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Introduction: Despite Colombia having adopted a health system based on an insurance market, Bogota in 2004, as part of a left-wing government (elected for first time in the city), decided to implement a Primary Health Care (PHC) strategy to improve quality of life, level of population health and reduce health inequities. The PHC strategy has been implemented through the HomeHealth program by three consecutive governments over the last eight years in the context of continuous political tension stemming from differences between national and district health policies. This thesis is an attempt to provide a better understanding of the overall experience of implementing a PHC strategy in the context of a market-oriented health care system. The research aimed to evaluate results of the PHC strategy through the intervention of the Home Health program and to identify factors that have enabled or limited the on-going PHC implementation process in Bogota. Methods: This study used a combination of quantitative and qualitative methods. A descriptive analysis was performed to assess direct results of the PHC strategy in terms of progress in the Home Health program coverage and increases in health personnel ratios reaching out to poor and vulnerable groups in Bogota. A cross sectional analysis was carried out to evaluate qualities of the delivery of PHC services through the attainment of PHC essential dimensions in the network of first-level public health care facilities. An ecological analysis was performed to estimate the contribution of the PHC strategy, through the Home Health program, to improve child health outcomes and to reduce health inequalities. A qualitative multiple case study was conducted to identify contextual factors that have enabled or limited the on-going PHC implementation process in Bogota. Results: The descriptive analysis showed a notable initial increase and rapid expansion in the development of the PHC strategy between 2004 and 2007, followed by a period of slower growth and stagnation between 2007 and 2010. The cross-sectional analysis suggested that the Home Health program could be helping to improve the performance of first-level public health care facilities. Ratings assigned to PHC dimensions by different participants pointed out the need to strengthen family focus, community orientation, financial resources distribution, and accessibility. The ecological analysis showed that localities with high PHC coverage had a lower risk of under-five mortality, infant mortality and acute malnutrition as well as a higher probability of being vaccinated than low PHC coverage localities. The belonging to a high-coverage locality was significantly associated with risk reductions of under-five mortality (13.8%) and infant mortality by pneumonia (37.5%) as well as increases in the probability of being vaccinated for DPT (4.9%). Concentration curves and concentration indices indicated inequality reductions in all child indicators betwen 2003 and 2007. In 2007 (period after implementation), the PHC strategy was associated with a reduction in the effect of the inequality that affected disadvantaged localities in under-five mortality (24%), infant mortality rate (19%), acute malnutrition (7%) and DPT vaccination coverage (20%). The main facilitators of the results achieved so far by the PHC strategy were all related to the commitment and good will of actors at different levels. Longterm political commitment, support by local mayors and hospital managers, organized communities historically active in the process of social participation, as well as extramural work carried out by community health workers and health care teams were highly valued. Barriers to the implementation included the structure of the national health system itself, lack of a stable funding source, unsatisfactory working conditions, lack of competencies among health workers regarding family focus and community orientation, and limited involvement of institutions outside the health sector in generating intersectoral responses and promoting community participation. Conclusion: Despite adverse contextual conditions and limitations imposed by the Colombian health system itself, Bogota’s initiative of a PHC strategy has helped to improve the performance of first-level public health care facilities in the essential dimensions of PHC and has also contributed to improvement of child health outcomes and reduction of health inequalities associated with socioeconomic and living conditions. Significant efforts are required to overcome the market approach of the national health system. Structural changes to social policies at the national and district level are needed if the PHC strategy is expected to achieve its full potential. Specific interventions must be designed to have well-trained and motivated human resources, as well as to establish available and stable financial resources for the PHC strategy.

This case study explores participation in Aboriginal health planning as perceived by members of the Aboriginal Health and Wellness Advisory Committee of the Interior Health Authority, a regional health authority in British Columbia. By prominently featuring the voices of Committee members as recorded in personal interviews, this research identifies issues and tensions in participatory Aboriginal health planning. Document review and personal observations enrich and support the analysis. The research findings convey that, although Committee members express a range of perceptions and beliefs about Aboriginal health planning, the Committee provides a foundation for meaningful participation. Strengthening accountability relationships and employing Aboriginal population health approaches are suggested means by which meaningful participation in Aboriginal health planning can be actualized. This study emphasizes the importance of genuine relationship building between the health authority and Aboriginal communities for achieving gains in Aboriginal health.

Background: Obesity and physical inactivity rates have reached epidemic levels in Canada, but differ based on whether they are self-reported or directly measured. Canadian research examining the combined and independent effects of social and built environments on adult physical activity (PA) and body mass index (BMI) is limited. Furthermore there is a lack of Canadian studies to assess these relationships using directly measured PA and BMI. Objectives: The objectives of this thesis were to systematically compare self-reported and directly measured PA and to examine associations between neighbourhood built and social environmental factors with both self-reported and directly measured PA and overweight/obesity in adults living in Ottawa, Canada. Methods: A systematic review was conducted to identify observational and experimental studies of adult populations that used both self-report and direct measures of PA and to assess the agreement between the measures. Associations between objectively measured neighbourhood-level built recreation and social environmental factors and self-reported individual-level data including total and leisure-time PA (LTPA) and overweight/obesity were examined in the adult population of Ottawa, Canada using multilevel models. Neighbourhood differences in directly measured BMI and PA (using accelerometry) were evaluated in a convenience sample of adults from four City of Ottawa neighbourhoods with contrasting socioeconomic (SES) and built recreation (REC) environments. Results: Results from the review generally indicate a poor level of agreement between self-report and direct measures of PA, with trends differing based on the measures of PA, the level of PA examined and the sex of the participants. Results of the multilevel analyses identified that very few of the built and social environmental variables were ii significantly associated with PA or overweight/obesity. Greater park area was significantly associated with total PA in females. Greater green space was shown to be associated with lower odds of male LTPA. Factors from the social environment were generally more strongly related to male outcomes. Further to the recreation and social environment, factors in the food landscape were significantly associated with male and female PA and overweight/obesity. Results of the directly measured PA and BMI investigation showed significant neighbourhood-group effects for light intensity PA and sedentary time. Post-hoc tests identified that the low REC/high SES neighbourhood had significantly more minutes of light PA than the low REC/low SES. BMI differed between the four neighbourhoods, but the differences were not significant after controlling for age, sex and household income. Conclusions: Results of this dissertation show that the quantity of PA can differ based on its method of measurement (i.e. between self-report and direct methods) with implications for the interpretation of study findings. It also identifies that PA and BMI can differ by neighbourhood and recognizes that the relationships between neighbourhood environments and PA and body composition are complex, may be differ between males and females, and may not always follow intuitive relationships. Furthermore it suggests that other factors in the environment not examined in this dissertation may influence adult PA and BMI and that longitudinal and intervention studies are needed.

Background and Rationale: There is a well-documented practice gap in the rates at which evidence-based smoking cessation treatments are delivered to patients in primary care settings. Multi-component intervention that combine practice, provider, and patient-level supports have been shown to increase the rates at which primary care providers deliver smoking cessation treatments to patients and increase rates of smoking abstinence amongst patients. The incremental value of adjunct telephone-based smoking cessation counselling when delivered as part of a multi-component intervention has not been examined. Aim: The primary objective of this study was to determine whether adjunct telephone-based smoking cessation follow-up counselling (FC), when delivered as part of a multi-component intervention program within primary care clinics is associated with increases in (a) the delivery of evidence-based smoking cessation treatments, (b) patient quit attempts, and (c) patient smoking abstinence when compared to the provision of practice and provider supports (PS) alone. The secondary objective of this study was to determine whether the introduction of a multi-component smoking cessation program is associated with increased delivery of evidence-based smoking cessation treatments by primary care providers and patient smoking outcomes, compared to pre-intervention rates. The study also sought to examine the association between patient, provider, clinic and implementation factors, and study outcomes. Methods: A two-group, pre-post cluster randomized controlled trial was conducted. Eligible clinics were randomly assigned to the PS group or FC group. Both groups were supported with implementing a multi-component intervention program that involved outreach facilitation visits, provider training, real time provider prompts and patient tools, and performance feedback. Clinics assigned to the FC group were also able to refer patients who smoke to a telephone-based follow-up support program for supplemental counselling support. An exit survey was completed with a cross-sectional sample of patients who smoked daily at each study clinic before and after the introduction of the intervention program, and all patients were contacted 4 months later to complete a brief telephone-based interview. Outcome measures included the rate at which evidence-based smoking cessation treatments (5As: ask, advise, assess, assist, arrange) were delivered to patients, the number of patients who made a quit attempt, and patient smoking abstinence at the 4-month follow-up. All data was analyzed using multi-level hierarchical modelling. Results: Seven family medicine clinics and 115 providers were enrolled in the study. A total of 12,585 patients were screened, and 835 eligible patients (mean age 45.8 SD± 14.6, 41% male) who smoke participated in the study. Contrary to the study hypothesis, a higher and statistically significant 7-day point prevalence abstinence (OR 6.8, 95% CI 2.1-21.7; p=<0.01) and continuous abstinence (OR 13.7, 95% CI 2.1-128.3; p=<0.05) rate was observed in the PS group compared to the FC group at the post-assessment after controlling for differences in smoking cessation rates between intervention groups during the baseline period. The introduction of the multi-component intervention program was associated with higher rates of provider 5As delivery and patient quit attempts compared to baseline, with no differences between groups documented. The odds ratios (OR) and 95% confidence intervals (CI) for 5As delivery between the pre- and post-intervention assessments for both intervention groups combined were: “ask” (OR 1.5; 95% CI 1.1, 2.0); “advise” (OR 2.0; 95% CI 1.5, 2.7); “assess” (OR 2.1; 95% CI 1.6, 2.9); “assist” with cessation (OR 2.30; 95% CI 1.70, 3.12); “arrange” (OR 1.9; 95% CI 1.2, 3.0); and “patient quit attempts” (OR 1.4; 95% CI 1.04, 1.94). Differences in 7-day point prevalence abstinence were not statistically significant between the pre- and post-intervention assessments (OR 1.5; 95% CI 0.94, 2.5). The study documented intra-provider variability in the rates at which evidence-based smoking cessation treatments are delivered to patients. Patient characteristics (readiness to quit, time to first cigarette, previous quit attempt in the last year), and the purpose of the clinic visit being for an annual health exam were associated with higher rates of 5As delivery. Conclusion: This is the first study to evaluate a multi-component smoking cessation intervention within the primary health care setting in Canada. The study findings demonstrate that the introduction of a multi-component intervention program in primary care settings was associated with significant improvements in the rates at which providers deliver evidence-based smoking cessation treatments, and increase patient quit attempts. The added value of adjunct telephone counselling was not evident at the 4-month follow-up. The conclusions that can be drawn from the present study are limited by the study design and sample size. A larger trial is required to conclusively determine the impact of the program on long-term smoking abstinence and examine the importance of clinic-level variables in explaining observed differences between study clinics.

Uganda has a predominantly young population, and there is a need for targeted HIV/AIDS prevention programming. Peer education is a health intervention style that has been used with appreciable success in adolescent groups, but some issues exist. We hypothesize that more can be done in the program planning stages to increase the chances of sustained success, and have completed two different types of cross-sectional analyses to investigate this aspect. We used Social Network Analysis to examine the social structure of two secondary schools in Fort Portal, Uganda. We identified existing modes of influence and natural channels of communication, and used these to create a feasible model of peer educator selection. We also studied present levels of communication about sexual and reproductive health within youth relationships, and found that youth are willing to talk to their friends, but high levels of communication do not generally occur. This provides an important point of entry for health promotion programs. / Population Health

Amphibian populations are declining on a global scale and although disease outbreaks are a commonly accepted hypothesis they are not the only one. My aims for my thesis were to study the home range of Leiopelma hamiltoni, to determine whether a photographic database could be used to individual identified them and monitor the health status of the population. Habitat loss is a possible cause. For this reason monitoring an animals' home range is a possible method to detect early impacts the population is facing. By tracking 12 L. hamiltoni within a 12 m x 6 m grid on Maud Island, it was shown that the home range size can vary from 0.5 m2 to 25 m2 based on the minimum convex polygon method. However, to track multiple individuals it is important to be able to distinguish among frogs. The commonly used methods of identification, such as toe clipping, pose potentially detrimental effects. Therefore, non-invasive methods based on natural markings need to be established. Through the use of the dark pigmented patterns found on the skin of L. hamiltoni individuals can be identified on recapture with a mean accuracy of 93%. By developing a database to maintain the photographs used for individual identification, the database can also be used to monitor the status of the population. During 2003 numerous L. hamiltoni were observed with denuded patches predominantly on the facial region. By monitoring five individuals within the captive facility at the University of Canterbury it was discovered that frogs appear to be able to cure themselves. Through researching the home range requirements and developing a photographic database to monitor the population status of L. hamiltoni, it will aid in the management of ensuring the long-term survival of this archaic species of frog.

Available data from the quinquennial Infant Feeding Surveys (IFS) show that breastfeeding rates in Great Britain (GB) rose steadily between 1985 and 2010. However, the rates of breastfeeding continuation and exclusivity remain relatively low, and there is evidence that breastfeeding in public may still be considered unacceptable by many in GB. To date, no study has examined the reasons behind the increase in breastfeeding rates between 1985 and 2010, and the factors which influence women's practice of breastfeeding in public in GB remain under-researched. Therefore, this DPhil research aimed to investigate whether the increase in breastfeeding rates in the first six weeks after childbirth in GB between 1985 and 2010 were driven by changes in the distribution of population characteristics, or changes in the differences in breastfeeding behaviours between subgroups of women. It also aimed to investigate the factors which influenced the practice of breastfeeding in public in GB in 1995 to 2010. Data from the IFS surveys in 1985 to 2010 were analysed to, firstly, describe and summarise the distribution of selected explanatory factors among the childbearing population of GB from 1985 to 2010. This was followed by an estimation of the independent effects of these explanatory factors on breastfeeding initiation, breastfeeding continuation at one week and at six weeks, and breastfeeding in public, in each survey year. There was an assessment of the changes over time in the effects of each factor on breastfeeding initiation, and on breastfeeding continuation at one week and at six weeks. This was followed by an examination of the extent to which changes in the distribution of factors among the childbearing population contributed to the increase in breastfeeding rates in the first six weeks in GB between 1985 and 2010. This DPhil research found no evidence of changes in the effects of factors on breastfeeding in the first six weeks between 1985 and 2010. This suggests that breastfeeding behaviours had not improved over time. At the same time, there were increases in the distribution of those factors which positively influence breastfeeding, suggesting that the increase in breastfeeding rates in the first six weeks between 1985 and 2010 were indeed attributable to population changes rather than improved breastfeeding behaviours. Additionally, breastfeeding in public was seemingly most influenced by women's perceptions of the normality and acceptability of breastfeeding in GB. There is a clear need for more equitable interventions to target the needs and perceptions of those women in GB who remain characteristically less likely to breastfeed.

<b>Background:</b> Perinatal depression is a significant contributor to maternal morbidity and mortality worldwide. Left untreated, perinatal depression has severe and far-reaching consequences for women, their families and wider society. Migrant women, including labour migrants and refugees, may be particularly prone to developing perinatal depression as a result of multiple stressors associated with displacement. Despite the vast majority of global migration flows occurring within low- and middle-income countries, evidence from these regions is severely lacking. This research addresses this imbalance by examining perinatal depression in migrant women living on the Thai-Myanmar border: a resource-poor setting of political tension and socio-economic disadvantage. <b>Aims:</b> This research aims to review the existing evidence around perinatal depression among migrant women from low- and middle-income settings; identify an appropriate tool to detect perinatal depression in migrant women on the Thai-Myanmar border; determine the prevalence of, and risk factors for, perinatal depression in this setting; explore women's experiences of perinatal depression; and develop recommendations for policy and practice. <b>Methods:</b> A sequential-exploratory mixed-methods design was used. The research included the following five study components: a systematic literature review; a validation study to identify a culturally-acceptable and appropriate assessment tool; a prospective cohort study of migrant women on the Thai-Myanmar border followed-up from the first trimester of pregnancy to one month post-partum; in-depth interviews with a subgroup of women with severe perinatal depression; and an informal exploration of stakeholder views. <b>Findings:</b> The systematic review found a wide range in prevalence of perinatal depression among migrant women and confirmed the absence of studies conducted in low-and middle-income destination countries. A total of 568 migrant women on the Thai-Myanmar border participated in the prospective cohort study, of whom 18.5% experienced moderate-severe depression and 39.8% experienced depression of any severity during the perinatal period. Almost a third (29%) of women reported suicidal ideation. Interpersonal violence (OR 4.5), experience of trauma (OR 2.4), a self-reported history of depression (OR 2.3) and perceived insufficiency of social support (OR 2.1) were significantly associated with perinatal depression. Lives of women with severe perinatal depression were characterised by difficult partner relationships, alcohol use among partners and interpersonal violence. A lack of mental health services currently limits the effective management of perinatal depression in this setting. Alongside training of health staff, primary, secondary and tertiary prevention efforts are required to effectively address perinatal depression on the Thai-Myanmar border.