Magister Public Health - MPH / Background: Actions on addressing the social determinants of health are necessary for reducing health inequities and improving health outcomes. These actions can, however, fall outside the scope of the health sector alone and require collaborative actions across sectors. Through the Western Cape Government’s stated commitment to following a whole-of-society approach to increase the wellness of people, this Province has committed to exploring intersectoral collaboration and action for health. This study is therefore aimed at exploring the experiences and perceptions of intersectoral collaboration and action for health amongst mid-level and frMethodology: The study design was qualitative and explorative in nature, using non-probability sampling to deliberately select study participants that were both relevant to the study and represented a diversity of views. Semi-structured interviews were conducted with seven health managers and non-participant observation of one intersectoral meeting was utilised to observe interactions that were relevant to the study. A thematic coding analysis approach was followed to inductively determine themes and analyse the data.ontline health managers working at the primary health care level in two sub-districts within the City of Cape Town, Western Cape Province. Results: Intersectoral collaboration for health at the primary health care level tends to take the form of collaborations between government departments, between the department of health and non-governmental organisations, between the public and private health sectors and between the Department of Health and the communities it serves. These collaborations overwhelmingly focus on expanding health services provision rather than addressing the social determinants of health. Conclusion: The concept of intersectoral collaboration and partnerships at the primary health care level in two sub-districts of the City of Cape Town, Western Cape, is perceived by health managers as being critical in addressing the social determinants of health. In practice, however, intersectoral collaboration and partnerships tend to focus on expanding health service provision and have limited value for addressing social determinants of health.

While previous health research with Aboriginal populations focused almost exclusively on Aboriginal Peoples of First Nations descent living on reserves or in isolated rural communities in Canada, this study focusing on diabetes aimed to engage Aboriginal Peoples of First Nations and Métis descent living in an urban Ontario setting. Type 2 diabetes mellitus is a progressive metabolic disorder that affects Aboriginal Peoples of Métis and First Nations descent disproportionately compared to the rest of the Canadian population. To understand this disparity in diabetes incidence and to address issues with existing diabetes prevention and management strategies, this study: a) explores the perceptions surrounding Type 2 diabetes and its prevention from First Nations and Métis community people and health service providers and policy makers; and b) informs the existing diabetes prevention, management and care strategies in light of these perceived understandings. Primary data was collected through 40 in-depth one-on-one narrative interviews with First Nations and Métis people, health service providers and policy makers. Thematic codes that emerged through the narrative analysis of this data revealed that to fully understand the social determinants of diabetes in an urban First Nations and Métis people’s context required the application of intersectionality theory, since production of First Nations and Métis diabetes is socially determined and deeply intersectional. By combining the concepts of the social determinants of health and intersectional approaches, narrative analysis of the primary data revealed that diversities in socio-economic, cultural, legal and spatial contexts determine First Nations and Métis people’s life choices and have a strong bearing on their health outcomes. First Nations and Métis participants’ narratives revealed that dimensions of marginalization were reflected not only through inadequate material resources, but also through intersections of multiple factors such as colonial legacies, stereotyping, legal statuses, and the pan-Aboriginal nature of government policies and services. First Nations and Métis community members indicated that preventive programming aimed at avoiding or managing diabetes should be grounded in balancing and restoring the positive aspects of physical, mental, spiritual and emotional health and should also balance their diverse needs, lived realities, and social circumstances. The views of health service providers and policy makers captured in this thesis tended to reflect an understanding of diabetes causation grounded in both biomedical and intersecting social determinants of health. At the pragmatic level, however, the solution to this health issue presented by health service providers and policy makers addresses only the measurable individualistic biomedical risk factors of diabetes. Policy makers also discussed the need for developing qualitative indicators of the success of presently implemented health programs. Overall, the results of this study indicated that effective diabetes prevention and management strategies for urban First Nations and Métis people must recognize and address the diversities in their historical, socio-economic, spatial and legal contexts as well as their related entitlement to health services. A comprehensive diabetes prevention strategy should target the social determinants of health that are specific to urban First Nations and Métis people and must build on community strengths.

Book Summary: Designed as a supplemental text for introductory courses in public health practice at the undergraduate and graduate levels, Contemporary Public Health provides historical background that contextualizes the current state of the field and explores the major issues practitioners face today. It addresses essential topics such as the social and ecological determinants of health and their impact on practice, marginalized populations, the role of community-oriented primary care, accreditation, and the organizational landscape of the American public health system. Finally, it examines the opioid epidemic, the impact of pandemics including COVID-19, and international public health and explores the potential of systems based on multilevel partnerships of government, academic, and nonprofit organizations. With fresh historical and methodological analyses conducted by an impressive group of distinguished authors, Contemporary Public Health is an essential resource for practitioners, health advocates, students, legislators, and informed citizens.

With yearly rates ranking clearly above world average in Europe, suicide constitutes a substantial public health problem. Because of that, prevention has become a major concern for German mental health institutions. A requirement for successful prevention strategies is to address all key factors that contribute to suicidality. It is highly relevant in this respect that suicidal behaviour itself exhibits a social gradient: drawing on the relevant literature, low socioeconomic status (SES) and a high extent of social isolation (SI) are related to increased suicide risks (Lorant et al. 2005; Li et al. 2011; Qin et al. 2003; Agerbo et al. 2007). The purpose of this study was therefore to add to these findings and to further investigate associations of SES and SI with suicide in order to define starting points for public health interventions. It was consequently hypothesized that lower individual levels of SES and higher individual levels of SI are correlated with increased suicide rates. SI potentially compromises the perception of social support in stressful live events associated with low SES (Cohen et al. 2006; Kumari et al. 2010). Since such life events correlate with suicidal behavior (Beautrais et al. 1997; Cohen et al. 2019), the effects of low SES were further hypothesized to be aggravated in individuals with high SI levels (SES x SI interaction). In order to test the hypotheses, all 149.033 suicide deaths between 1997 and 2010 (T = 14 years) were extracted from the official German death record as coded by ICD categories E950 - E959 for 1997 and X60 - X84 for the years from 1998 onwards, respectively. Information on SES and SI was gained by merging the dataset with Germany’s main household survey, i.e. the Microcensus. In accordance with the existing literature, established indexes on occupational status (ISEI, Ganzeboom & Treiman 1996) and educational achievements (CASMIN, König et al. 1988) were applied as well as items on income, minor employment, unemployment, the number of received public transfers and the reception of social bene fits due to unemployment (ALG I/II) in order to capture SES. SI was proxied with variables measuring single marital status, living in a one-person-household and relocations throughout the year before the survey was conducted. Due to German data protection regulations that do not permit the analysis of death record data based on individual level information, suicide deaths were examined as aggregated rates at the level of N = 390 administrative districts. In order to deal with two problems associated with this kind of statistical analysis, Prentice and Sheppard’s model for aggregate data (1995) was applied accounting for potential estimation biases due to differences in baseline suicide rates between districts and between time periods. The model specification further corrected for spatial effect correlations. An important limitation to this procedure is that the estimates represent a blend of effects at the individual and district levels. However, an adequate solution is only available through the application of individual level data. The statistical analysis turned out the following results: The positive effect on suicide rates of unemployment and the negative effect of income as two out of seven SES proxies and the positive effect of living in a one-person-household as one out of three SI proxies validate the proposed hypotheses on the relations of SES and SI with suicide rates. Confirming the hypothesis on SI mediating SES effects, the model revealed positive effects on suicide rates of income decreases in single individuals. Likewise, we observed positive effects on district suicide rates for decreasing levels of CASMIN in district population shares who had relocated throughout the past year. In contradiction to the theoretical claims, however, increases in CASMIN scores were found to result in positive effects on suicide rates just as a history of relocation prior to suicide was related to decreasing suicide rates. Furthermore, decreases in income were found to result in negative effects on suicide rates in the district population of persons living in a one-person-household. The results indicating associations of SES and SI with increases in district suicide rates represent appropriate starting points for the definition of suicide prevention strategies. Thus, particularly the unemployed, individuals with low incomes, persons living in one-person-households and relocated individuals with lower educational levels should be targeted by public health interventions. Moreover, the observations of the present study clearly demonstrate the significance of longitudinal individual level data for public health policies. Respective research incorporating such data would permit a better understanding of the causal mechanisms resulting in suicidality and help to further investigate the robustness of the shown results. By this means, prevention strategies could be better adapted to the specfic needs of the individuals under concern. Regarding the findings contradicting the theoretical claims, it needs to be mentioned that associations of low SES and high SI levels with increases in suicide risks can not be ruled out at the individual level. Rather, the observed inconsistent effects might be attributable to differences in district compositions than to differences in characteristics of the respective subjects. Also a statistical separation of compositional effects from effects of individual traits would be made possible by including individual level data in future work.:Abbrevations II Tables II 1 Introduction 1 1.1 Suicide - A Global Health Burden 1 1.2 Risk Factors and Etiology of Suicide 1 1.3 Suicide Prevention 2 1.4 Social Disparities in Suicide 2 1.4.1 Socioeconomic Status 2 1.4.2 Social Isolation 3 1.4.3 Health Inequalities and Health Inequities 4 1.4.4 Causation and Selection 5 1.4.5 Individual Life Courses 7 1.5 Stress and Diathesis 8 1.5.1 Critical Life Events 9 1.6 Neurobiological Correlates of Suicidality 9 1.6.1 Neurobiological Correlates of SES and SI 10 1.7 SES, SI and Social Support 11 1.8 Aims of the Thesis 11 1.9 Methods 12 2 Original Publication 14 Summary 23 References 26 Supplementary Materials - Further Statistical Tests & Models 41 Structural Breaks in Suicide Numbers 41 Age- and Gender-Adjustment of District Suicide Rates 42 Alternate Model Specifications Anlagen i Erklärung über die eigenständige Abfassung der Arbeit i Spezifizierung des eigenen wissenschaftlichen Beitrags iii Danksagung iii

HIV is a virus that leads to AIDS. Millions of people are living with HIV. Globally, there is an increased incidence of this disease among adolescents. In literature, there is a gap regarding how social determinants of health have jointly or singly contributed to HIV/AIDS transmission. With the application of the AIDS risk reduction model (ARRM) to the secondary analysis of survey data, the purpose of this study was to determine whether any significant relationships existed between adolescents' childhood health care factors, demographic factors, social-level factors, structural-level factors, aspects of disease management factors, and knowledge about HIV transmission/AIDS among Nigerian adolescents. Survey data were used from Measure Demographic and Health Survey (MDHS) in Nigeria for 2008. Multiple linear regression revealed that childhood vaccinations were a weak predictor for HIV transmission risk (R2 - 0.020). Gender, age, place of residence, education, religion and culture, some disease management aspects (e.g., accessibility and affordability of care), and wealth index were all significant but weak predictors of knowledge of HIV/AIDS (R2 = 0.016, R2 = 0.019, R2 = 0.003 & R2 0.015). The potential positive social change effect of the study would be HIV transmission reduction through increasing knowledge of HIV/AIDS among adolescents in Nigeria. The results could be used by both governmental and nongovernmental organizations to influence childhood healthcare improvements and advance education to help reduce or eradicate the causes of HIV/ AIDS transmission among adolescents in Nigeria.

Stroke causes substantial morbidity and mortality, and physical activity can reduce the risk of stroke occurrence. The purpose of this study was to test the association between biopsychosocial factors and levels of physical activity and to develop a model to predict inactivity for US stroke survivors. A quantitative, cross-sectional analysis was performed of the 2013 National Health Interview Survey (NHIS), which is a representative sample of US households. Association for 1,077 stroke survivors was tested with chi-square between physical activity and independent variables: biological factors (age, sex, race, body mass index, musculoskeletal conditions, and cardiovascular diseases), psychological factors (mental distress, perception of health), and sociological factors (income, health provider contact, family structure, neighborhood, region, marriage, and education). Multiple variable logistic regression was weighted and adjusted for a complex sampling design. Independent associations were found among biopsychosocial variables. A multiple logistic regression model demonstrated statistically significant variables of older age (OR 6.1, 95% CI 2.1 to 17.6), poor perceived health (OR 4.6, 95% CI 3.0 to 6.8), lower levels of education (OR 2.8, 95% CI 1.5 to 5.0) and living in the Northwest (OR 2.2, 95% CI 1.2 to 4.1) or Midwest region (OR 1.6, 95% CI 1.0 to 2.7), predicting the likelihood of inactivity for stroke survivors. This biopsychosocial model may contribute to positive social change by identifying stroke survivors at risk for inactivity and directing interventions and supportive care. Targeting those most at risk and increasing activity could help to reduce morbidity and mortality among stroke survivors, which could improve their lives and the lives of their families and communities.

BACKGROUND: Patient reported outcomes (PROs) are important cancer outcomes that can be measured electronically but are understudied in the safety-net hospital setting. Routine electronic screening to address social determinants of health (SDH) has been established in primary care clinics and the emergency department of New England’s largest safety-net hospital. The burden of SDH in safety-net oncology patients is less well-studied. This study aimed to determine the feasibility and challenges of routine administration of ePROMs in a safety-net Radiation Oncology clinic, describe treatment toxicities and quality of life (QOL) experienced by this vulnerable population during radiotherapy, and evaluate SDH and the need for SDH screening in the oncology clinic. METHODS: Patients with lung or head and neck cancer scheduled for radiation oncology consultation from 3/2019–1/2020 were deemed eligible for electronic questionnaire participation based on primary language spoken and absence of metastases. At consultation, patients were administered a set of baseline ePROMs (EQ-5D-3L, FACT, PRO-CTCAE) and a social needs screener (THRIVE) using a widely-used cloud-based, patient-centered outcomes platform. Associations between patient demographics and questionnaire completion were retrospectively evaluated. The set of ePROMs were collected at the end of treatment to characterize treatment-related toxicities and changes in self-reported QOL. RESULTS: In total, 99 eligible head and neck cancer (51.5%) and lung cancer (48.5%) patients were identified. Median age was 65. The majority of patients were male (71.7%), and English-speaking (82.8%). Whites, Blacks, and Asians/Others comprised 42.4%, 38.4%, and 6.1% of patients, respectively. Fifteen patients were Hispanic (15.2%). Patients were most likely to have private health insurance (39.4%), followed by joint Medicare-Medicaid (25.3%), Medicaid (17.2%), and Medicare (16.2%). Two patients were insured by Corrections (2.0%). Eight patients (8.1%) no-showed or cancelled, while 91 patients were seen in consultation. Forty-four patients (48.4%) completed the initial questionnaires. For the remaining 47 patients (51.6%), the most common reason for lack of ePROM completion was clinic understaffing and/or clinical decision based on the absence of indication for radiotherapy (n=27, 57.4%). Ten patients refused to complete questionnaires (21.3%), with reasons cited including length of questionnaires and low energy. Ten patients were physically unable to attempt questionnaires (21.3%), for reasons including disabilities and low-literacy. Age, language, race, ethnicity, insurance, marital status, gender, and disease site were not significantly associated with ePROM completion (P≥0.05). For patients who completed the general (QOL) questionnaire EQ-5D-3L, there was no significant difference in general QOL domains nor self-reported overall health score at baseline vs. end of treatment. For head and neck cancer patients, FACT-H&N Total scores, measuring disease-specific QOL, were significantly worse at end of treatment vs. baseline (P=0.006). For lung cancer patients, FACT-L Total scores at the end of radiation treatment were not significantly worse at end of treatment vs. baseline (P=0.953). For head and neck cancer patients who completed PRO-CTCAE, there was a significant increase in the number with moderate to very severe taste issues (P=0.008) and decrease in appetite (P=0.025) by end of treatment. For lung cancer patients, there was a trend towards an increase in the number reporting moderate to very severe nausea (P=0.083). Eighty-one of 99 patients (81.8%) were screened for at least one SDH domain using the THRIVE screener at the study hospital. Nineteen patients (19.1%) had all 8 THRIVE social determinants of health statuses documented. Only housing status was documented for 61 patients (61.6%). There was a trend for married individuals (P=0.068) and females (P=0.074) to be associated with the completion of at least one THRIVE domain. Age, race, language, and insurance status were not associated with THRIVE screening (P>0.05). Transportation to appointments (21.1%), food insecurity (20%), and affording medications (10.5%) were the most prevalent concerns among these oncology patients, with 100% of patients who reported insecurities with medication and transportation requesting resources for these needs. CONCLUSION: Routine ePROs collection in a busy safety-net oncology setting is feasible, but challenging and labor-intensive. Implementation was met with both patient and staff challenges and revealed the need for dedicated project management, staff training, and opportunities to increase patient accessibility. Preliminary PROs analyses revealed several significant detriments in quality of life and increased symptoms for this patient population during treatment, but additional data collection is required. Safety-net oncology patients report significant social needs. Routine SDH screening and resource referral should be considered in these vulnerable patients. Efforts in a specialized department such as Radiation Oncology could fill gaps in existing efforts in a large safety-net hospital. Safety-net oncology clinics can likely help vulnerable cancer patients access available community resources and reduce disparities due to SDH.

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

Black women are most likely to receive mastectomies, yet the least likely to have receipt of breast reconstruction. This disparity in breast and plastic surgery care is unethical and has been documented in the literature and has been witnessed clinically, but far most importantly, it is continued to be lived by Black women all over the nation. The bioethical principles of agency and social justice are called into question as Black women are not given an adequate understanding of their reconstructive options and are not being treated equally or equitably by the healthcare system. As noted by literature, race and ethnicity, socioeconomic and insurance status as well as comorbidities are contributing to this gap in care. As far as solutions go, there must be a multifaceted approach to mitigating this disparity. I have adopted Dr. Butler’s categorization of solutions to understand the exact approach we need to have, which includes patient education, legislation and academic medical institution, to make the recovery from breast cancer ethical for all women. In this thesis, I will go through the literature and garner perspectives from surgeons as well as patients who received breast reconstruction to aid in the understanding of this disparity and what needs to be done to fix it. / Urban Bioethics

Indoor air quality is a critical determinant of physical and mental health. Despite evidence linking poor indoor air quality to adverse health outcomes, this issue is understudied in the context of First Nations children and youth health and wellbeing. The objectives of this study were to (1) characterize indoor air quality, housing conditions, and respiratory health of children living in the Kanesatake First Nation and (2) evaluate the feasibility of using remote community-based participatory methods in the context of First Nations health research. Community-assisted data collection occurred between June 2021 and February 2022 in the Kanesatake First Nation, Quebec. Indoor air data were collected from 31 randomly selected houses. Results showed elevated levels of contaminants, including particulate matter, benzene, toluene, and xylene, compared to the Canadian averages. Houses generally lacked adequate ventilation, and over one-quarter were reported to be in need of major repairs. We developed instruction tools for air sampling and house inspection to facilitate off-site data collection. High rates of participant completion (95%) and low attrition rates (5%) indicated the feasibility of remote community-based participatory research methods. Lessons learnt are summarized and important recommendations are made for adaptation to improve future data collection. This research served as a pilot project for a multi-year, cross-Nation study, as well as the first study to evaluate the indoor air environment in the Kanesatake First Nation.