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Objetivo: Descrever o comportamento da tuberculose (TB) na comunidade boliviana residente em quatro distritos do município de São Paulo (MSP), Belém, Bom Retiro, Brás e Pari, no período de 1998 a 2008, analisar seu possível impacto na tendência dessa doença e investigar possíveis disparidades em relação ao acesso aos serviços e na qualidade do atendimento entre bolivianos e brasileiros. Metodologia: Estudo descritivo de casos notificados de TB entre migrantes bolivianos. Os dados foram obtidos junto à vigilância da TB do MSP. As variáveis de interesse foram: características sócio-demográficas, aspectos diagnósticos, clínicos e terapêuticos, comportamentais, co-morbidades e indicadores de acesso aos serviços e de qualidade do atendimento. A análise foi efetuada comparando a as variáveis de interesse entre pacientes de nacionalidade boliviana e brasileira residentes nos mesmos distritos. Para a comparação de proporções aplicamos o teste do qui-quadrado ou teste exato de Fisher e para médias o teste de Kruskal-Wallis. Resultados: Foram notificados 2434 casos de TB nos distritos estudados, dos quais 67,5 %, 30,4% e 2,1% eram, respectivamente de nacionalidade brasileira, boliviana e outras; a participação boliviana foi crescente no período, elevando-se de 15% para 53% dos casos; observando-se uma queda de 43,5% no número absoluto de casos entre os brasileiros e um incremento de 250% entre bolivianos. A incidência na área de estudo em 2008 era 3,5 vezes maior do que a verificada, em média, no MSP. Comparados aos brasileiros os bolivianos eram mais jovens (média: 26 versus 39 anos; p<=0,0001) e a prevalência de desemprego entre eles era mais baixa (2,4% versus 10,4%; p<0,0001). Para o período de 2006 a 2008, os bolivianos apresentam taxas mais elevada de cura (70,9% versus 62,1%; p<0,001) e de tratamento supervisionado (81,9% versus 62,2%; p<0,001) e menores de história de TB no passado (6,9% versus 16,9%; p<0,0001), abandono de tratamento (16,9% versus 22,4%; p<0,001), de letalidade por TB (1,6% versus 4,8%; p<0,001) e de recidiva (4,9% versus 9,2%; p<0,001). A prevalência de co-morbidades era mais baixa entre bolivianos. Em torno de 88% dos casos de ambas as nacionalidades o diagnóstico e o tratamento foi efetuado em serviços públicos de saúde. Conclusão: A TB mostrou-se um relevante problema entre bolivianos, contribuído para a manutenção de elevada incidência na área de estudo, justificando estratégias específicas de intervenção. Os resultados sugerem que o cumprimento das diretrizes do Sistema Único de Saúde, de acesso universal aos serviços constitui instrumento efetivo de promoção da equidade em saúde. / Objective: Describing the tuberculosis in the bolivian community resident in the districts of Belém, Bom Retiro, Bras and Pari, located in the municipality of São Paulo (MSP), in the period 1998 to 2008, analyze its possible difference in relation to access services and quality of health care among bolivians and brazilians. Methods: Descriptive study of notified cases of TB among bolivian immigrants. The data are obtained from the TB surveillance of the MSP. The variables of interest were socio-demographic characteristics, diagnostic aspects, clinical and therapeutical, behavioral, comorbidities and indicators of access to services and quality of care. The analysis was performed comparing the variables between bolivians and brazilians patients residing in the same districts. For comparison of proportion was applied the chi-square test or Fisher exact test and for means the Kruskal-Wallis test. Results: Were reported 2434 TB cases in districts studied, whom 67,5%, 30,4% e 2,1% were respectively brazilians, bolivians and others nationalities; the bolivian participation increased in the period, rise from 15% to 53% of all cases, observing a drop of 43,5% in the absolute numbers of cases among the brazilians and a increase of 250% among bolivians. The incidence in study area in 2008 was 3,5 times greater than that seen on average in MSP. Compared to brazilians, bolivians were younger (mean: 26 versus 39 years, p=0.0001 and the prevalence of unemployment was lowest (2,4% versus 10,4%, p<0,0001. In 2006 to 2008, bolivians have higher rates of cure (70,9 versus 62,1%, p<0,001) and supervised treatment (81,9% versus 62,2%), and lower rates of TB in past (6,9% versus 16,9%, p<0,0001), neglect (16,9 % versus 22,4%, p<0,001), TB mortality (1,6% versus 4,8%, p<0,001) and relapse (4,9% versus 9,2%, p<0,001). The prevalence of comorbidities was lower among bolivians. Around 88% of cases of both nationalities the diagnosis and treatement was done in public health services. Conclusions: The TB is significant problem among bolivians, contributing to the maintenance of high incidence in the study area, justifying specific strategies of intervention. The results suggest that compliance with the guidelines of Sistema Único de Saude of universal access to services is an effective instrument for promoting equity in health.

State dependency and the lingering impacts of colonialism dancing with Aboriginal peoples are known realities across the Canadian health care landscape. However, delving into the discourses of how to reduce health disparities of a colonized population is a sophisticated issue with many factors to consider. Specifically, nurses can play a central role in the delivery of essential health services to the ‘Other’ within isolated Northern Aboriginal communities. As an extension of the state health care system, nurses have a duty to provide responsive and relevant health care services to Aboriginal peoples. The conducted qualitative research, influenced by a postcolonial epistemology, sought to explore the roles and challenges of nurses working within rural, remote, and Northern Canadian Aboriginal communities, as well as individual, organizational, and system level factors that supported or impeded nurses’ work in helping to meet Aboriginal peoples’ health needs with meaningful care. Theorists include the works of Fanon on colonization and racial construction; Kristeva on semiotics and abjection; and Foucault on power/knowledge, governmentality, and bio-power were used in providing a theoretical framework to help enlighten the research study presented within this dissertation. Critical Discourse Analysis of twenty-five semi-structured interviews with nurses, physicians, and regional health care administrators was deployed to gain a better understanding of the responsibilities and challenges of nurses working in Northern Canada. Specifically, the research study was conducted in one of the three health regions within Northern Saskatchewan. Major findings of this study include: (1) the Aboriginal person did not exist without being in a relation with their colonial agent, the nurse, (2) being ‘Aboriginal’ was constructed as a source of treating illnesses and managing diseases, and (3) as a collective force, nursing was utilized as means of governmentality and as provisions of care situated within colonial laws. Historically, nurses functioned as a weapon to ‘save’ and ‘civilize’ Aboriginal peoples for purposes of the state. Primarily, present day nursing roles focused on health care duties to promote a decency of the state, followed by missionary tasks. In turn, the findings of this research study indicate that nurses must have a better understanding of the impact of colonialism on Aboriginal peoples’ health before they engage with local communities. Knowledge development through postcolonial scholarship in nursing can help nurses and health service providers to strengthen their self-reflective practice, in working towards de-signifying poor discourses around Aboriginal peoples’ health and to help create new discourses.

Despite harm reduction’s social justice roots, the broader understanding of harm reduction is often influenced by morals and values which leaves harm reduction to be conceptualized within a morality policy domain. This study adopts the Qualitative-Narrative Policy Framework (Q-NPF) (Gray & Jones, 2016), to explore the policy beliefs and values that steer current harm reduction policy documents in British Columbia. Four questions guide this study: i) What are the underlying beliefs and values steering harm reduction policy in B.C.? ii) How are these beliefs and values narrated through policy?, iii) In what way do the underlying policy beliefs align with principles of social justice for harm reduction?, and iv) How have policy beliefs shifted since the 2016 public health emergency declaration? The social justice lens for harm reduction (Pauly, 2008) serves as this study’s analytical framework and is supplemented by the Systems Health Equity Lens (Pauly, Shahram, van Roode, Strosher & MacDonald, 2018); both of which emphasize the need for harm reduction to acknowledge and address social and structural conditions that contribute to substance use harms and their inequitable distribution. As this study reveals, there is an ongoing tension between equity-related and non-equity policy beliefs and values characterized within policy documents, thus fueling a policy climate with incongruent and contradictory beliefs. Further, equity-related beliefs are positioned in the confines of equitable access, thus they are not equity-oriented in entirety. Additionally, there have been minimal shifts in policy beliefs since the post-2016 public health emergency declaration yet shifts occur in terms of the specific constructs which form equity-related and non-equity beliefs. Finally, the study outlines potential implications of these beliefs and proposes recommendations to improve harm reduction policy in terms of becoming equity-oriented. This study also outlines methodological contributions to the Q-NPF for future policy narrative and analysis studies. / Graduate / 2022-08-15

The COVID-19 pandemic highlighted the well documented health disparities affecting racial and ethnic minorities, particularly those living in underserved urban settings. Due to historic and contemporary structural racism, these areas are often food deserts, lack adequate access to primary care services, and have higher rates of maternal and infant mortality. The lack of public health infrastructure to respond to emergencies, such as pandemics, can be rapidly met with collective action from communities to take care of their most vulnerable. After providing a basic overview of how structural racism has created the present-day disparities seen in communities such as North Philadelphia, this thesis investigates and makes the case for the capacity of these resilient communities to take care of themselves. To this end, I describe the work of North10 Philadelphia, Fabric Masks for North Philly, and the Maternal Wellness Village—community-based organizations that rapidly pivoted their work to fill the unmet needs of people in North Philadelphia related to food insecurity, personal protective equipment, and childbirth preparation and social support, respectively. I describe the utilization of the services provided by these groups and evaluate the evolution of their work from the onset of the pandemic through present day. Following each case study, I share the stories of the leaders behind each project to give voice to the people fighting for the health and wellbeing of their community. Lastly, I reflect on my positionality as a Black woman and medical student at a large academic institution partnering with these groups and assert the need to maintain partnerships with these and similar organizations to ensure the sustainability of their programming in the long term. / Urban Bioethics

Many community-based organizations in urban areas of the United States exist to address the needs of their neighborhood and bridge the gap between the healthcare system and their community. In the Primary Care setting, healthcare providers have the opportunity to address those needs, either through their own expertise or through connecting patients with other resources. Despite this unique role of Primary Care Providers (PCPs), many of them are unaware of the resources that exist in their very own community. PCPs need awareness of, as well as partnership with, these community-based organizations. Integrating these resources into patient care will allow providers to improve health on a population level through a more robust response to patient and community needs. This will ultimately lead to a reduction of health disparities and improved quality of life in the community. This thesis seeks to explore strategies and resources that PCPs can use to better address patient and community needs. / Urban Bioethics

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Background: Health technology assessment (HTA) is a form of policy analysis to inform recommendations for decision-makers. An equity-focused HTA recommendation consists of one that explicitly addresses the impact of health technologies on individuals disadvantaged in society because of their social conditions. However, there is a need for more evidence on the relationships between patient engagement and the development of equity-focused HTA recommendations. Objectives: The objectives of this dissertation were to examine the association between patient engagement and equity-focused HTA recommendations and identify implementation considerations for patient engagement in HTA. Methods: I used explanatory sequential mixed methods to analyze 60 HTA reports and 11 interviews with patients and analysts from Canadian organizations: the Canadian Agency for Drugs and Technologies in Health (CADTH) and Health Quality Ontario (HQO). Results: Quantitative analysis of the HTA reports showed that patient engagement significantly predicts equity-focused HTA recommendations (OR: 0.26; 95% CI: [0.16 – 0.41]). HTA reviews where HTA analysts directly interviewed patients (OR: 3.85; 95% CI: [2.40 – 6.20]) and where an advisory committee used consensus were more likely to contain equity-focused recommendations (OR: 2.27; 95% CI: [1.35 – 3.84]). Qualitative analysis of the interviews identified strategies for engaging diverse patients in HTA. Conclusion: The findings of this dissertation can inform the designing of patient engagement in HTA.

This study showed that health equity must be achieved through education, awareness, and advocacy. A structured program must be put in place to provide accountability towards achieving health equity within organizations, communities, cites, and states. In Virginia, the Health Equity Campaign was a program put in place to provide such accountability to the citizens of Virginia. This study attempted to evaluate the Health Equity Campaign implemented by the Virginia Department of Health Office of Minority Health and Public Health Policy Division of Health Equity in order to get all Virginians to become advocates for health equity in their organizations, communities, neighborhoods. Organizational/group leaders were interviewed in addition to surveying various staff members. This study provides a detailed description of the strength of the Health Equity Campaign's ability to promote education and awareness about health equity and why many participants found it difficult to transition from motivation to advocacy. / Ph. D.

Life course literature states that early childhood development (ECD) can influence most aspects of health throughout the life-cycle. Canada ranked last among 25 wealthy nations in meeting ECD objectives. Fewer than 5% of children born have clinically detectable shortcomings in developmental health, increasing to 26% by school age with emerging socioeconomic associations. Understanding how social determinants of health (SDH) influence ECD at the household and neighbourhood scales would help identify conditions for optimal developmental outcomes. The effects of SDH on ECD in the Kingston, Ontario area were studied. SDH were classified via marginalization (ONMarg) and deprivation (Pampalon) indices. ECD was measured via 2006 Early Development Instrument (EDI) scores for children most at risk upon school entry (Grade One). The basic spatial unit of analysis was 2006 Census of Canada Dissemination Areas, subdivided into quintiles of deprivation (Q1 being the least deprived and Q5 the most). EDI results from each of the quintiles within the two indices were compared and then combined. The socioeconomic health gradient assumes that EDI scores will directly correlate to material and social deprivation. Social deprivation had a slightly greater impact than material deprivation on children’s developmental vulnerability, with Q5 being the most vulnerable in all competencies. Surprisingly, emotional health and social competence were significant areas of vulnerability for children in Q1 and Q2. “Village effects” – when social determinants at the neighbourhood level have protective effects on ECD despite material deprivation at the household level – were present within the Q3 and Q4 groups for the domains of social competency and emotional health. While the highest proportions of early childhood developmental vulnerability are found within the most deprived households, the largest numbers of vulnerable children are spread throughout the middle-class in a variety of neighbourhoods. Canadian policy should focus on mediating avoidable risks within this critical time to avoid future deleterious health effects and costs. Mapping the effects of SDH at the neighbourhood level generates knowledge that informs intersectoral action by policy makers to provide the supports needed to foster healthy children. / Thesis (Master, Geography) -- Queen's University, 2013-05-04 10:36:25.165