Background: Within the Ontario context, a recent shift towards integrated care has led to primary care reforms that have aimed to achieve the quadruple aim benchmarks. Particular focus has been placed on population health management, a key pillar of the quadruple aim metrics, which recognizes and aims to address the broader social, structural and institutional determinants that impact upon population health outcomes. As a result, this study aims to identify and describe the key characteristics of integrated primary care and social care models, programs, and initiatives in Ontario that aim to address the social determinants of health. It also aims to identify barriers and facilitators in the implementation of these integrated care initiatives to support future implementation efforts. Methods: A qualitative descriptive study design was utilized and was conducted in two phases: 1) document analysis; and 2) 13 in-depth semi-structured interviews with policymakers, managers/ administrators, clinicians and service providers involved in leading integrated primary and social care initiatives in Ontario. Results: Developing and implementing these initiatives had primarily required the introduction of new governance and delivery arrangements. This included the adoption of shared governance structures where equal decision-making authority was often established between health and social partners, and the introduction of a system navigator role who was commonly co-located within primary care. There were minimal insights in relation to the development of new financial arrangements aside from a few joint funding agreements, as almost all initiatives did not share financial resources and few modified staff or provider remuneration. Initiatives experienced barriers including a lack of permanent or long-term funding and technological infrastructure to support patient tracking, follow-up, and information sharing between health and social partners. However, the system navigator position was found to be an essential role in bridging communication gaps between sectors and delivering integrated care for clients. In addition, factors such as pre-existing informal and formal partnerships between primary care and social care organizations, communication and trust between health and social partners, and organizational leadership support for integration were viewed as enablers. Discussion and Conclusions: The lessons learned from participants’ experiences in planning and implementing integrated primary care and social care models are timely and can inform future implementation and scale up as the province continues to move towards integrated care arrangements in efforts to achieve the quadruple aim benchmarks. Specific recommendations for policy and future research are proposed. / Thesis / Master of Public Health (MPH) / Health systems in Canada are positioned to treat symptoms of health issues instead of addressing the root causes of illness and disease, such as lack of housing, access to healthy and nutritious food, and stable employment opportunities. Recently, health system reforms in Ontario have shifted to population health-based approaches to care which recognize and aim to address these non-medical determinants of health outcomes. Primary care, which is often an individual's first point of contact with the health system, may be uniquely positioned to fulfill this mandate due to the capabilities of primary care providers to develop and sustain relationships with patients along the life course. Primary care practitioners may be more aware of patients' underlying social needs that result in adverse health outcomes. This study aimed to identify models of care in Ontario that coordinate care for patients between health and social services such as housing and employment support. It was conducted in two phases. Phase one included a targeted document search which used government policy documents, stakeholder websites, and journal databases to identify these integrated models of care in Ontario. In phase two, 13 stakeholders identified from existing models were interviewed to explore their experiences with models that integrate primary care and social care services and the barriers and facilitators to implementing such models. The study found that most initiatives had made modifications to governance and delivery arrangements to support implementation, including the adoption of shared governance approaches and a system navigator position responsible for coordinating care for clients. The initiatives primarily experienced barriers with funding insecurity, communication and information sharing between health and social partners, and technology. However, communication and trust between health and social partners and organizational leadership support were factors that supported the implementation of initiatives. The findings from this research may support future implementation and scale-up of these coordinated models of care in Ontario.

Background: The childbearing years place socioeconomically disadvantaged African American women at increased risk for poor diet quality, excess weight gain, and cardiometabolic complications. Little is known about the attitudes, beliefs, values, and contextual constraints that shape these high risk mothers’ dietary and physical activity behaviors. Objective: The purpose of this study was to examine health perceptions of diet quality and physical activity among low-income African American women in the early postpartum period, and how these perceptions manifest as barriers or facilitators to health. Additionally, we examined how they may differ by known predictors of health, such as education, age, parity, and BMI. Methods: We conducted semi-structured, individual interviews with 20 women who were between 3-6 months postpartum. Mothers were approached and recruited in the waiting room of a university-affiliated, outpatient prenatal care clinic in Philadelphia, PA. Enrollment in the study was restricted to women who self-identified as African American, were at least 18 years old, and met the federal income guidelines to qualify for assistance (Medicaid, WIC). Individual interviews were audio recorded and transcribed verbatim, with transcripts verified by research staff. Thematic coding and content analysis were performed by 3 researchers using NVivo 10 software to assist with data management. Results: Barriers and facilitators of healthy eating and physical activity after childbirth fell into 4 major themes of mothers’ lives: 1) new structural reality in the postpartum period; 2) physiologic changes after delivery; 3) correct/incorrect perceptions of healthy eating and activity; and 4) social determinants influencing behaviors. Mothers described the transition from pregnancy to the early postpartum period as having a significant negative impact on their eating and activity behaviors due to heightened fatigue, time constraints, and the monotony of daily life with a newborn. We found more than double the number of perceived barriers to engaging in healthy eating than facilitators with regard to fluctuations in food supply, cost of food, and the built environment. Mothers with obesity and less education were more likely to have misperceptions; these misperceptions additionally served as strong barriers to making healthy lifestyle choices. Changes in mothers’ physical symptoms and health status (e.g., developing diabetes, hypertension), on the other hand, facilitated healthy behaviors. Conclusion: This research deepens our understanding of the primary drivers of health behaviors among low-income African American women in the postpartum period. We identified barriers which limit and facilitators which support these mothers’ ability to engage in healthy behaviors, though there were far fewer facilitators of healthy eating and physical activity. Interventions designed to overcome these barriers and capitalize on these facilitators have the potential to improve health outcomes for this population. / Urban Bioethics

The current fragmented delivery of health care has contributed to unplanned hospital readmissions as a leading problem in the United States. Reducing readmissions to urban teaching hospitals is difficult. Many patients living in urban communities face social, economic, language, and transportation barriers to maintaining their health. Both the patient and the medical center experience the burden of readmission and are challenged with addressing SDoH and social injustices at several levels. Medicare views hospital readmissions as a marker representing lower quality of health care delivery to penalize hospitals providing care to the poor. This thesis addresses multiple social and economic factors associated with hospital readmissions, explores the interrelated components of readmissions at the personal and hospital system level, and delves into the interactions of bioethical principles associated with urban living. Hospital readmissions remain a serious issue nationwide and in order to reduce the rates of re-hospitalization the social and economic inequalities contributing to hospital readmissions are significant and must be addressed. / Urban Bioethics

Housing is a key social determinant of health. Further to this, my research will show that it is through housing that all other health determinants are fully actualized. For refugee claimant (RC) families, housing is the most immediate and pressing need upon their arrival in Canada. The objective of this exploratory qualitative study is to examine the housing experiences of refugee claimant (RC) families in the Greater Toronto and Hamilton Area (GTHA) and its impact on the health, well-being, settlement and integration of this population from the perspectives of services providers. Given the increasing inflows of asylum seekers in Canada over the past few years, there is an urgent need to examine their housing experiences and subsequent impacts on health and well-being. Using purposive sampling, seven service providers from five different refugee centres and family shelters in the GTHA were recruited. Individual, semi-structured interviews were conducted, recorded, transcribed, and then analyzed thematically. Findings demonstrate that accessing both emergency and permanent housing upon arrival is particularly difficult for RCs, given that the demand for housing continues to surpass availability in the emergency shelter system and private housing market in the GTHA. In their search for permanent housing, many RCs rely on the private housing market, where discrimination and affordability are common barriers. With an uneven and difficult trajectory towards housing access, many RCs face health issues associated with stress, poverty, and homelessness, which disrupt their settlement and integration in Canada. This research concludes by offering recommendations for policy and program level changes to improve refugee housing access in the GTHA. These recommendations include increasing service provision capacity in shelters, expanding transitional housing options for RCs, increasing investments in subsidized housing, limiting government involvement in REITS and increasing incentives to build more subsidized housing. / Thesis / Master of Social Work (MSW)

Inflytande och delaktighet utgör det första målområdet i svensk folkhälsopolitik och anses vara grundläggande för människors hälsa. Sambandet mellan delaktighet och hälsa är etablerat, men framför allt bland vuxna. Hur sambandet mellan delaktighet, och i synnerhet hur olika komponenter av delaktighet, och hälsa ser ut bland gymnasieungdomar är inte lika väl undersökt. Syftet med studien var att dels undersöka samband mellan delaktighet i form av vilja att påverka frågor i kommunen samt föreningsaktivitet och självskattad hälsa bland gymnasieungdomar, dels hur sambanden förändras vid kontroll av andra faktorer. Studien hade en tvärsnittsdesign och baserades på befolkningsenkäten Liv och hälsa ung i Uppsala län från 2013. Urvalet bestod av 2453 gymnasieelever. Sambanden analyserades med hjälp av binär logistisk regression. Att vilja påverka frågor i kommunen hade ett svagt samband med självskattad hälsa, men vid justering av sociodemografiska, sociala samt skolrelaterade faktorer försvann sambandet. Föreningsaktivitet var däremot signifikant associerat med självskattad hälsa, där föreningsinaktivitet var förknippat med högre odds för självskattad ohälsa. Faktorer närmare ungdomarnas liv hade emellertid starkare samband med deras självskattade hälsa. Riktningen i sambanden kunde inte fastslås, men baserat på tidigare forskning, indikerar resultatet att föreningsaktivitet kan vara ett område att rikta folkhälsoinsatser mot. Både som ett sätt att främja hälsa, men också för att öka demokratist deltagande och inflytande. / Influence and participation is the first target area in the Swedish public health policy and is considered essential to people’s health. The link between participation and health is established, but especially among adults. How participation, and in particular how various components of participation, are related to health among high school students is not as well investigated. The aim of the study was partly to investigate if participation in terms of wanting to influence issues of the municipality and also engagement in different associations relate to self-rated health among high school students, partly how the relationships change when adjusting for other factors. The study had a cross-sectional design and was based on the population survey Liv och hälsa ung in Uppsala County from 2013. The study population consisted of 2453 high school students. The correlations were analysed using binary logistic regression. Wanting to influence issues in the municipality had a weak correlation with self-rated health, and when adjusting for socio-demographic, social and school-related factors, the relationship disappeared. Engagement in an association, however, was significantly associated with self-rated health. Not being engaged in an association was associated with higher odds of self-rated health less then good, although factors closer to the adolescents had a stronger relationship with their self-rated health. The direction of the relationship could not be confirmed, but based on previous research, the results suggest that public health initiatives aimed at increasing the involvement in associations may be relevant, both as a step to promote health and to increase democratic participation and influence.

The purpose of this dissertation was to explore the mechanism of association between social determinants of health (SDH), particularly limited health literacy, and disparate outcomes related to cardiovascular disease in vulnerable populations. Specific aims were to 1) compare quality of life (QOL), anxiety, and depressive symptoms between genders in implantable cardioverter defibrillator (ICD) recipients; 2) examine the association between multi-morbidity burden and QOL; 3) determine whether health literacy levels independently predict CVD risk in the male prison population; 4) examine the relationship between health literacy and decisiveness regarding end of life (EOL) choices, and 5) examine SDH as predictors of perceived poor health status in ICD recipients. Specific aim one was addressed by analysis of data collected from individuals in the Swedish ICD and Pacemaker Registry. Multiple linear regression was used to determine predictors of anxiety, depression, and quality of life in men and women. A higher prevalence of anxiety symptoms in women was noted with no differences in depressive symptoms noted between the genders. The majority of the variance in the predictive models for QOL was explained by the addition of the psychosocial variables for both genders. Specific aim two was addressed by analysis of data collected from individuals in the Swedish ICD and Pacemaker Registry. Logistic regression was used to determine predictors of QOL. Greater multi-morbidity burden was associated with lower QOL in ICD recipients. Specific aim three was addressed by analysis of data collected from male inmates enrolled in a bio-behavioral educational and counselling intervention program to reduce CVD risk. Nonlinear regression was used to determine whether health literacy was an independent predictor of CVD risk while controlling for social and clinical variables. Inmates with adequate levels of health literacy had lower ten year CVD risk profiles than those inmates with inadequate health literacy. Specific aim four was addressed by analysis of data collected from ICD recipients. Multinomial regression was used to determine predictors of decisiveness regarding EOL choices. Within the context of terminal illness, health literacy and race were found to be predictors of decisiveness regrading generator replacement while gender was found to be a predictor of decisiveness regarding the withdrawal of defibrillation therapy. Specific aim five was addressed by analysis of data collected from ICD recipients. Logistic regression was used to determine predictors of perceived poor health status. Residential status in the Central Appalachian region of Kentucky, not working outside the home, higher levels of health literacy, and comorbid depression were predictors of perceived poor/very poor health status.

Introdução: O Projeto Viva Seu Bairro (PVSB) foi uma iniciativa desenvolvida em seis regiões urbanas da cidade de Campo Grande MS, no período de 2001 a 2004, nas áreas de maior risco social, identificadas pelas equipes de agentes comunitários de saúde e saúde da família. O projeto teve como objetivo a redução das desigualdades sociais por meio de ações que atuaram sobre Determinantes Sociais da Saúde (DSS). Objetivo: A pesquisa buscou conhecer a relação entre o PVSB e os determinantes sociais da saúde, bem como identificar a presença da participação social e da intersetorialidade nas ações desenvolvidas. Material e Métodos: Trata-se de pesquisa de abordagem qualitativa. Foram realizadas entrevistas individuais com gestores da administração municipal e com técnicos da Unidade Técnica Central (UTC), responsável pelo gerenciamento do projeto. Seis grupos focais foram realizados, um em cada região urbana que teve a implementação da iniciativa, com representantes dos Conselhos Regionais Urbanos (CRU). Além disto, foi feita a análise de documentos relacionados ao PVSB. Para a análise dos dados, utilizou-se a análise de conteúdo, por meio da análise temática com a triangulação dos dados obtidos. Resultados: Os resultados da pesquisa apontam uma série de ações que incidiram sobre as condições materiais e psicossociais nas quais as pessoas vivem e trabalham, como proposto pelo modelo adotado nas recomendações do Relatório Final da Comissão Nacional sobre Determinantes Sociais da Saúde (2008). As mais descritas pelos participantes foram as que visaram assegurar saneamento básico, habitação adequada, emprego, serviços de saúde e de educação de qualidade. Verificou-se o protagonismo do setor saúde no desencadeamento da iniciativa. Conclusões: A participação social foi fortalecida na cidade durante e após a iniciativa. Quanto à intersetorialidade, houve a busca por parcerias e o reconhecimento, por parte dos representantes de governo, da necessidade de se implementar redes sociais, o que, no entanto, não se institucionalizou como práticas da administração municipal. A discussão sobre a sustentabilidade ocorreu de modo insuficiente e a avaliação da iniciativa começou um ano e meio após o seu início, o que comprometeu a avaliação de processo. Os participantes da pesquisa reconheceram que o PVSB interferiu na melhoria da qualidade de vida da população local. Conclui-se que o PVSB configurou-se como iniciativa do campo da promoção da saúde, atuou sobre os DSS, fortaleceu os mecanismos de participação nos CRU e buscou mecanismos de ação intersetorial / Introduction - The Project \"Viva Seu Bairro\" (PVSB) was an initiative developed in six urban regions of the city of Campo Grande - MS, from 2001 until 2004, in the areas of greater social risk, identified by the teams of community health and family health agents. The project had as its aim to reduce the social inequalities through actions, which acted on the Social Determinants of Health (SHD). Objective - The research tried to know the relation between PVSB and the Social Determinants of Health, as well as to identify the presence of the social participation and the intersectoriality in the developed actions. Material and Methods - It is about a research of qualitative approach. Individual interviews were performed with managers of the municipal administration and with technicians from Central Technical Unity, responsible for the project administration. Six focal groups were carried out, one in each urban region that had the initiative implementation, with representatives from the Urban Regional Councils. Moreover, an analysis of the documents related to PVSB was done. The Content Analysis was used for the analysis of the data through the thematic analysis and then the triangulation of the obtained data. Results - The results of the research point out a series of actions that occurred to the material and psychosocial conditions in which the people lived and worked, as proposed by the model adopted in the recommendations of the Final Report of the National Commission on Social Determinants of Health (2008). The items most described by the participants were the ones that targeted to assure basic sanitation, appropriate dwelling, employment, health and education services of quality. It was verified the prognostic of the health sector in the breaking of the initiative. Conclusions - The social participation was strengthened in the city during and after the initiative. In relation to the intersectoriality, there was a search for partnerships and the recognition, from the government representatives, of the necessity to implement social nets, which however, was not institutionalized as a practice in the municipal administration. The discussion about the sustainability occurred in an insufficient way and the initiative evaluation started one year and a half after its beginning, which compromised the process of evaluation. The research participants recognized that PVSB interfered in the improvement of the local population life quality. It was concluded that PVSB configured as an initiative in the field of health promotion, acted on SHD, strengthened the mechanisms of participation in the CRU and looked for mechanisms of intersectorial action.

Introdução: Dentre as várias áreas, abordagens e temas que compõem a Saúde Pública, a Promoção da Saúde constitui-se como um dos mais estabelecidos o que indica a pertinência de reflexão sobre sua produção. E dentre as linhas de pesquisa na área de Promoção da Saúde, nos últimos anos, tem se destacado o tema de Determinantes Sociais de Saúde, essa preocupação expressa por essa linha de pesquisa e atuação sobre os Determinantes Sociais de Saúde (DSS) assim como as propostas de promoção da saúde remetem necessariamente à reflexão sobre a dinâmica social visto que estão voltadas para a transformação das condições de vida. Objetivo: Esse estudo teve por objetivo identificar a produção da pesquisa em DSS na Faculdade de Saúde Pública da Universidade de São Paulo, no período de 2004 a 2008, e apontar as áreas de interesse e tendências desse campo de estudo. Metodologia: A metodologia consistiu em uma revisão bibliográfica de estudos sobre DSS, realizada a partir de um levantamento de dados baseado na consulta às seguintes bases de dados: BVS (Biblioteca Virtual em Saúde), SciELO (Scientific Electronic Library Online) e banco de tese da Capes. Os indexadores para a pesquisa foram selecionados segundo os Descritores em Ciência da Saúde (DeCS). Resultados: Dentre os diversos determinantes sociais de saúde encontrados durante a coleta de dados, os mais citados foram: inclusão social, segurança, justiça social, transporte, qualidade de vida, modelos de atenção à saúde, educação, lazer, ambiente de trabalho, equidade, distribuição de renda, recursos sustentáveis, ecossistema saudável, stress e saneamento. Deu-se preferência pelos resultados que se referiram diretamente ao tema da pesquisa sobre Determinantes Sociais de Saúde, resultados esses que foram classificados por ano, tipo de publicação: teses, dissertações, artigos de periódicos e por classificação de determinantes sociais de saúde. Conclusão: Verificou-se que a produção cientifica com Determinantes Sociais de Saúde na Faculdade de Saúde Pública USP tem crescido continuamente nesses últimos anos e que a maioria dos trabalhos está voltada para o estudo sobre as iniquidades em saúde seguido, de estudos sobre o empoderamento e a qualidade de vida / Introduction: Among the various areas, approaches and themes that compose the Public Health, Health Promotion was established as one of the most established which indicates the relevance of reflection on their production. And among the lines of research in the area of Health Promotion, in recent years has highlighted the topic of Social Determinants of Health, this concern expressed by this line of research and action on the Social Determinants of Health (SDH) as well as proposals for health promotion necessarily refer to a reflection on the social dynamics as they are geared towards the transformation of living conditions. Objective: This study aimed to identify the production of research in SDH at the School of Public Health, University of São Paulo in the period 2004 to 2008, and point out areas of interest and trends of this field of study. Methodology: The methodology involved a literature review of studies in SDH. Data collection was based on consultation with the following databases: BVS (Virtual Library in Health), SciELO (Scientific Electronic Library Online) and CAPES thesis database. The indices for the study were selected according to the Health Sciences Descriptors (DeCS). Results: Among the many social determinants of health found during the data collection, the most cited were: social inclusion, security, social justice, transportation, quality of life, models of health care, education, leisure, work environment, fairness and distribution in income, resources sustainable, healthy ecosystem, stress and sanitation. It was given preference for results that are reported directly to the research theme on Social Determinants of Health, these results were sorted by year, type of publication: theses, dissertations, journal articles and for classification of social determinants of health. Conclusion: It was found that the scientific production with the Social Determinants of Health in the School of Public Health - USP has grown steadily in recent years and that most work is directed toward the study of inequities in health, followed by studies on the empowerment and quality of life

If there is one thing that policy makers at the World Health Organisation (WHO) and residents of the South African township of Langa are likely to agree on, it is that ‘just sitting’ is not good for you. The positions from which they approach this conclusion however differ profoundly. This research investigates different conceptualisations of physical activity, health, and wellbeing, and the implications of these differences for policy on the prevention of noncommunicable diseases (NCDs) in low and middle income countries, taking South Africa as a case study. With four out of five deaths from diseases such as diabetes, heart disease and stroke now occurring in low and middle income countries, prevention, of what have been termed ‘NCDs’, in these countries is rising rapidly up the global public health agenda. Physical activity is one of the four primary risk factors which have been identified as intervention targets, but there is an acknowledged paucity of research which helps us to understand how physical activity, and inactivity, are conceptualised in low and middle income country contexts. As a result the evidence base for design of physical activity policy interventions to address NCDs is also weak. The global discourse recognises the determinants of health as socially embedded, but struggles with what this means for policy on prevention. This study explores the detail of this social embeddedness by way of ethnographic research into wellbeing, health and physical activity carried out in a South African township, and juxtaposes this with conceptualisation of these same themes emerging from a review of academic and policy-oriented literature on the prevention of NCDs in low and middle income countries. The struggles of local research groups to reconcile the demands made on them from these very different worlds are explored, and strategies for addressing the specifics of NCD prevention without abstracting health from the broader context of the person or society are discussed. The research is theoretically informed by work on wellbeing in developing countries.

Cette thèse s’intéresse à la contribution des expositions professionnelles —chimiques, biomécaniques, et psychosociaux—tout au long de la vie dans les inégalités sociales de santé liés au vieillissement. Les trois papiers de la thèse essaient de combler les lacunes dans les connaissances sur les effets à long terme des expositions professionnelles et la contribution des expositions individuelles et conjointes dans ces inégalités. Le premier papier cherche à savoir si le niveau d’éducation atteint dans l’enfance modifie l’effet de l’exposition professionnelle aux solvants au cours de la carrière sur la fonction cognitive après 55 ans.. Nous avons trouvé que l’effet de l’exposition aux solvants sur la fonction cognitive était différent selon le niveau d’éducation.. Le deuxième papier discute les effets combinés des expositions biomécaniques et psychosociaux au cours de la vie professionnelle sur la santé physique et fonctionnelle après la retraite. Nous avons trouvé qu’une forte exposition à la fois aux risques physiques et psychosociaux au cours de la vie active est associée à une capacité fonctionnelle bien plus faible après la retraite que l’exposition à un seul type de risques. Aussi, l’effet était différent chez les hommes et chez les femmes. Le troisième papier est un papier méthodologique qui discute des alternatives aux formes longues des échelles généralement utilisées pour évaluer les expositions biomécaniques au travail. Nous avons cherché à vérifier si la question « Trouvez-vous votre travail fatiguant physiquement?» pourrait être une mesure de substitution acceptable pour évaluer des expositions détaillées.. Nous avons comparé la mesure à un item à une mesure plus complète de 38 expositions spécifiques dans huit domaines. Nous avons trouvé que la mesure à un item était plus valide chez les participants fortement exposés à des contraintes biomécaniques de travail. En somme, cette thèse a montré que les expositions professionnelles peuvent à la fois exacerber les disparités existantes en matière de santé et les perpétuer au delà de la retraite. / This dissertation focuses on how occupational exposures throughout the lifecourse—chemical, physical, and psychosocial—contribute to social patterns in aging outcomes, addressing the gap in knowledge about lasting effects of occupational exposures and the contribution of individual and combined exposures to social patterns in aging. The first paper explores whether childhood educational attainment modifies effects of occupational solvent exposure during the career on cognitive function after age 55. We found differential effects of solvent exposure on cognition by educational attainment. The second paper looks at combined physical and psychosocial exposures during working life and effects on physical health and functioning after retirement. This paper finds that high exposure to both physical and psychosocial hazards at work is associated with worse functional capacity in retirement than exposure to either one separately; the pattern of this relationship differs for men and women. The third paper is a methodology paper exploring alternatives to extensive testing batteries often used to evaluate physical workplace exposures. We tested whether the question “Do you find your work physically strenuous?” was an acceptable proxy measure for more detailed exposure assessments by comparing the measure to a comprehensive self-report measure of 38 specific biomechanical strains across eight domains. We found that the measure was most valid in the populations that were most highly exposed to physical strains at work. In general, this dissertation found that occupational exposures can exacerbate existing disparities in health and perpetuate disparities into and beyond retirement.