This doctoral thesis presents an exploratory case study of Kids in Shape (KIS), a community-institution initiative (CII) in which the author operated as an intermediary change agent responsible for facilitating community mobilization around the initiative. This study sought to examine the processes and dynamics underlying the mobilization of intersectoral local organizations involved in the project, as well as the role the first author played from her posture. A single case analysis was constructed based on qualitative methods and analysis of the community mobilization process and intermediary change agent's practice over a 29-month period (December 2005-April 2008). The data derived from five sources: (1) intermediary change agent participant observation and descriptive notes, (2) intermediary change agent reflective notes, (3) local partners' monthly meeting recording transcripts and notes, (4) debriefing notes from KIS research team meetings, and (5) written and electronic material. The analysis involved a two-stage process: (1) inductive, thematic coding and analysis of the raw data (Patton, 1990); and (2) theoretical, conceptual coding and interpretation of emerging themes (Braun & Clarke, 2006; Paquette, 2007) based on four concepts derived from resource dependence theory (i.e., resource interdependence, autonomy, ownership, and control over the use and contribution of resources). The results showed that the intermediary change agent's work was characterized by a set of tensions occurring along three continuums: process-product, insider-outsider, and bottom-up/top-down. Inherent to these tensions were organizational autonomy and ownership (i.e., control) over various types of processes/capacities and resources, notably between KIS's research team and local partners. This case analysis also revealed key managerial strategies (i.e., activating, synthesizing, framing, mobilizing) which strengthened relationships of interdependence between local organizations, and barriers which hindered the development of collective capacities. Finally, local organizations were found to move through different stages as they learned to work together and achieve collective goals. Results from this case study enabled the conceptualization of a theoretical construct of interdependence dynamics operating among organizations involved in KIS, and strategies used by the intermediary change agent to manage these dynamics throughout the community mobilization process. The results suggest that the notions of organizational resources (i.e., financial, in-kind, political), capacities, autonomy, and ownership need to be considered in an integrated model in order to understand the complex dynamics and relationships operating among organizations involved in CII.

Low-income Franco-Ontarian women have a higher prevalence of smoking than the general population. Smoking cessation programmes specifically designed for low-income women and in the French language are not offered in the Champlain region of Eastern Ontario. In order to redress inequities in delivery of French language services, a culturally sensitive smoking cessation programme for low income Franco-Ontarian women was designed. The following three studies were conducted: 1) a systematic review of the effects of smoking cessation interventions for low-income women; 2) an exploration study on the meaning of smoking to disadvantaged Franco-Ontarian women and their programme needs; 3) a narrative synthesis that informed the development of a logic model for a culturally sensitive smoking cessation programme for the population of interest. The first study, the systematic review, no evidence was found to support that smoking cessation interventions were effective in a population of low-income pregnant women. In addition, there was limited evidence that smoking cessation interventions were effective in low-income non-pregnant women. Overall, this systematic review was inconclusive: there were few studies included in this review, and several studies had limitations. This review has important implications for future research, suggesting that further attention should be given to the design of smoking cessation interventions by including outcome measures of cessation at 6-month and 12-month as well as biochemical validation of self-reported cessation. In addition, interventions should be tailored to meet the specific needs of low-income women and target the underlying causes of smoking. The second study provided new and important contextual information surrounding a population of low-income and Franco-Ontarian female smokers that are living in the community of Vanier. The third study involved a narrative synthesis which integrated several forms of knowledge and informed the development of a logic model. The logic model explains the pathways for a culturally sensitive smoking cessation program for low-income Franco-Ontarian women. The main levers of the intervention are to improve coping strategies/mechanisms, improve self-esteem while providing social support within a working group. Potential programme components were recommended: a gender-centered, holistic and culturally competent approach; the inclusion of empowerment, skill building and self-care; as well as community involvement.

The problem. The AIDS Case Reporting Surveillance System (ACRSS) is a passive surveillance system that was initiated in 1982. It is used to follow the health impact of HIV in the population at large and to determine HIV prevalence through back-calculation. An assessment of the proportion of all AIDS cases reported out of all AIDS cases diagnosed (i.e., reporting completeness) was required as part of the evaluation of this surveillance system. Methods. A number of secondary data sources were considered; the use of death certificate data from the Canadian Mortality Data Base (CMDB) was chosen by a process of elimination. Reporting completeness to the AIDS Case Reporting Surveillance System is about 85% which compares well with that seen in other countries. Reporting completeness is lower for females than males. Reporting completeness varies by province with Quebec, P.E.I., and New Brunswick having the lowest rates of reporting. Alberta and Ontario have the highest rates of reporting. Reporting is less complete in those that die in smaller communities. Reporting completeness decreased slightly during the 1980s. The most important finding is the trend to increased underreporting with time. Future validations of reporting completeness will become more difficult in Quebec due to the lack of initials on their dataset. The causes of incomplete reporting will only be elucidated with qualitative investigation. (Abstract shortened by UMI.)

This present investigation is a prospective study of 123 cardiac patients who attended a community-based program of education and support, following hospital admission for acute cardiovascular disease. The objective of the study was to derive a predictive model that would maximally discriminate between participants who were vs. participants who were not successful in modifying a health-risk behaviour. The four behaviours examined were following a low-fat diet, performing regular exercise, weight reduction and smoking cessation. Readiness for change was assessed prior to the commencement of the eight-week program, at post-treatment and at five-month follow-up. Participants were grouped into two outcome groups based on their stage of change as delineated by the Transtheoretical Model. Subjects who were in the action or maintenance stages of change at seven-month follow-up were classified as Progressors, and those who were in pre-action stages were classified as Non-progressors. The variables included in the predictive model were optimism, psychological distress, social intimacy and self-efficacy. Neuroticism was also included to explore its relationship with optimism. Discriminant function analysis showed that the variables that maximally separated individuals who were successful in risk-factor modification from those who were unsuccessful were social intimacy and self-efficacy. A secondary objective of this study was to compare Progressing subjects with Non-progressing subjects on psychological distress and on two Transtheoretical Model measures, decisional balance and the processes of change. Repeated measures analysis of variance indicated a slight reduction over time in scores on the measure of psychological distress for all participants as a group. However, no differences were found in psychological distress between participants who changed their health-risk behaviour and those who did not. Because more subjects than anticipated were successful in changing their target health-risk behaviour, there were insufficient data to further compare successful changers with unsuccessful changers. Thus the data did not provide for a robust test of how individuals progress through the Transtheoretical model stages of change following a coronary event. Overall this thesis emphasizes the importance of the social context of behaviour change as evidenced by the contribution of the measure of social intimacy. In addition, this thesis offers some information on the relationship between personality constructs (e.g., neuroticism) and behaviour change, although this requires further investigation.

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