Background : The majority of patients with Crohn’s Disease (CD) will be hospitalized and receive surgery for their disease. Hospitalizations and surgical procedures account for the majority of the direct costs of CD. Purpose : Our objective was to use population-based administrative data from the province of Quebec, Canada, to estimate the effectiveness of infliximab therapy in reducing CD-related surgery, hospitalization and health care resource consumption in subjects with CD. Methods : We obtained patient level prescription data, physician billing claims and hospitalization data from the Régie de l'Assurance Maladie du Québec (RAMQ) a Canadian provincial health care provider. Subjects who were enrolled in the system for a minimum of two years and who received prescription drug benefits for each year they participated in the study were identified as being affected by CD using a validated algorithm. For each subject treated with infliximab, up to two closely matched comparison subjects were selected using propensity score methods. We compared time to first CD-related intra-abdominal surgery and hospitalization as well as total hospitalized days and physician visits between infliximab users and non-users. Results : We were able to match 319 (77%) out of the 414 infliximab users to comparison subjects using propensity score matching; 300 were matched to two infliximab non-users and 19 were matched to one non-user to create 619 matched-pair sets. Subjects who received infliximab therapy had a significantly reduced risk of experiencing a CD-related intra-abdominal surgery (HR=0.674, 95%CI 0.533-0.853, p=0.001), any hospitalization (HR=0.753, 95%CI 0.619-0.917 p=0.005), and CD-related hospitalization (HR=0.726, 95%CI 0.565-0.934 p=0.013). Infliximab users experienced lower rates of hospitalized days (RateR=0.6418, 95%CI 0.4399-0.9362; P=0.021) and gastroenterologist visits (RateR=0.810, 95% CI 0.700-0.937; P=0.005). Infliximab users and non-users had similar rates of non-gastroenterologist physician visits (RateR=0.928, 95% CI 0.851-1.057; P=0.262). Conclusion : Infliximab therapy was associated with significant reductions in CD-related intra-abdominal surgeries, hospitalizations, hospitalized days and gastroenterologist visits. Our results confirm the population-based effectiveness of infliximab beyond the ideal conditions of clinical trials.

Master of Public Health / Department of Diagnostic Medicine and Pathobiology / Robert L. Larson / Variant H1N1 influenza (vH1N1) virus is an issue both in swine production medicine and in the arena of public health. Influenza viruses can infect but not always produce disease in avian, humans and swine. Swine are unique among the three previously mentioned species in that their respiratory epithelium possesses three receptor sites for the virus types common to each of the three mentioned species. Swine influenza virus (SI) is common and widespread in nearly all Midwestern swine herds and can be transmitted by both direct contact and aerosolization. All of the three previously mentioned species have the potential to re-assort (produce virons containing genetic material of different virons to produce a unique influenza virus (IV). Because of their three specific receptor sites, swine have the greatest re-assortment capability. This re-assortment has the potential is a low mortality/high morbidity disease that is a substantial cost to the swine industry due to its negative effect on production parameters such as average daily gain (ADG) and feed efficiency (FE). It is a public health concern due to its potential to produce different virus types which may have increased mortality/morbidity in humans. Avian are the IV reservoir and have the ability to introduce virus types that are foreign to specific populations in all venues on the planet. It is in the mutual best interest of public health and swine production to mitigate the introduction of different virus types in swine and to control existing infections in swine populations with a goal of establishing SI-free herds. Mitigation for swine populations can occur through vaccination, diagnosis/isolation, and Biosecurity procedures designed to reduce/eliminate IV introduction into swine production facilities. In addition, preventing the interaction of infected humans with swine is another component of swine population Biosecurity.

Aboriginal Canadians (First Nations, Métis, and Inuit) have the highest prevalence of overweight and obesity compared to other ethnic groups in Canada. In order to assess the evolution of the problem over time and to understand potential risk factors, three studies were conducted using nationally-representative survey data. Direct comparisons between Aboriginal and non-Aboriginal Canadians from the same surveys provide important perspectives on the magnitude of health disparities that cannot be obtained by small regional studies that dominate the current available literature. Body mass index (BMI) trajectories from 1994 to 2009 were estimated for Aboriginal and non-Aboriginal Canadians. Aboriginal Canadians experienced higher rates of BMI increase over the 14-year period between 1994 and 2009. Rate of BMI increase was specifically higher for Aboriginal adults born in the 1960s and 1970s when compared with non-Aboriginal adults, and later-born cohorts had consistently higher BMI compared with earlier-born cohorts. The role of potentially modifiable lifestyle factors in obesity among Aboriginal and non-Aboriginal youth was also investigated. Compared to non-Aboriginal youth, consumption of fruits/vegetables and dairy products was lower, and more Aboriginal youth were "high" TV watchers. Physical activity participation did not differ between "high" and "low" TV watchers for both groups, and was associated with lowered odds for obesity only among Aboriginal youth. The complex relationship between obesity and socioeconomic status for Aboriginal and non-Aboriginal Canadians was explored. Employment status was strongly and negatively associated with obesity among Aboriginal men and women. Aboriginal men of high socioeconomic status (SES) were most likely to be obese, whereas Aboriginal women of high SES were least likely to be obese. Important descriptive and analytical information on an emerging and serious public health issue among Aboriginal people in Canada can inform the design and planning of intervention programs and development of public health strategies targeted at obesity.

Aboriginal Canadians (First Nations, Métis, and Inuit) have the highest prevalence of overweight and obesity compared to other ethnic groups in Canada. In order to assess the evolution of the problem over time and to understand potential risk factors, three studies were conducted using nationally-representative survey data. Direct comparisons between Aboriginal and non-Aboriginal Canadians from the same surveys provide important perspectives on the magnitude of health disparities that cannot be obtained by small regional studies that dominate the current available literature. Body mass index (BMI) trajectories from 1994 to 2009 were estimated for Aboriginal and non-Aboriginal Canadians. Aboriginal Canadians experienced higher rates of BMI increase over the 14-year period between 1994 and 2009. Rate of BMI increase was specifically higher for Aboriginal adults born in the 1960s and 1970s when compared with non-Aboriginal adults, and later-born cohorts had consistently higher BMI compared with earlier-born cohorts. The role of potentially modifiable lifestyle factors in obesity among Aboriginal and non-Aboriginal youth was also investigated. Compared to non-Aboriginal youth, consumption of fruits/vegetables and dairy products was lower, and more Aboriginal youth were "high" TV watchers. Physical activity participation did not differ between "high" and "low" TV watchers for both groups, and was associated with lowered odds for obesity only among Aboriginal youth. The complex relationship between obesity and socioeconomic status for Aboriginal and non-Aboriginal Canadians was explored. Employment status was strongly and negatively associated with obesity among Aboriginal men and women. Aboriginal men of high socioeconomic status (SES) were most likely to be obese, whereas Aboriginal women of high SES were least likely to be obese. Important descriptive and analytical information on an emerging and serious public health issue among Aboriginal people in Canada can inform the design and planning of intervention programs and development of public health strategies targeted at obesity.

This dissertation pools time-series and cross-section data among Canadian provinces to examine: (1) whether provincial welfare generosity (health, social services, and education expenditures), power resources and political parties (unions and left, centre, and right political parties), and political democracy (voter turnout and women in government) affects population health; (2) whether the effect of leftist politics channels through or combines with provincial welfare generosity to affect population health; and (3) whether provinces cluster into distinct political regimes which are predictive of population health. Data is retrieved from the Canadian Socio-Economic Information Management System (CANSIM) II Tables from 1976 to 2008 and Canadian Parliamentary Guides from various years. Population health is measured using total, male, and female age-standardized mortality rates. Estimation techniques include Prais-Winsten regressions with panel-corrected standard errors (PCSE), a first-order autocorrelation correction model (AR1), and fixed unit effects. Hierarchical cluster analysis is used to identify how provinces cluster into distinct regimes. Primary findings are three-fold. First, provincial welfare generosity has a significant impact in lowering mortality rates, net of other factors, such as demographic and economic variables. Second, the political power of left and centre political parties and women in government have significant negative effects on mortality rates. Whereas left political parties and women in government combine with provincial welfare generosity to improve population health, the effect of centre political parties is channeled through provincial expenditures. Third, provinces cluster into three distinct regimes based on left political party power and women in government: 1) leftist (Saskatchewan, British Columbia, and Manitoba); 2) centre-left (Ontario and Quebec); and 3) conservative (Alberta, Nova Scotia, New Brunswick, Prince Edward Island, and Newfoundland). Compared to the leftist regime, centre-left and conservative provinces have significantly higher mortality rates; however, provincial welfare generosity accounts for most of the observed inter-provincial differences in population health.

Background: When Canadian public health officials issued thousands of quarantine orders during the SARS outbreak in 2003, it raised difficult questions about the legitimacy and acceptability of restrictive measures to achieve public health goals. While public health interventions have traditionally been justified on utilitarian grounds, this project aims to establish an empirical basis to justify public health action. The objectives are: 1) Descriptive: To describe the views of members of society on the justifiability of using restrictive measures to achieve public health goals; 2) Analytic: To analyze the use of restrictive measures at the intersection of public health policy, human rights norms, and ethics; and 3) Normative: To situate public health ethics within a Habermasian model of communicative ethics that can serve as the basis of justification for the legitimate use of restrictive measures based on the intersubjective recognition of public health and human rights. Methods: Individual interviews were conducted with 62 participants, including 23 health care providers, 16 members of the public, 13 community and/or spiritual leaders from the Greater Toronto Area, as well as six public health officials and four health care regulators at the local, provincial, and federal levels of jurisdiction. Findings: Participant views were analyzed and organized into themes that revolve around the following concepts: 1) common good; 2) types of quarantine; 3) compliance; 4) reciprocity; 5) uncertainty; and 6) communication. Conclusions: Combining empirical research with conceptual scholarship, it is argued that the recognition of and commitment to the common good by participants, which emerged as an overarching theme, provide justificatory power for the use of quarantine during communicable disease outbreaks. But to respect rights, while being committed to the common good, it is argued that we must move beyond the see-sawing between ostensibly competing requirements toward a conception that gives equal weight to public health and human rights; that is, both imperatives – the community and the individual – refer to one another without dissolving into one another. Following a Habermasian account of opening processes of decision-making to a moral-practical discourse, it is argued that public health ethics offers an important site for integrating his model of discourse ethics within public health deliberations to expand the scope of moral argumentation on--and ultimately to ground the justification of--the use of restrictive measures.

Background: When Canadian public health officials issued thousands of quarantine orders during the SARS outbreak in 2003, it raised difficult questions about the legitimacy and acceptability of restrictive measures to achieve public health goals. While public health interventions have traditionally been justified on utilitarian grounds, this project aims to establish an empirical basis to justify public health action. The objectives are: 1) Descriptive: To describe the views of members of society on the justifiability of using restrictive measures to achieve public health goals; 2) Analytic: To analyze the use of restrictive measures at the intersection of public health policy, human rights norms, and ethics; and 3) Normative: To situate public health ethics within a Habermasian model of communicative ethics that can serve as the basis of justification for the legitimate use of restrictive measures based on the intersubjective recognition of public health and human rights. Methods: Individual interviews were conducted with 62 participants, including 23 health care providers, 16 members of the public, 13 community and/or spiritual leaders from the Greater Toronto Area, as well as six public health officials and four health care regulators at the local, provincial, and federal levels of jurisdiction. Findings: Participant views were analyzed and organized into themes that revolve around the following concepts: 1) common good; 2) types of quarantine; 3) compliance; 4) reciprocity; 5) uncertainty; and 6) communication. Conclusions: Combining empirical research with conceptual scholarship, it is argued that the recognition of and commitment to the common good by participants, which emerged as an overarching theme, provide justificatory power for the use of quarantine during communicable disease outbreaks. But to respect rights, while being committed to the common good, it is argued that we must move beyond the see-sawing between ostensibly competing requirements toward a conception that gives equal weight to public health and human rights; that is, both imperatives – the community and the individual – refer to one another without dissolving into one another. Following a Habermasian account of opening processes of decision-making to a moral-practical discourse, it is argued that public health ethics offers an important site for integrating his model of discourse ethics within public health deliberations to expand the scope of moral argumentation on--and ultimately to ground the justification of--the use of restrictive measures.

This dissertation pools time-series and cross-section data among Canadian provinces to examine: (1) whether provincial welfare generosity (health, social services, and education expenditures), power resources and political parties (unions and left, centre, and right political parties), and political democracy (voter turnout and women in government) affects population health; (2) whether the effect of leftist politics channels through or combines with provincial welfare generosity to affect population health; and (3) whether provinces cluster into distinct political regimes which are predictive of population health. Data is retrieved from the Canadian Socio-Economic Information Management System (CANSIM) II Tables from 1976 to 2008 and Canadian Parliamentary Guides from various years. Population health is measured using total, male, and female age-standardized mortality rates. Estimation techniques include Prais-Winsten regressions with panel-corrected standard errors (PCSE), a first-order autocorrelation correction model (AR1), and fixed unit effects. Hierarchical cluster analysis is used to identify how provinces cluster into distinct regimes. Primary findings are three-fold. First, provincial welfare generosity has a significant impact in lowering mortality rates, net of other factors, such as demographic and economic variables. Second, the political power of left and centre political parties and women in government have significant negative effects on mortality rates. Whereas left political parties and women in government combine with provincial welfare generosity to improve population health, the effect of centre political parties is channeled through provincial expenditures. Third, provinces cluster into three distinct regimes based on left political party power and women in government: 1) leftist (Saskatchewan, British Columbia, and Manitoba); 2) centre-left (Ontario and Quebec); and 3) conservative (Alberta, Nova Scotia, New Brunswick, Prince Edward Island, and Newfoundland). Compared to the leftist regime, centre-left and conservative provinces have significantly higher mortality rates; however, provincial welfare generosity accounts for most of the observed inter-provincial differences in population health.

Background : The majority of patients with Crohn’s Disease (CD) will be hospitalized and receive surgery for their disease. Hospitalizations and surgical procedures account for the majority of the direct costs of CD. Purpose : Our objective was to use population-based administrative data from the province of Quebec, Canada, to estimate the effectiveness of infliximab therapy in reducing CD-related surgery, hospitalization and health care resource consumption in subjects with CD. Methods : We obtained patient level prescription data, physician billing claims and hospitalization data from the Régie de l'Assurance Maladie du Québec (RAMQ) a Canadian provincial health care provider. Subjects who were enrolled in the system for a minimum of two years and who received prescription drug benefits for each year they participated in the study were identified as being affected by CD using a validated algorithm. For each subject treated with infliximab, up to two closely matched comparison subjects were selected using propensity score methods. We compared time to first CD-related intra-abdominal surgery and hospitalization as well as total hospitalized days and physician visits between infliximab users and non-users. Results : We were able to match 319 (77%) out of the 414 infliximab users to comparison subjects using propensity score matching; 300 were matched to two infliximab non-users and 19 were matched to one non-user to create 619 matched-pair sets. Subjects who received infliximab therapy had a significantly reduced risk of experiencing a CD-related intra-abdominal surgery (HR=0.674, 95%CI 0.533-0.853, p=0.001), any hospitalization (HR=0.753, 95%CI 0.619-0.917 p=0.005), and CD-related hospitalization (HR=0.726, 95%CI 0.565-0.934 p=0.013). Infliximab users experienced lower rates of hospitalized days (RateR=0.6418, 95%CI 0.4399-0.9362; P=0.021) and gastroenterologist visits (RateR=0.810, 95% CI 0.700-0.937; P=0.005). Infliximab users and non-users had similar rates of non-gastroenterologist physician visits (RateR=0.928, 95% CI 0.851-1.057; P=0.262). Conclusion : Infliximab therapy was associated with significant reductions in CD-related intra-abdominal surgeries, hospitalizations, hospitalized days and gastroenterologist visits. Our results confirm the population-based effectiveness of infliximab beyond the ideal conditions of clinical trials.

This thesis examines an integrative health care (IHC) clinic set within a tertiary hospital located in large city in Canada. The enquiry began by exploring how biomedical and CAM practitioners, artists, hospital administrators, and the Artists’ Health Centre Foundation (AHCF) members interacted, communicated, and collaborated with one another for integrative patient/client care at the Artists’ Health Centre (AHC). Individual stakeholders’ knowledge and attitudes toward IHC are explored, to understand how these affected the everyday interactions among stakeholders. The thesis also examines the organizational structures of the hospital and the AHCF. The use of qualitative research provided useful in-depth accounts of respondents’ experiences of IHC. Semi-structured focus groups with artists, health-care practitioners, hospital administrators, and AHCF members, and ten in-depth interviews with the health-care practitioners were conducted between June, 2006, and February, 2007. Steps were taken to ensure the trustworthiness of the collected data. Qualitative research software, NVIVO, was used to manage the data. The findings suggest that despite a perceived lack of scientific evidence, attitudes towards IHC were positively influenced when biomedical practitioners had a personal experience with CAM therapies and when practitioners developed more confidence in their own work. There remained questions about the need for and presence of IHC at the AHC, as neither the hospital nor the AHCF worked in consultation with the practitioners and artists to develop a shared vision of IHC. The majority of respondents described the level of communication as “sporadic” and one-sided and thus not optimal for creating a communicative environment. Most respondents perceived communication among the stakeholders as one-sided and thus not optimal for creating a communicative environment. There was a lack of understanding regarding scope of practice and how to integrate the various practitioners, particularly CAM. This led to a lack of referrals and had a direct effect on practitioners’ level of confidence. Mechanisms of communication were informal and there were no formalized structures in place to facilitate communication or integration with one another. Additionally, there was no systematic way of charting patient information at the AHC. Respondents all agreed that IHC was an ideal to strive for and many noted how financial limitations impeded the evolution of integrative health care at AHC, truly forming a barrier to IHC. Strategies for sustainability and management of AHC funds included using a business model or an insurance model. Important implications of this research include enhancing the current knowledge of teamwork, collaboration, and integration among practitioners in general, and biomedical and CAM practitioners in particular. This research used existing IHC models, interdisciplinary teamwork models, and educational and organizational theories for building a theoretical and conceptual framework of IHC at the AHC. Combining these models with organizational theory shed light on relationship dynamics among CAM and biomedical practitioners while taking into consideration the several structural and process dimensions of integration.