People with disabilities are a ‘disadvantaged’ group, not only due to their impairment, but also due to the formal and informal institutional inertia that they contend with in Western Societies. This disadvantage has been recognised and acknowledged in the social model of disability. This model understands that disability is a social construction placed on people with impairments. The Health Impact Assessment (HIA) is a tool which identifies inequities in policy, and is potentially a useful tool to aid the response of policy makers to the needs of people with disabilities. Arguably, the New Zealand HIA guidelines reflect the underlying principles of the social model of disability. Using a mixed methods research strategy, this thesis sets out to understand in a global context using a top-down quantitative analysis, to what extent the New Zealand HIA guidelines which acknowledge the social model of disability are translated into practice. It then subsequently investigates from a bottom-up qualitative perspective, what factors influence this relationship. It is argued in this thesis that there are barriers to translating the rhetoric about people with disabilities found in the HIA guidelines into practice. Three sets of inter-related barriers identified include attitudinal barriers to people with disabilities, generic HIA barriers, and barriers related to the feminist interpretation of the construction of disability. In this thesis, the research findings conclude that it is difficult to operationalise the disability awareness present in the HIA guidelines due to barriers which are related to the ‘othering’ of people with disabilities. This is discussed in relation to feminist analyses of the construction of people with disabilities, and it needs to be addressed by wider societal reforms. The thesis makes the recommendation that a national awareness-raising campaign about people with disabilities be undertaken in New Zealand in an attempt to rectify this situation.

A significant number of studies have identified clear links between chronic health issues, including asthma, obesity, and diabetes, and the design of the built environment. As shapers of the built environment, urban planners can play a central role in ameliorating these current health epidemics. Indeed, during the early history of the planning profession the fields of planning and public health were closely connected, and improved public health was seen as a key mission of the planning profession. Today, however, public health issues are not a central concern in planning, neither as a normative value of the field nor as a core element of daily planning practice. Instead, health is a value-based cause taken up by concerned practicing planners, who face numerous challenges in incorporating a health focus into their daily work. This research argues that there is a need for a focus on health outcomes within the planning field, based on the initial mission of planning discipline and current research showing the impact of the built environment on public health. Through a nationwide survey of planners and interviews with planning and health professionals in five cities, findings show that collaboration between health and planning departments is key to instilling a health focus within the practice of planning. Planners who seek to promote a health focus in planning are pursuing this value-based imperative through a variety of ad-hoc strategies, since existing regulations and professional guidelines are inadequate in terms of facilitating collaboration between public health and planning in order to systematically address health issues related to land use and the built environment. Research also shows that collaboration between planning and public health departments, when this does occur, is often initiated and driven by processionals in the public health discipline. Though planners and health professionals who have sought to collaborate have faced institutional, political, and awareness challenges, there are opportunities that can be leveraged to overcome these obstacles. These opportunities include the professional expertise available in the public health field, the availability of health data in order to reframe planning issues, and the potential of individual champions of health to drive health considerations in planning projects, and promote health as a normative value. Ultimately, individual planners who see the creation of healthier communities as central to their professional practice pursue collaborative strategies with health professionals despite the challenges they face. From the perspective of collaborative planning theory and theories of institutional change, this individual engagement and initiative by planners through their everyday practice has the potential to effect institutional change by forging a focus on health as a normative value central to the planning discipline. / text

BACKGROUND: In the past decade urbanization has increased, with over half the world’s population and 83% of the total United States population, residing in urban areas as of 2021. Urbanization has the potential to decrease connectivity between nature and humans, impacting health and exacerbating urban heat islands. Previous research has found that the natural environment (i.e., trees and bluespace) provide vital ecosystem services through both direct and indirect pathways that positively impact health. Objective: The objective of my dissertation was to assess the current state of the natural environment in urban areas and gain a better understanding of the relationship between exposure to nature, health, and heat. METHODS: Research aims were addressed by focusing on publicly available data and a range of metrics used in previous literature to characterize exposure to greenness and natural landscapes and their associations with health and land surface temperature. In Chapter 2, I report on a nationwide quantitative health impact assessment to estimate the reduction in all-cause mortality in populations aged 65 and older in the largest metropolitan areas (n=35) in the United States associated with an increase in greenness in selected years across twenty years (2000, 2010, and 2019). Census tract mean seasonal greenness exposure was estimated by using the Normalized Difference Vegetation Index (NDVI) from Landsat 30 m 16-day satellite imagery from April to September. All-cause mortality estimates were downscaled from county to tract-level from the CDC WONDER Portal. Mortality reduction was estimated using a recently published exposure-response function. Chapter 3 focuses on urban census tracts in Massachusetts (n=525), in order to assess the cumulative exposure of the urban natural environment. Thirty candidate, validated measures of the natural landscape space were derived from data published between 2016 and 2019. Principal component analysis was used to reduce the number of candidate items and confirmatory factor analysis was used to test the underlying hypothesized latent structure of three sub-domains: green space, parks and recreation and blue space. Items hypothesized to measure each latent structure were summed using equal weights and each sub-domain was rescaled from 0–100. The tract-level cumulative exposure index was the sum of the three sub-domains. Lastly, in Chapter 4 using generalized linear models, I investigated the relationship between urban heat and nature using the natural landscape index created in Chapter 3 and mean five-year Land Surface Temperature (LST). The City of Boston was then used as a case-study to identify vulnerable tracts with low nature and high heat to inform planning for climate adaptation strategies and public health planning. RESULTS: In Chapter 2, overall greenness in the largest metropolitan areas in the US increased from 3% between 2000 and 2010 to 11% between 2010 and 2019. Approximately 34,000 to 38,000 all-cause mortality deaths could have been prevented with an increase in 0.1 NDVI units from 2000 to 2019. In developing the cumulative natural landscape index, in Chapter 3, we found that greenness measures (NDVI, tree canopy, percent impervious, etc.) explained the most variance among all of the items hypothesized to measure the cumulative natural landscape index. The three sub-domains explained 69% of the total variance, with greenness accounting more than half the total variance explained. Lastly, in Chapter 4, we report that with an interquartile shift in overall nature, LST decreased by 0.8°C. More specifically, higher overall greenness, higher percent tree canopy, and higher percent impervious surfaces resulted in the largest change in LST. With an increase in greenness and tree canopy we found a decrease in LST by over 1°C. In contrast, an increase in impervious surfaces resulted in an increase in LST by 1.31°C. Within the City of Boston, we found that 9% of the total population resides in tracts that were within the highest quartile of LST and lowest quartile of overall nature. CONCLUSION: Overall, this work finds that large urban areas in the United States saw a small increase in overall greenness across the past two decades. With a trend of increasing greenness there is also the potential to reduce all-cause mortality in those 65 years and older. Going beyond overall greenness, we created a cumulative natural landscape index to capture simultaneous exposures to the urban natural environment. Greenness measures such as tree canopy, NDVI, open space, and impervious surfaces explained the most variance in the cumulative nature index and was the most associated with LST as compared to parks and recreation and bluespace. We assessed the impacts of the natural landscape on temperature, and found that an increase in nature resulted in a significant decrease in LST with greenness measures having the largest impact. Results from these studies can be used to support climate action plans and greening initiatives to show the co-benefits of increased exposure to the natural environment and help identify areas that are lacking in these exposures to better implement initiatives.

Particulate matter (PM) is one of the most studied and problematic pollutants due to its toxicity and relati­vely high concentrations. This thesis aims to clarify the main sources and exposures of PM in Tallinn and Tartu, study the associations with health effects, and estimate the extent of those effects with health impact assessment (HIA). It appeared that the main sources of particulate air pollution in Tallinn (the capital of Estonia) and Tartu (the second largest city of Estonia) are local heating and traffic, inclu­ding road dust. In addition to local emissions, particulate levels are affected by transboundary pollution. If the transboundary air masses originated from the Eastern European areas, the concentration as well as the oxidative capacity of fine particles was significantly higher in urban background air in Tartu compared to air masses coming from Scandinavian areas (Paper I). During the last 15 years, traffic increase has been very fast in Tartu. However, due to the improvement in vehicle technology during this period, there has been only a slight increase in concentration of exhaust particles (Paper II). Nevertheless, a greater increase in road dust emissions was detected. A statistically significant relationship between long-term exposure to those traffic induced par­tic­les and cardiac disease in the RHINE (Respiratory Health in Northern Europe) Tartu cohort was shown (Paper III). However, no significant associations with respira­tory health were found. The HIA in Tallinn demonstrated 296 (95% CI = 76–528) premature deaths annually, because of PM (Paper IV). The average decrease in life expectancy was predicted to be 0.64 (95% CI 0.17–1.10) years. However, among risk groups it can be higher. In addi­tion, several cardiovascular hospitalizations are related. The costs to society be­cause of health effects reach up to €150 million annually (95% CI = 40–260) from pre­mature deaths and hospitali­zation constitute an additional €0.3 million (95% CI = 0.2–0.4). The special HIA scenario, when more pollution fuel peat will be used in boiler houses was analysed as well (Paper V). It indicated that peat bur­ning would result in up to 55.5 YLL per year within the population of Tartu. However, the health effects of pollution from current traffic, local heating, and industry are at least 28 times bigger. In conclusion, exposure to PM cause considerable health effects in the form of cardio­pulmo­nary diseases in main Estonian cities.

There is an increasing number of international migrants worldwide and in Canada. The majority of migrants arrive with a health status higher than the average of their host country. This advantage is often lost within ten years of migration due to various reasons, most notably through the social determinants of health. These determinants are the conditions in which individuals live and work and the most relevant to migrant health include racialization, education, employment, housing, social capital, and gender. Health impact assessment (HIA) is a process with the capacity to address changes in health due to the social determinants of health by assessing the intended and unintended impacts on health that a policy, program, or project might have and recommend ways to promote positive and mitigate negative impacts. For this reason, HIA has the potential to address the observed decrease in health experienced by migrants. Various frameworks have been developed to guide the undertaking of HIA including frameworks explicitly aiming at addressing health inequities by considering particular socially disadvantaged population groups. One such example is the Health Equity Impact Assessment (HEIA) tool developed by the Ontario Ministry of Health and Long-Term Care. Although there have been a few studies addressing the inclusion of inequities in HIA in general, there has been no previous assessment of the inclusion of migrants in HIA. This doctoral thesis sought to assess the degree and way in which migrants are included in HIAs globally and across various types of HIAs and contexts. It also sought to assess the degree to which migrants were considered in local initiatives through an examination of the implementation of the Ontario HEIA tool in public health units. A scoping review of the international literature including 117 HIAs and two HIA evaluations found that only 14% of hand-searched HIAs mentioned migrants, 5% analysed migrants and only 2% included them in their recommendations. Although migrant groups were sometimes included in the process, this was seldom the case for citizens. The main reported barriers to considering migrants were a lack of available data and the significant additional resources needed. In order to undertake an evaluation throughout the province, it was first necessary to assess the way in which the Ontario HEIA had been implemented and used by public health units across the province. The scan found that nearly half of public health units had used the HEIA tool either in its original form or modified to the needs of the unit. The use of the tool was found to be influenced by the following factors: the available inputs or resources, the nature of the HIA tool, the actors and stakeholders involved, the decision-making processes within the unit or team involved, the context of the social, economic, and political environments, the nature of the project, program, or policy being assessed, and lastly, the various outputs of completing the HEIA process. Lastly, a Process and Impact evaluation assessed the way in which PHUs with a high proportion of migrants considered these migrants in their HEIAs. This study found that although migrants had been included in HEIAs, this tended to be done when the impact on migrants was anticipated. Additionally, there remains an incoherent terminology accompanied by a confounding of the concepts of migration, racialization, and ethnicity, which are reflected in the type of recommendations developed. These recommendations often focused on translation of documents into various languages and the acquiring of greater information through community partnerships. The process and capacity to include migrants in HEIAs were influenced by the availability of resources and evidence, the prioritisation of recommendations relating to migrants, and the overall impressions the staff had on the HEIA process. Nonetheless, the HEIA process was beneficial in that it strengthened relationships with migrant community organisations. This thesis work also resulted in the development of a HIA-specific theoretical framework based on the literature and empirical findings of this work. This framework is conducive to adopting a tactical approach to HIA by considering the various contextual factors influencing the completion of an HIA and implementation of its recommendations. In conclusion, although migrants are understood to be an important group often facing circumstances of disadvantage, they are only sometimes considered in HIAs. Several procedural and contextual barriers are encountered which influence their consideration. Significant guidance is still required to facilitate their adequate consideration and ensure the development of optimal recommendations. HIA frameworks should explicitly mention migrants as a potentially disadvantaged group and guidance documents could be developed to address the current gaps in understanding migrant issues.

Das Ziel dieser Arbeit war die Bestimmung der kleinsten relevanten Veränderung des wahrgenommenen Mundgesundheitszustandes, der Minimal Important Difference (MID), des Oral Health Impact Profile (OHIP). Die MID sollte für die deutsche Version des OHIP mit 49 Fragen (OHIP-G49), die deutsche Kurzversion mit 14 Fragen (OHIP-G14) sowie für die einzelnen Dimensionen der deutschen und englischen Version des OHIP bestimmt werden. Es handelt sich um eine klinische Fallserie mit 224 konsekutiv rekrutierten, prothe-tischen Patienten. Die mundgesundheitsbezogene Lebensqualität wurde mittels des OHIP- G49 an zwei Terminen vor der Behandlung (Basisuntersuchungen) sowie vier und sechs Wochen nach Behandlungsende (Nachkontrolluntersuchun-gen) bestimmt. Zu den Nachkontrolluntersuchungen schätzten die Patienten zu-sätzlich die Veränderung ihres Mundgesundheitszustandes gegenüber dem Zeit-punkt vor der Therapie anhand einer globalen Frage ein. Anhand der Ergebnisse der Basis- und Nachkontrolluntersuchungen wurde der Median der Differenzen der OHIP-Summenwerte errechnet. Dieser Wert entspricht der MID. Für die deutsche Version des OHIP mit 49 Fragen wurde ein Wert von 6,0 OHIP-Punkten ermittelt. Der Wert für den kurzen Fragebogen OHIP-G14 betrug 2,0 OHIP-Punkte. Für die Dimensionen der deutschen und englischen Sprachversion des OHIP konnten nur teilweise Ergebnisse gefunden werden. Das Studienergebnis lässt den Schluss zu, dass für beide untersuchten Versionen des OHIP ein klar definierter, minimal relevanter Unterschied (MID) der Summen-werte existiert. Die MID unterstützt die Interpretation der klinischen Bedeutung von Veränderungen des vom Patienten wahrgenommenen Mundgesundheitszustan-des. Sie stellt eine wichtige Größe zur Bewertung prothetischer Therapieeffekte dar.

Das Ziel dieser Arbeit war die Bestimmung der kleinsten relevanten Veränderung des wahrgenommenen Mundgesundheitszustandes, der Minimal Important Difference (MID), des Oral Health Impact Profile (OHIP). Die MID sollte für die deutsche Version des OHIP mit 49 Fragen (OHIP-G49), die deutsche Kurzversion mit 14 Fragen (OHIP-G14) sowie für die einzelnen Dimensionen der deutschen und englischen Version des OHIP bestimmt werden. Es handelt sich um eine klinische Fallserie mit 224 konsekutiv rekrutierten, prothe-tischen Patienten. Die mundgesundheitsbezogene Lebensqualität wurde mittels des OHIP- G49 an zwei Terminen vor der Behandlung (Basisuntersuchungen) sowie vier und sechs Wochen nach Behandlungsende (Nachkontrolluntersuchun-gen) bestimmt. Zu den Nachkontrolluntersuchungen schätzten die Patienten zu-sätzlich die Veränderung ihres Mundgesundheitszustandes gegenüber dem Zeit-punkt vor der Therapie anhand einer globalen Frage ein. Anhand der Ergebnisse der Basis- und Nachkontrolluntersuchungen wurde der Median der Differenzen der OHIP-Summenwerte errechnet. Dieser Wert entspricht der MID. Für die deutsche Version des OHIP mit 49 Fragen wurde ein Wert von 6,0 OHIP-Punkten ermittelt. Der Wert für den kurzen Fragebogen OHIP-G14 betrug 2,0 OHIP-Punkte. Für die Dimensionen der deutschen und englischen Sprachversion des OHIP konnten nur teilweise Ergebnisse gefunden werden. Das Studienergebnis lässt den Schluss zu, dass für beide untersuchten Versionen des OHIP ein klar definierter, minimal relevanter Unterschied (MID) der Summen-werte existiert. Die MID unterstützt die Interpretation der klinischen Bedeutung von Veränderungen des vom Patienten wahrgenommenen Mundgesundheitszustan-des. Sie stellt eine wichtige Größe zur Bewertung prothetischer Therapieeffekte dar.

The use of pharmaceutical products has steadily increased in the United States from 2 billion prescriptions in 1999 to 3.9 billion in 2009. Half of patients do not comply with the recommended prescription regimen and dispose of unused drugs in the environment. The U.S. Environmental Protection Agency and many researchers have highlighted the human-health risks associated with improperly disposing of pharmaceutical products. This quantitative cross-sectional study examined the potential correlations between people's actual disposal practices and their knowledge of the impact of disposal practices on the environment and human health, and availability of disposal options. The conceptual framework selected for this study comprised 2 models: the health belief model and the theory of planned behavior. Respondents to an online survey were 485 residents of the northeast United States, polled from the general population. Descriptive statistics and logistic regression were used to model responses from the dependent variable actual disposal practice (ADP) across the independent variables, and analysis of variance explored whether ADP differed across demographic variables. Statistically significant associations emerged among individuals' knowledge of environment and human-health impact, recommended disposal practices, disposal options, and that person's likelihood to practice recommended disposal. Demographic variables did not impact disposal behavior. To promote positive social change, it is recommended that policymakers plan and implement the expansion of convenient drug disposal options, as well as information campaigns on proper disposal practices. In parallel, health care professionals should stress to their patients the importance of complying with prescribed regimens, thus minimizing the amount of unused or expired medications.

Diss. (sammanfattning) Umeå : Umeå universitet, 2009. / Härtill 5 uppsatser. Även tryckt utgåva.

The aim of this study was to identify difficulties experienced by caregivers of children orphaned by HIV/AIDS. The aim was achieved through the following objectives: investigate the family background of caregivers of AIDS orphans; investigate the general emotional impact of caring for AIDS orphans on caregivers; investigate the health impact of caring for AIDS orphans on caregivers; investigate the extent of financial impact of caring for AIDS orphans on caregivers; investigate the impact of caring for AIDS orphans on the social life of caregivers; to make recommendations so as to assist in helping caregivers. A literature review and the qualitative empirical research method were used to achieve the aim and thus, the objectives stated above. The literature review revealed the following difficulties experienced by caregivers of AIDS orphans: lack of knowledge regarding the formal adoption of orphans; lengthy process administered by an increasingly overstretched system; bad behaviour by orphans; stress resulting to poor physical and mental health, strained personal relationships and lowering of standards of care; poverty; "role strain" and "identity"; interpersonal and family conflicts; isolation and fear for the future; excessive workload of having to care for children; and stigma and discrimination relating to HIV/AIDS. However, this study highlighted the following difficulties: poverty; stress and depression; family fights; adoption; bad influence on orphans by neighbours; education; lack of training; lack of social services support; lack of community support structures; and lack of prior planning by orphans' parents. The conclusions drawn from this study are that there were similar problems revealed in this study to those identified in the literature. For example, both literature and this study revealed poverty, stress and interpersonal and family conflicts as major problems experienced by caregivers. Grandparents and other family members who were caregivers in this study did not see "role strain" and "identity" as major stumbling blocks. Stigma and isolation were also some of the problems not directly experienced by most caregivers. However, it was evident that lack of involvement of some of these caregivers with the community, has led to their not experiencing stigmatisation and isolation. The following recommendations were made: caregivers should be given adequate training on how to use the grants given to orphans; researchers should use their research findings to influence government policy regarding termination of grants for orphans, that is, as long as orphans are still attending school or university, grants should not be terminated; universities and government should set aside special bursaries or study loans for orphans at universities, and these loans must only be paid when the orphans are in the position to do so; government should make extra funds available to give to caregivers as incentives; Social Welfare Department should be strengthen so that free counselling could be given to caregivers whenever is necessary; School-Based Support Teams (SBST) committees in schools should be capacitated and empowered; capacitate and empower non -governmental organisations (NGOs); and there should be a strong interaction between schools, NGOs, social workers, nurses and police. Limitations of the current study were also identified. This study could not show with absolute certainty whether the problems identified are related to orphanhood in general, rather than orphanhood by HIV/AIDS. Thus it was deemed necessary in future to have a comparison group of caregivers of orphans due to reasons other than HIV/AIDS. Other limitations included reliance on one population race. The study cannot ascertain whether these findings can be applicable to caregivers from other race groups such as white or coloured races. South Africa is a multicultural society with different norms and values. Thus, the way we react to certain stimuli might be influenced to a large extent by our customs and values. Further limitations included reliance on one specific type of caregiving. The study did not explore other type such as orphanages, but concentrated on what is regarded as the traditional safety net. / Thesis (M.Ed.)--North-West University, Vaal Triangle Campus, 2009.