This thesis takes an innovative approach to examining health care policy by applying the concept of policy drift to the issue of access to abortion across Canada through analyzing three explanations: the structure of Canadian federalism, women’s organizations, and rights litigation. The Supreme Court of Canada ruled that section 251 of the Criminal Code of Canada was unconstitutional in R v. Morgentaler (1988). Section 251 forced women to secure the approval of a panel of medical experts in order to gain legal consent to seek an abortion. As a result of this decision, women are now able to undergo a therapeutic abortion procedure without facing criminal sanctions. However, the issue of equitable access to abortion services across Canada is still unresolved. For example, women living in Prince Edward Island have to travel out of province at their own expense to undergo an abortion procedure. Meanwhile, women in Ontario are able to undergo an abortion procedure at a number of hospitals and private clinics with provincial insurance subsidizing the financial burdens. Abortion is a time-sensitive procedure and different from other health care procedures because it is also gender-sensitive. Findings within this thesis suggest that the model of Canadian federalism contributes to the inability of women’s organizations to gain audience from the federal government and inhibits the courts from assisting in expanding provincial access, which further facilitates policy drift. Recognizing policy drift concerning access to abortion is significant because it is an issue that involves gender equity at its core as well as discussions over what society deems is a right and what society deems is fair.

Canada fortifies certain products with folic acid and has periconceptional supplementation guidelines – policies designed to improve folate status and reduce the incidence of poor birth outcomes. Though optimal folate concentrations have been linked to health benefits, concerns have been raised regarding potential associations with adverse health outcomes. Direct biochemical assessment of the folate status of Canadians based on a nationally representative sample has not been done in more than 40 years. The overall purpose of this research was to investigate the folate status of the Canadian population. All analyses used the nationally representative 2007–2009 Canadian Health Measures Survey (CHMS). Red blood cell (RBC) folate was measured by Immulite 2000 immunoassay. Key findings indicate that folate deficiency (<305 nmol/L) was virtually non-existent in the Canadian population (6–79 years old). Still, one-fifth of women of childbearing age (WCBA; 15–45 years old) had sub-optimal concentrations for the prevention of neural tube defects (<906 nmol/L). Folic acid supplement intake was a primary determinant of WCBA achieving a RBC folate concentration ≥906 nmol/L. A distinct shift towards elevated RBC folate concentrations emerged. Three hypothetical cut-offs (1450 nmol/L, 1800 nmol/L and 2150 nmol/L) were examined to create dialogue since a universal definition of high RBC folate concentration does not exist. Females, participants aged 60¬–79 years, and those who were overweight or obese had the greatest prevalence of having high RBC folate at each cut-off. We conducted the first national-level comparison of RBC folate concentrations between the United States and Canada. Two different folate assay methods – microbiologic assay (NHANES) and Immulite 2000 immunoassay (CHMS) – necessitated the application of a conversion equation. Median Canadian RBC folate concentrations (adjusted to microbiologic assay) were lower than those of Americans but unadjusted Canadian median RBC folate values were higher. Canadian WCBA were less likely than American WCBA to have RBC folate ≥906 nmol/L, though Canadian WCBA with unadjusted RBC folate values were more likely to achieve this cut-off. These results indicate a need for strategies targeting WCBA to improve compliance with folic acid supplement recommendations. The strength and necessity of supplements for the general population should be re-assessed. Further, harmonization of folate measurement procedures in future surveillance efforts would support comparisons and inform policy directions.

Background: The relationships between both obesity and diabetes and the exposure to insecticides, specifically organophosphates and pyrethroids, in the adult Canadian population are not well-understood. Methods: Urinary concentrations of 4 organophosphate metabolites (DEP, DEPT, DMP, and DMPT) and of 4 pyrethroid metabolites (cis-DBCA, cis-DCCA, 3-PBA, and trans-DCCA) were measured for 1,147 adult Canadians aged between 18-79 years old. The geometric means and medians of both creatinine-adjusted and unadjusted urinary insecticide metabolites were estimated. Multiple linear regression and logistic regression analyses were employed to examine the associations between the insecticide metabolite concentrations and obesity and diabetes measures. Results: Both insecticides had detectable levels in over 70% of CHMS respondents. Most metabolites demonstrated a negative significant relationship between their urinary concentrations and BMI as well as waist circumference. No significant relationship was found in regard to HbA1c levels or for diabetes. Conclusion: Organophosphate and pyrethroid metabolites were detected in more than 70% of Canadian adults. Our data showed no evidence that organophosphate and pyrethroid exposures increase the risks of obesity and diabetes in adults. These results should be interpreted with caution as diet may play a large confounding role in the relationships of study.

This thesis is missing page 168. The other copies do not have this page. -Digitization Centre / The Canadian Health Insurance program has been in place for quite some time now and it has always been said that Canadians have some of the best healthcare in the world. Canadian healthcare is very well known throughout the world because every Canadian citizen has the right to healthcare without having to pay for it. The benefits of this program are quite well known but some benefits one might think would result, just might not be there. This paper looks at whether the inception of Canadian Health Insurance has had an effect on the mortality rates of Canadians. Through a statistical analysis, this paper shows that there is no evidence that the Canadian Health Insurance program has had an effect on Canadian aggregate mortality rates. This paper shows that Canadian mortality rates follow a trend to that of the United States. To say Canadians have a similar trend in mortality rate to the United States is perhaps surprising since Canadians are supposed to have a far superior healthcare system. / Thesis / Master of Science (MS)

Proponents of Canadian health reform in the 1990s argued for regional structures, which enables budget silos to be broken down and integrated budgets to be formed. Although regionalization has been justified on the basis of its potential to increase home care resources, political science draws upon the scope of conflict theory, which instead suggests marginalized actors, such as home care, may be at risk of being cannibalized in order to safeguard the interests of more powerful actors, such as hospitals. Prince Edward Island, Nova Scotia, and New Brunswick, constitute a natural policy experiment. Each has made different decisions about the regionalization model implemented to restructure health care delivery. The policy question underpinning this research is: What are the implications of the different regional models chosen on the allocation of resources to home care? Provincial governments are at liberty to fund home care within the limits of their fiscal capacity and there are no federal terms and conditions which must be complied with. This policy analysis used a case comparison research design with mixed methods to collect quantitative and qualitative data. Two financial outcomes were measured: 1) per capita provincial government home care expenditures and 2) the home care share of provincial government health expenditures. Hospital data was used as a comparator. Qualitative data collected from face-to-face, semi-structured interviews with regional elite key informants supplemented the expenditure data. The findings align with the scope of conflict theory. The trade-off between central control and local autonomy has implications for these findings: 1) home care in Prince Edward Island increased it share from 1.6% to 2.2% of provincial government health spending; 2) maintaining central control over home care in Nova Scotia resulted in an increase in its share from 1.4% to 5.4%, and 3) in New Brunswick, home care share grew from 4.1% to 7.6%. Inertia and entrenchment of spending patterns was strong. Health regions did not appear to undertake resource reallocation to any great extent in either Prince Edward Island or New Brunswick. Resource reallocation did occur in Nova Scotia where the hospital share of government spending went down and was reallocated to home care and nursing homes. But, Nova Scotia is the only province of the three in which home care was not regionalized. Regional interests in maintaining existing levels of in-patient hospital beds was clearly a source of tension between the overarching policy goals formulated for health reform by the provincial governments and the local health regions.

This paper considers the Aboriginal population in Canada (composed of First Nations, Métis and Inuit peoples) and explores the hypothesis that the degree to which traditional knowledge concepts, specifically in the area of mental health, is impacted by the extent to which a given population has achieved self-government. Additionally, from a public policy standpoint, this study – using a single case comparison methodology – examines the gap between intentions outlined in policy formulation stage guidance documents, indicating that the Canadian federal government intends to incorporate traditional knowledge to a greater degree, and evidence present at the policy implementation and budgeting stage, where it is clear that the application of the guidance does not always result in the stated outcome. By looking at similarities and differences between the case populations, this study will highlight some successes in the field of mental health policy, assess the challenges that policymakers face in the area of Aboriginal health, and offer suggestions to arrive at a place in the future where fundamental mental health disparities have been reduced for Aboriginal people in Canada.

This paper considers the Aboriginal population in Canada (composed of First Nations, Métis and Inuit peoples) and explores the hypothesis that the degree to which traditional knowledge concepts, specifically in the area of mental health, is impacted by the extent to which a given population has achieved self-government. Additionally, from a public policy standpoint, this study – using a single case comparison methodology – examines the gap between intentions outlined in policy formulation stage guidance documents, indicating that the Canadian federal government intends to incorporate traditional knowledge to a greater degree, and evidence present at the policy implementation and budgeting stage, where it is clear that the application of the guidance does not always result in the stated outcome. By looking at similarities and differences between the case populations, this study will highlight some successes in the field of mental health policy, assess the challenges that policymakers face in the area of Aboriginal health, and offer suggestions to arrive at a place in the future where fundamental mental health disparities have been reduced for Aboriginal people in Canada.

Proponents of Canadian health reform in the 1990s argued for regional structures, which enables budget silos to be broken down and integrated budgets to be formed. Although regionalization has been justified on the basis of its potential to increase home care resources, political science draws upon the scope of conflict theory, which instead suggests marginalized actors, such as home care, may be at risk of being cannibalized in order to safeguard the interests of more powerful actors, such as hospitals. Prince Edward Island, Nova Scotia, and New Brunswick, constitute a natural policy experiment. Each has made different decisions about the regionalization model implemented to restructure health care delivery. The policy question underpinning this research is: What are the implications of the different regional models chosen on the allocation of resources to home care? Provincial governments are at liberty to fund home care within the limits of their fiscal capacity and there are no federal terms and conditions which must be complied with. This policy analysis used a case comparison research design with mixed methods to collect quantitative and qualitative data. Two financial outcomes were measured: 1) per capita provincial government home care expenditures and 2) the home care share of provincial government health expenditures. Hospital data was used as a comparator. Qualitative data collected from face-to-face, semi-structured interviews with regional elite key informants supplemented the expenditure data. The findings align with the scope of conflict theory. The trade-off between central control and local autonomy has implications for these findings: 1) home care in Prince Edward Island increased it share from 1.6% to 2.2% of provincial government health spending; 2) maintaining central control over home care in Nova Scotia resulted in an increase in its share from 1.4% to 5.4%, and 3) in New Brunswick, home care share grew from 4.1% to 7.6%. Inertia and entrenchment of spending patterns was strong. Health regions did not appear to undertake resource reallocation to any great extent in either Prince Edward Island or New Brunswick. Resource reallocation did occur in Nova Scotia where the hospital share of government spending went down and was reallocated to home care and nursing homes. But, Nova Scotia is the only province of the three in which home care was not regionalized. Regional interests in maintaining existing levels of in-patient hospital beds was clearly a source of tension between the overarching policy goals formulated for health reform by the provincial governments and the local health regions.

This paper considers the Aboriginal population in Canada (composed of First Nations, Métis and Inuit peoples) and explores the hypothesis that the degree to which traditional knowledge concepts, specifically in the area of mental health, is impacted by the extent to which a given population has achieved self-government. Additionally, from a public policy standpoint, this study – using a single case comparison methodology – examines the gap between intentions outlined in policy formulation stage guidance documents, indicating that the Canadian federal government intends to incorporate traditional knowledge to a greater degree, and evidence present at the policy implementation and budgeting stage, where it is clear that the application of the guidance does not always result in the stated outcome. By looking at similarities and differences between the case populations, this study will highlight some successes in the field of mental health policy, assess the challenges that policymakers face in the area of Aboriginal health, and offer suggestions to arrive at a place in the future where fundamental mental health disparities have been reduced for Aboriginal people in Canada.

Objectives: This thesis examines the risks among Canadian children and adolescents for developing cardio-metabolic diseases, extending evidence that is well-established for adults to pediatric populations. As well, novel indicators and cut-offs for the measurements of disease risks are proposed and associations between physical activity, weight status, socio-economic status and cardio-metabolic health are examined. Methodology: Secondary data analysis was conducted using data from three cycles of the Canadian Health Measures Survey (CHMS), a nationally representative data set which includes measured anthropometric characteristics. A population health approach was applied throughout, underpinned by the World Health Organization’s Conceptual Framework for Action on the Social Determinants of Health. The thesis was designed such that a series of four manuscripts successively built on the key findings from each previous research paper: 1. Establishing the prevalence of Metabolic Syndrome and its risk factors for 10-18 year olds using the International Diabetes Federation child, adolescent and adult definitions. 2. Estimating pre-obesity epidemic waist circumference reference values for Canadian children 6-10 years using reference data from the 1981 Canada Fitness Survey, the Third National Health and Nutrition Examination Survey (1988-1994), and the CHMS through regression of linear, logarithmic and quadratic functions. This work facilitated an expanded age range for the subsequent projects as age- and sex-specific cut-offs based on a Canadian population prior to the obesity epidemic had not been available. 3. Cardio-metabolic risk by body mass index (BMI), waist circumference (WC), and a combined BMI-WC indicator quantified the associations between a dichotomous cardio-metabolic risk variable, and obesity, using three indicators of obesity including a novel indicator, for ages 6-18 years. 4. Association between cardio-metabolic risk and inflammation quantified the associations between inflammation, using high-sensitivity c-reactive protein (CRP) as a marker, and cardio-metabolic risk to determine if high CRP was a significant predictor of cardiometabolic risk among 6-18 year olds. Results: For Paper 1 (n=1228), only 2.1% were classified as having the Mets though 38% had at least 1 MetS risk factor. For Paper 2, logarithmic regression predicted WC cut-offs with the lowest degree of error. For Paper 3 (n=2678), 35% were classified as having cardio-metabolic risk with significantly higher levels among those classified as obese and/or having a low level of physical activity. All indicators of obesity had significant associations with cardio-metabolic risk. For Paper 4 (n=1831), 43.6% of children and 62.0% of adolescents with high CRP levels were classified as having cardio-metabolic risk, a significant relationship. Participants from households with moderate to high income and/or education had the lowest prevalence of MetS risk factors and abdominal obesity. Conclusions: High CRP is a useful indicator of cardio-metabolic risk for pediatric populations. With further research, novel combinations of BMI and WC may be shown to be more predictive for cardio-metabolic risk than these indicators individually. The substantial prevalence of multiple risk factors which predict premature onset of chronic disease foreshadows potential years of morbidity in adulthood for Canada’s youth population.