 3) determine whether economic and social policy responses appeared to mitigate anticipated increases in food insecurity during the COVID-19 (Chapter 7). The countries of interest were identified based on the similarity in the languages spoken, food environments, and culture among other characteristics. Methods and results: Three inter-related studies addressed the thesis objectives, with two of the studies integrating consultation with a collaborative working group to facilitate the relevance and applicability of study findings by considering country-specific contexts. Two studies drawing upon the International Food Policy Study considered food insecurity data reported by adults aged 18 to 100 years and directly by adolescents aged 10 to 17 years, enabling comparison in trends among the two population subgroups over time. Among adults, food insecurity was measured using the 18-item Household Food Security Survey Module, enabling categorization of the households in which participants lived as food secure or food insecure over the past 12 months. Among adolescents, the 10-item Child Food Insecurity Experiences Scale was used, enabling consideration of the number of food insecurity experiences (i.e., no, few, many, or several) they had over the past 12 months. The first study (Chapter 5) drew upon repeat annual cross-sectional data from adults (n = 63,278) and adolescents (n = 23,107) to examine changes in food insecurity prevalence and severity from before (2019) to during (2020) the COVID-19 pandemic in the countries of interest. Based on adjusted binary and multinomial logistic regression models, adults in Australia (adjusted odds ratio (AOR): 0.81; 95% CI: 0.72-0.92) and Canada (AOR: 0.87; 95% CI: 0.77-0.99) were less likely to live in food-insecure households during (2020) relative to before (2019) the pandemic. There was little indication of changes in the odds of adults living in food-insecure households in the United Kingdom (AOR: 0.90; 95% CI: 0.79-1.02) and the United States (AOR: 1.05; 95% CI: 0.93-1.19) in 2020 relative to 2019, while in Mexico, adults were more likely (AOR: 1.15; 95% CI: 1.02-1.31) to live in food-insecure households in 2020. Findings related to changes in the severity of food insecurity were similar. Adolescents in Mexico were more likely (AOR: 1.43; 95% CI: 1.19-1.71) to report experiencing food insecurity in 2020 compared to 2019. In Australia (adjusted relative risk ratio (ARRR): 2.24; 95% CI: 1.65-3.02) and the United States (ARRR: 1.39; 95% CI: 1.04-1.86), adolescents had a higher relative risk ratio of many compared to no experiences of food insecurity in 2020 compared to 2019. No differences in the prevalence or number of experiences of food insecurity among adolescents were observed in other countries. In the second study (Chapter 6), packages of economic and social policy responses to, in part, mitigate the impacts of the pandemic and safety measures to limit spread of the virus in the countries of interest were characterized. Potentially relevant policy responses implemented or revised by national governments between January 2020 and December 2022 were identified using eight policy response trackers. A theory of change articulating the hypothesized influence of different types of policy responses on household food insecurity guided the inclusion criteria. Two rounds of screening were conducted to identify the final set of 142 relevant economic and social policy responses. Hypotheses about how policy packages influenced household food insecurity in 2021 and 2022 were developed based on observed changes in household food insecurity from 2019 to 2020 and broader contextual events. Consideration of the influence of policies on food insecurity in 2021 and 2022 integrated evidence from other sources. Financial-based policy responses (e.g., unemployment protection) were emphasized in Australia, Canada, and the United Kingdom. In Chile, Mexico, and the United States, there was a more equal distribution of financial-based and resource-based (e.g., food assistance) policy responses. Across most countries and years, policy packages provided long periods of coverage (six months or more). Mexico was an exception in 2021 with a mix of policy responses that had short- and long-term coverage. The third study (Chapter 7) drew upon repeat cross-sectional data from 104,418 adults and 44,759 adolescents from 2018 (adults only), 2019, 2020, 2021, and 2022 to determine whether economic and social policy responses mitigated anticipated increases in food insecurity among adults and adolescents during the COVID-19 pandemic. Three lines of inquiry were used to realize this objective. First, year-to-year changes in food insecurity among adults and adolescents and in the known determinants (e.g., difficulty making ends meet) and consequences (e.g., poor quality diets) of food insecurity were compared. Alignment in changes would instill confidence that the nature of food insecurity did not change during the pandemic and set the foundation for the subsequent two lines of inquiry. Second, among adults living in households, the predicted prevalence of food insecurity in 2020, 2021, and 2022 had the pandemic not occurred was estimated (this analysis was not conducted for adolescents given the lack of data for 2018). Hypothesized changes in food insecurity among adults living in households for each country by year given that the pandemic occurred and considering broader contextual events (e.g., global inflation, Brexit in the United Kingdom) were developed to guide assessment of whether economic and social policy responses mitigated anticipated increases in food insecurity. Observing that the observed proportion of adults in food-insecure households was lower or did not differ from the predicted proportion would suggest that economic and social policy responses mitigated anticipated increases in food insecurity. Third, adjusted multinomial or binary logistic regression models with interactions for the survey year and selected characteristics that indicate high risk of experiencing food insecurity (e.g., households with children) assessed changes in the odds or relative risk ratio of food insecurity among adults living in households and adolescents during (2020 to 2022) relative to before (2019) the COVID-19 pandemic among the subgroups selected. Subgroups with selected characteristics were anticipated to be more likely to experience food insecurity during the pandemic. If this finding was not observed, it would suggest that economic and social policy responses mitigated anticipated increases in food insecurity among those at high risk during the pandemic. Alignment between changes in food insecurity among adults living in households and adolescents and its known determinants and consequences ranged across countries and over time. The variation in alignment was likely due to the range of factors that could influence food insecurity and the unlikelihood that a one percent change in the proportion of food insecurity would equate to a one percent change in the singular category examined for each determinant and consequence. The observed proportions of food insecurity among adults living in households were lower than predicted had the pandemic not occurred in Australia, Canada, and the United States at various time points, suggesting that policy responses to address pandemic-related disruptions mitigated increases in food insecurity that were otherwise anticipated to due to shocks related to COVID-19 safety measures. Subgroups that were anticipated to be more likely to experience food insecurity during (2020 to 2022) relative to before (2019) the COVID-19 pandemic largely did not, with indication that some subgroups were better protected by policies introduced during the pandemic compared to beforehand. Conclusions: Although some increases in food insecurity among adults were observed through the pandemic in the countries examined, it appears that economic and social policies introduced by national governments mitigated otherwise large, anticipated increases due to loss of income and other shocks to households. The lack of increases in the proportions of adolescents experiencing food insecurity in most countries reinforces the notion that policy packages influenced food insecurity during the pandemic. Nonetheless, household food insecurity remains prevalent and increased in later years, likely due to the expiration of policy responses, inflation, and other events globally. Though long-term economic and social policies to address household food insecurity are lacking in the countries examined, this work indicates it is possible for governments to ameliorate this serious public health problem using policy levers. Packages of policy responses that focused on financial-based support and/or scaled up existing policy responses mitigated anticipated increases in food insecurity among adults in 2020. Policy packages also appear to have contributed to the observed prevalence of food insecurity among adults living in households being the same or lower than the predicted prevalence through the pandemic. These findings are salient as the world works to achieve the 17 Sustainable Development Goals by 2030 against the backdrop of ongoing crises anticipated to sharply increase risk of household food insecurity, including the climate emergency and conflicts.

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