Introduction: Bandura’s self-efficacy theory postulates that confidence is a stronger determinant of behaviour than one’s actual skills or abilities. The Day and Night time Driving Comfort Scales (D-DCS and N-DCS) are new tools to measure perceived confidence in older drivers. Developed inductively with older drivers, the DCSs have good structural properties and preliminary psychometric support, including test-retest reliability. Purpose: This thesis builds on previous work by further examining the construct validity of the DCSs via (1) temporal associations (Study 1) and (2) cross-sectional relationships (Study 2). Study 1 prospectively examined the relationship between DCS scores and self-reported driving behaviour. Study 2, meanwhile, examined cross-sectional associations between DCS scores and selected sample characteristics, self-reported driving behaviour and driving problems, perceived abilities and seven objectively measured driving-related abilities (visual acuity, contrast sensitivity, disability glare, brake reaction time, lower body mobility, executive skills and visual attention). Methods: For Study 1, a convenience sample of 82 older drivers (aged 63 to 93) were assessed at baseline and follow-up (five to 17 months later). Study tools comprised the DCSs, multi-item ratings of driving frequency, avoidance and perceived abilities and a background questionnaire. Telephone interviews were conducted with a subgroup of 45 drivers to examine reasons for changes in driving comfort. For Study 2, cross-sectional relationships with the DCSs were examined using baseline data from 65 drivers (aged 63 to 93). A subgroup of 42 participants completed objective assessments of driving-related abilities assessed via ETDRS charts, Pelli-Robson charts, Brightness Acuity Tester, brake reaction time apparatus, the Rapid Paced Walk, the Trail Making Tests (Parts A and B) and the UFOV subtest 2. Results: Prospectively, lower baseline N-DCS scores (p<.001) and decreased N-DCS scores (p<.001) were significant predictors of lower self-reported situational driving frequency (R2 = 34%) and greater situational avoidance (R2 = 51%) at follow-up. While DCS scores did not change appreciably for those who continued driving, N-DCS scores were significantly lower at follow-up for seven individuals who stopped driving (p<.05). Cross-sectionally, lower DCS scores were significantly associated with lower self-reported situational driving frequency, higher situational avoidance and lower ratings of perceived abilities (p<.001). Poorer left eye acuity scores were significantly associated with lower D-DCS (p<.05) and N-DCS (p<.05), while slower performance on Part A of the Trail Making Test was significantly related to lower D-DCS scores (p<.05). Participants with a discrepancy between their perceived and actual abilities had significantly higher D-DCS, situational driving frequency and lower situational avoidance (p<.05). Conclusions: Findings are consistent with Bandura’s self-efficacy theory and Rudman’s model of driving self-regulation and, thus, provide further support for the construct validity of the DCSs. Further studies are needed with larger, more diverse samples, including those with diagnosed impairments, to establish benchmarks for driving comfort in healthy drivers and various clinical populations (such as those with stroke, Parkinson’s or visual conditions). Prospective studies should also involve longer follow-up periods, examination of actual driving behaviour and barriers to self-restriction, and attempt to pinpoint whether there is a critical level of discomfort at which voluntary cessation is likely to occur.

Objective: The primary aim of this study was to better understand the role of depressive and negative symptoms in patients with schizophrenia. As such, two specific research questions guide this analysis: (1) What factors are associated with depressive and negative symptoms at Time 1 across four major psychiatric diagnoses (patients with schizophrenia, mood disorder, both schizophrenia and mood disorders, and patients whose primary diagnosis is neither schizophrenia nor mood disorder)? (2) To what extent do depressive and negative symptoms improve over time among individuals with schizophrenia? More specifically, what variables predict an improvement in these symptoms? Methods: The study involved analysis of secondary data from 3269 in-patients from 15 psychiatric facilities in the Province of Ontario, Canada. Patients were assessed using the Resident Assessment Instrument – Mental Health (RAI-MH). Bivariate analyses were performed examining demographic, clinical, social, and other factors as independent variables and depressive and negative symptom scores among each of the four diagnostic groups: schizophrenia, mood disorder, both schizophrenia and mood disorder, and neither schizophrenia nor mood disorder. Logistic regression of depressive and negative symptoms, as dependent variables, were performed on demographic, psychiatric, clinical, social, and other variables, as the independent variables. Results: Variables associated with depressive and negative symptoms did not necessarily predict an improvement of depressive and negative symptoms over time. Findings from logistic regression models showed that statistically significant predictors of improvement in depressive and negative symptoms included the following variables: (1) not having a diagnosis of schizophrenia; (2) insight into one’s condition; (3) fewer number of recent psychiatric admissions (over the last two year period); and (5) being administered both atypical and typical antipsychotic medications. Conclusions: Depressive and negative symptoms are prevalent in schizophrenia and are associated with demographic, psychiatric, and social variables. Depressive and negative symptoms do not share the same pattern across diagnoses, suggesting that these symptoms represent a unique profile within each diagnostic group. Moreover, both atypical and typical antipsychotic medications, in combination, were shown to be more effective at treating depressive and negative symptoms than either typical or atypical medications alone.

Considerable socioeconomic disparities have been identified for smoking and cessation: lower socioeconomic status (SES) groups have higher rates of tobacco use, are less likely to successfully quit, and may also be less likely to intend or attempt to quit. However, results are inconsistent for some quitting-related outcomes, and little is known about how socioeconomic disparities may vary across countries and over time. This study examined the extent to which SES was associated with smoking cessation and related constructs among representative samples of smokers in Canada, the US, the UK, and Australia, using data from the first five waves (2002-2006) of the ITC Four Country Survey (35 532 observations from 16 458 respondents). Generalized estimating equations modeling was used to examine whether education and income were related to intentions to quit (any, and within the next six months), incidence of quit attempts, smoking abstinence (for at least one, six and 12 months), and reduction in daily cigarette consumption by at least half. Potential differences in the associations over time and across countries were also considered. In addition, logistic regression modeling examined associations between education and income, reasons for quitting, and use of cessation assistance, using a cross-sectional sample of the most recent survey wave. Respondents with higher education were more likely to intend to quit, have made a quit attempt, and be abstinent for at least one and six months, and those with higher income were more likely to intend to quit and be abstinent for at least one month. Associations were stable throughout the time period under study. Country differences were observed in quit intentions: UK and US respondents were less likely to intend to quit than Australians and Canadians. Also, UK respondents were least likely to attempt to quit overall, but those that did attempt were more likely to be abstinent for at least one and six months. Socioeconomic and between-country differences were also identified in the cross-sectional analyses of use and access to cessation assistance and reasons for quitting. The results suggest that socioeconomic disparities exist at multiple stages in the path to smoking cessation.

Background: Planning has long been assumed to be an important element of any successful quit smoking strategy. However, recent research findings indicate that unplanned, or spontaneous quit attempts, may lead to more successful and longer cessation periods than planned attempts. This calls into question continued advice to plan and the validity of planning based behaviour change theories. Objectives: To: 1) assess the prevalence of planning; 2) identify the attributes of planners; 3) examine the association of planning and intentions to quit; 4) examine the association of planning and use of quit aids; and 5) examine the impact of planning on smoking cessation outcomes. Methods: Data from the longitudinal Ontario Tobacco Survey (OTS) were examined. Analyses consisted of 418 smokers who made a planned or unplanned quit attempt between their waves 4 and 5 survey response. Descriptive, bivariate, and multivariate analyses were conducted using specialized survey analysis procedures to account for the complex sampling and design features of the OTS. Multiple Imputation (MI) was used to fill in missing data to reduce bias. Results: The prevalence of planning among Ontario smokers who made a quit attempt in the past six months was 70%. Regression models indicated that women, smokers who felt that it would be “very hard to quit”, and those with intentions to quit in the next 6 months had higher odds of making a planned quit attempt. Individuals who made a planned quit attempt had increased odds for using a quit aid compared to those making unplanned attempts. Univariate regression models indicated that planned attempts did not result in higher odds ratios for being abstinent for at least one week and at least one month. Conclusions: The present results suggest that a majority of smokers who made a quit attempt did so with a plan. Planned quit attempts had higher odds use of any quit aid compared with unplanned attempts. Planning was not found to increase the odds of being abstinent compared to unplanned attempts. Although more research is needed, the current study contributes to the dialogue of planning and smoking cessation.

Background: The rehabilitation of older persons is often complicated by increased frailty and medical complexity – these in turn present challenges for the development of health information systems. Objective investigation and comparison of the effectiveness of geriatric rehabilitation services requires information systems that are comprehensive, reliable, valid, and sensitive to clinically relevant changes in older persons. The Functional Independence Measure is widely used in rehabilitation settings – in Canada this is used as the central component of the National Rehabilitation Reporting System of the Canadian Institute of Health Information. An alternative system has been developed by the interRAI consortium. We conducted a literature review to compare the development and measurement properties of these two systems and performed a direct empirical comparison of the operating characteristics and validity of the FIM motor and the ADL items on the PAC in a sample of older adults receiving rehabilitation. Methods: For the first objective english language literature published between 1983 (initial development of the FIM) and 2008 was searched using Medline and CINAHL databases, and the reference lists of retrieved articles. Additionally, attention was paid to the ability of the two systems to address issues particularly relevant to older rehabilitation clients, such as medical complexity, comorbidity, and responsiveness to small but clinically meaningful improvements. For the second objective we used Rasch analysis and responsiveness statistics to investigate and compare the instruments dimensionality, item difficulty, item fit, differential item function, number of response options and ability to detect clinically relevant change. Results: The majority of FIM articles studied inpatient rehabilitation settings; while the majority of interRAI/MDS articles focused on nursing home settings. There is evidence supporting the reliability of both instruments. There were few articles that investigated the construct validity of the interRAI/MDS. The analysis showed that the FIM may be slightly more responsive than the PAC, especially in the MSK patients. However, both scales had similar limitations with regards the large ceiling effect and many unnecessary response options. Conclusions: Additional psychometric research is needed on both the FIM and MDS, especially with regard to their use in different settings and ability to discriminate between subjects with functional higher ability.

Background and Purpose: Quality measurement is an essential, yet, complex component of mental health services that is often limited by a lack of clinically meaningful data across service providers. Understanding how services are organized, delivered, and effective is vital for ensuring and improving health care quality. In quality measurement of mental healthcare, structural indicators are common with fewer process and outcome indicators available. Using data from the RAI - Mental Health (RAI-MH), a comprehensive assessment system mandated for use in Ontario, this dissertation aims to define a set of mental health quality indicators (MHQIs), effectiveness quality indicators (EQIs), and risk adjustment strategy that can be used to evaluate and compare quality at the facility- and regional-levels. Methodology: The MHQIs were developed using a retrospective analysis of two data sets: A pilot sample of 1,056 RAI-MH admission and discharge assessments collected from 7 inpatient mental health units in Ontario and a sample of 30,046 RAI-MH admission and discharge assessments collected from 70 Ontario hospitals as part of the Canadian Institute for Health Information Ontario Mental Health Reporting System. The MHQIs were chosen based on clinically meaningful domains identified by mental health and quality stakeholders, MHQI rates that were consistently above 5% or below 95% among hospitals, and appropriate variation in rates among hospitals in both sets of data. For each MHQI domain, regression modeling using generalized estimating equations was employed to choose risk adjustment variables and logistic or linear regression was used to perform risk adjustment to compare MHQI and EQI rates among hospitals and regions. Results: A set of 27 MHQIs was defined measuring improvement and incidence/failure to improve in the following domains: depressive/psychosis/pain symptoms, cognitive/physical/social functioning, aggressive/ disruptive/violent behaviours, and control procedures. Also, 13 EQIs were defined to identify the magnitude of change in MHQI domains per 7 days between assessments. Regression models using generalized estimating equations identified between 1 and 8 risk adjustment covariates for each MHQI. Risk adjustment using logistic and linear regression resulted in over 50% of hospitals and LHINs changing in rank based on MHQI and EQI scores. Conclusion: This dissertation has developed an evidence-based set of MHQIs and EQIs based on a clinically rich set of data. Since the data is available provincially, the MHQIs and EQIs can be used for hospital based, regional, and public reports on quality of inpatient mental health services. The MHQIs/EQIs can be linked to care planning and funding using the RAI-MH to promote quality improvement and accountability for recipients, providers, managers, governors, and funders of mental health services. Opportunities are also available to extend the use of the MHQIs to community mental health, so that system level evaluations of quality can be developed.

Introduction: The high prevalence of obesity in Aboriginal Canadian youth is a major public health concern. Although little is known about the diets of children on-reserve, it is hypothesized that high intake of low nutrient dense foods has a negative impact on overall diet quality. Objectives: To describe the dietary quality of First Nation students using a Canadian adaptation of the Healthy Eating Index (HEI-C) and determine the relationships between HEI-C and BMI, intake of non-food group (“other”) foods, game consumption, frequency of eating outside the home and remoteness (latitude, °N). Methods: Between 2004-2009, from a 24 h dietary recall data were obtained using a validated web-based food behaviour questionnaire, from students in grades 6,7 & 8 from the First Nations communities of Georgina Island, Christian Island, Fort Albany, Attawapiskat, Peawanuck, Moose Factory, Kashechewan and Ouje-Bougoumou (Quebec). HEI-C was assessed as good (81-100), needs improvement (51-80) or poor (0-50). Results: Mean community HEI-C scores ranged from 57.38-70.04, with differences by community (p=0.027) and season (p=0.007); more northerly communities seemed to have lower HEI-C scores and fall seemed to have higher HEI-C scores compared to winter and spring. A non-significant negative correlation between BMI and HEI-C was observed (r=-0.107, NS). As percent energy from ‘other foods’ increased, the HEI-C score tended to decrease. Game consumption appeared to contribute to higher HEI-C scores. Eating outside the home did not seem to affect HEI-C. Conclusions: Poor diet quality in remote on-reserve youth populations is a concern. Lack of consistent access to healthy foods may have a negative impact on diet quality. Programs that help improve the provision of healthy foods, decrease the intake of “other foods” and that emphasize game may help to improve diet quality.

Background: Depression is a worldwide problem but studies have shown that after patients with depressive symptoms are in remission, difficulties in social relationships may persist. There is a need for future research on the relationship between social function and depressive symptoms in order to facilitate development of new clinical interventions. Objectives: This study aimed to identify what factors contribute to the relationship between depressive symptoms and social relationships and what factors predict improvement in depressive symptoms during psychiatric hospitalization. Methods: This longitudinal cohort study was based on a secondary analysis of RAI-MH data from the Ontario Mental Health Reporting System (OMHRS). Depressive symptoms were measured with the Depressive Symptoms Rating Scale (DRS) and social relationships difficulties were evaluated with the interRAI Social Relationships CAP. The sample comprised of 125,120 patients from acute, long stay, addiction, psychiatric crisis units and forensic units. Sub-sample of patients with depressive symptoms and mood disorder was created (N = 38,823). Results presented in a descriptive analysis for both samples and bivariate and multivariate analysis for the sub-sample. Logistic regression analysis was performed to predict rates of improvement of depressive symptoms. Results: The study revealed that many factors predict outcome of depressive symptoms. Difficulties in social relationships, older age, multi-morbidity, functional impairments, trauma, and poor physical health predict decreased odds of improvements but longer hospital stay, individual therapy and family/couples therapy predict increased odds of improvements. Conclusions: The interRAI Social Relationships CAP provides a valuable tool to address social issues in patient care, assist clinical staff in care planning and provide mental health authorities information for policy making.

INTRODUCTION: Canada’s Aboriginal population is growing at a faster rate than the rest of Canada. While Aboriginal health has improved in the last few decades, life expectancy of First Nations, Inuit and Métis continues to be lower compared to the rest of the Canadian population. Furthermore, current Aboriginal health research tends to focus on those living onreserves while more than half of the Aboriginal population currently resides in urban areas. Despite the importance of neighbourhood factors for understanding health in urban areas, the importance of neighbourhood characteristic for urban Aboriginal health has yet to be examined. OBJECTIVE: The objective of the research was, to determine both individual-level predictors and neighbourhood-level predictors of self-rated health and diagnosis of chronic conditions, amongst Aboriginal populations living in the City of Toronto; and to determine whether and how neighbourhood-level predictors influence individual-level predictors of self-rated health and diagnosis of a chronic conditions in Toronto neighbourhoods with Aboriginal populations living in them. METHODS: This study was a secondary analysis of two samples from the 2006 Aboriginal people Survey, consisting of 1080 and 500 Aboriginal individuals in the Toronto Census Metropolitan Area. A series of logistic regressions models were created to identify individual and neighbourhood predictors of “poor” self-rated health and having one or more diagnosed chronic condition(s). RESULTS: A best fitting model was derived from the individual-level variables to include the demographic variables age, gender and Aboriginal status; and the socio-economic variables average household income, education level and employment status. While neighbourhood-level variables had no significant influence in predicting either health outcome, there was some evidence to suggest influence over individual-level predictors. To further examine this relation, neighbourhoods were stratified based on income inequality, average household income and availability of Aboriginal specific services. This analysis yielded some different effects of individual-level variables for different neighbourhood types, suggesting that some effects of neighbourhood characteristics may interact with individual characteristics to influence health. CONCLUSION: While contextual factors have some effect on self-rated health, individual factors serve as stronger predictors of individual health. However, more neighbourhood level studies should be considered in order to better understand the growing urban Aboriginal population and potential ecological effects on health.

Background: Quality of care and patient safety have been demonstrated to be at increased risk during care transitions; making older adults with complex medical issues especially vulnerable due to the multifaceted care they require (Coleman, 2003; Cook et al., 2000; Forster et al., 2003; Murtaugh & Litke, 2002; Picker Institute, 1999; van Walraven et al., 2004). While a strong focus on patient issues during care transitions exists in current literature, there is a dearth of knowledge surrounding the role of informal caregivers in this process. As the senior population continues to grow in Canada, it is inevitable that the health system will be increasingly reliant upon informal caregivers to meet the demanding and complex care needs of older adults. This research explored informal caregiver experiences following an older patient’s medical crisis in order to foster a deeper understanding of caregiver needs during transitional care. This work will support efforts to develop viable interventions within formal care settings to better support and prepare individuals for informal care responsibilities (Canadian Caregiver Coalition, 2008; National Centre for Social and Economic Modelling, 2004). Methods: A qualitative, post-positivist grounded theory study was employed to acquire an understanding of the role and needs of informal caregivers during transitional care. Semi-structured interviews were conducted with six community and resource case managers, and informal caregivers of eight hip fracture and two stroke caregivers. Two additional interviews were conducted with hip replacement caregivers. Questions explored individual experiences interacting with and/or providing informal care, and honed in on observed and experienced challenges, support received, and recommendations for future efforts to support care. NVivo8 software facilitated qualitative data analysis through hierarchical coding (Glaser & Strauss, 1967). Results: Six properties of caregiver needs arose from the data, each consisting of several important ideas fostering its understanding. The core concept threading across all properties was building capacity to care. Combined, thematic interpretations were integrated into a comprehensive theory of caregiver needs to support a successful care transition from hospital to home, consisting of three layers: 1) Timeline of caregiver needs; 2) Instrumental needs; and 3) Emotional needs. A member-checking process of the theory consisting of both a focus group and individual interviews indicated high face and content validity, and highlighted priority areas for future interventions. Discussion: The developed substantive theory is a valuable tool for which to understand the instrumental and emotional needs of hip fracture and stroke caregivers along a timeline of transitional care between hospital and home. Focus group and individual feedback indicate strong endorsement for theory adoption as a guiding framework for an intervention strategy to support informal caregivers within formal care settings and throughout the transition home. Results suggest the potential to broaden the conceptualization of the substantive theory to a formal explanation of transitional care needs for other medical crises across numerous types of transitions between formal hospital settings and the community.