Public Health Sciences (School of)http://hdl.handle.net/10012/98642024-03-29T08:37:51Z2024-03-29T08:37:51ZUniversity Students’ Gynecology Care Experiences in the US and Canada: Implications for Equitable Access to Person-Centered CareRichards, Nicole Karenhttp://hdl.handle.net/10012/203982024-03-19T02:30:57Z2024-03-18T00:00:00ZUniversity Students’ Gynecology Care Experiences in the US and Canada: Implications for Equitable Access to Person-Centered Care
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.
2024-03-18T00:00:00ZUnderstanding Longitudinal Changes in The Performance of Activities of Daily Living in Long-Term Care Settings: Trajectories, Transition Patterns, Predictors and Associated Health OutcomesEgbujie, Bonaventure Amandihttp://hdl.handle.net/10012/203002024-01-27T03:31:06Z2024-01-26T00:00:00ZUnderstanding Longitudinal Changes in The Performance of Activities of Daily Living in Long-Term Care Settings: Trajectories, Transition Patterns, Predictors and Associated Health Outcomes
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.
2024-01-26T00:00:00Z“Even if we want help, there is no help”: Exploring Perceptions and Barriers in Home Care Services within the South Asian CommunitiesSubbiah, Krithikahttp://hdl.handle.net/10012/202792024-01-24T03:31:14Z2024-01-23T00:00:00Z“Even if we want help, there is no help”: Exploring Perceptions and Barriers in Home Care Services within the South Asian Communities
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.
2024-01-23T00:00:00ZCOVID-19, Mental Health, and Chronic Illnesses: A Syndemic PerspectiveSaqib, Kiranhttp://hdl.handle.net/10012/202282024-01-13T03:30:44Z2024-01-12T00:00:00ZCOVID-19, Mental Health, and Chronic Illnesses: A Syndemic Perspective
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.
2024-01-12T00:00:00Z