Using Burris et al.’s model of law as a social determinant of health, this thesis postulates that the law and its application contribute to abortion-related morbidity and mortality among those women who qualify for a legal and safe abortion according to the justifications stipulated in the Criminal Code. This thesis proposes a circular model in order to show how the application of the law, through courts rulings, contributes to unsafe abortion. On the one hand, Argentine law acts as a pathway along which inequity in socioeconomic status exposes certain women to pathogenic practices, such as self-induced abortions. On the other hand, the law acts as a shaper of socioeconomic status as it perpetuates gender stereotypes, constructing a normative world where sex-role stereotypes are naturalized, and having an impact in women’s lack of access to legal and safe abortions.

This thesis evaluates the utility of �social capital� for public health in four dimensions (communication, explanation, practice and measurement) and at two levels (macro and micro), using interviews with public health workers and a theoretical analysis of social capital. It concludes that the concept is potentially useful for public health but that there are limitations to its utility, arising from the presence of two competing discourses or world views identified in the social capital literature: the rational choice discourse and the political economy discourse. This thesis argues that although social capital is widely perceived to have rhetorical leverage in macro-level policy debates, its contested meaning draws into question the value of any consensus built on the glossing over of different world views. The concept has no value for communication at the micro level. The rational choice theory of social capital appears useful for explaining the social determinants of health although it does not adequately account for the power structures which shape and constrain access to social capital, and it undervalues many aspects of social relationships. The political economy approach is more useful in these respects but is far more complex and difficult to quantify. It is unclear whether either of these theories adds much value to the existing literature which social capital tends to eclipse. The concept has limited value for public health practice, as the dual world views embedded in it can be used to support widely varying policy directions. It is also limited by its inability to describe the dynamics of change or to identify levers for initiating change. The meaningfulness of social capital indicators is compromised by the reductionism of the rational choice paradigm. The political economy discourse renders the development of quantitative indicators far more problematic but may be useful for informing qualitative research.

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Breast cancer (BC) screening could reduce its mortality; however, its access is influenced by societal forces. Our objective is to identify the social determinants associated with mammography screening (MS) in women aged 50 to 59 in Peru. In this cross-sectional analysis of the Peruvian Demographic Health Survey, 2015, MS within the past two years was evaluated through self-report. Prevalence for MS was 21.9% [95% CI: 18.9 to 25.1]. The average age was 54 years (s.d.: 2.5). The higher the socioeconomic status, the higher the prevalence of screening (3.2% vs 41.4% in extreme quintiles, p <.001). In the adjusted models, higher socioeconomic status (PR: 5.81, 95% CI: 2.28 to 14.79), higher education level (PR: 2.03, 95% CI: 1.30 a 3,15) and having health insurance from the Ministry of Health (PR: 2.21, 95% CI: 1.28 to 3.82) and EsSalud (PR: 4.37, 95% CI: 2.67 to 7.15), were positively associated with MS. Social inequalities in screening access exist and might translate into inequalities in cancer morbidity and mortality. The Peruvian government urgently needs to improve screening rates in these vulnerable populations. / Revisión por pares

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Objective: Delay in diagnosis and treatment of endometrial cancer may be associated with disease progression and impact management and outcomes. Social and cultural barriers influence recognition of symptoms and self-advocacy in seeking and complying with care. Associations between social determinants of health (SDH) and disease presentation, treatment and outcomes has been shown in some healthcare systems. Our objective was to investigate these in Ontario’s universal access system. Methods: Endometrial cancer patients in Ontario diagnosed 2009-2017 were identified, and clinical, social and demographic information extracted from administrative databases. SDH were quantified using previously validated marginalization quintiles (material deprivation, residential instability and ethnic concentration). Associations between SDH, disease stage, treatment and outcome were explored using chi-square, log-rank and logistic regression. Results: 19530 patients were identified. 73% of cancers were confined to the uterus. Stage distribution differed across marginalization quintiles (p<0.001) with advanced disease found more frequently in highly marginalized patients (highest vs lowest quintile): OR=1.28 (95% CI 1.14-1.45) for deprivation, OR=1.2 (95% CI 1.06-1.35) for residential instability and OR=1.3 (95% CI 1.15-1.46) for ethnic concentration (<0.0001)). Highly marginalized patients also had less timely surgery (p<0.0001). Overall survival was shorter in patients in high deprivation and residential instability quintiles (log rank p-value<0.0001) but not in high ethnic concentration quintiles, with HR=1.4 for deprivation (p<0.0001) and HR=1.53 for instability (p<0.0001) for the highest marginalization quintile. Survival differences persisted in more uniform cohorts of early (stage I) disease and endometrioid tumors and on multivariable analysis. Conclusions: Marginalized populations diagnosed with uterine cancer present at more advanced stages, wait longer for surgery and have shorter overall survival. Associations of SDH with uterine cancer presentation and management in Ontario could shed light on the impact of these factors on disease trajectory, drive policies for patient advocacy and redistribution of resources and promote health equity in this population. / Thesis / Master of Public Health (MPH) / Conditions in the social environment in which people are born, live and work are powerful influencers of health and well-being. In fact, these circumstances have also been called Social Determinants of Health (SDH). Cancer outcomes are one of the domains impacted by SDH. In this study, we set out to investigate the association between SDH and uterine cancer outcomes in Ontario, Canada. We guessed that SDH may influence how soon patients with symptoms seek help from their doctors, how quickly their problem is investigated and how well they are able to undergo treatment. We used a tool called the Ontario Marginalization Index to break down Ontario’s uterine cancer patient population into groups according to degree of social, financial and ethnic marginalization. We found that more marginalized patients tended to present to care with more advanced cancers, that they took longer to have surgery for their cancer and that their survival was worse. These findings suggest there is more work to be done to promote health equity in cancer care.

ABSTRACT Background. A wealth of data highlights the health disparities and barriers to health care experienced by Aboriginal women and children when compared to non-Aboriginal women and children. The first thousand days time period, from conception to the age of two, is an opportunity for health professionals to positively impact the health of Aboriginal children with effects lasting into adulthood. Cultural safety has been reported to improve access to health care for Aboriginal Canadians, but little is known about the significance of cultural safety from the perspective of Aboriginal women during the first thousand days. Methodology. An interpretive descriptive design and a postcolonial perspective guided this study. In-depth interviews were conducted with six Aboriginal women at a community health centre located in the inner-city of Regina, Saskatchewan, between June and July of 2015. Data was analyzed using principles of interpretive description to determine themes. Findings. Culturally safe and unsafe care was experienced during the first thousand days. Three themes common to participants included: the importance of being able to trust that they are safe when accessing health care, the overwhelming impact of poverty on their ability to achieve or maintain good health, and finally, the experience of worry related to the first thousand days including the worry about being worthy of respectful, culturally safe treatment by all employed in health environments. Discussion. The perception of culturally safe care was significant in affecting access to health care for this group of participants. Findings of this study suggest that more attention needs to be paid to the development of trust in health care encounters, and future research could explore the concept of trust for Aboriginal peoples. Emphasis on awareness of the social determinants of health, including colonialism and racism, should be included in educational programming for health professionals locally.

In Canada, accessible and culturally relevant population health data for urban First Nations, Métis and Inuit people are almost non-existent. There is a need for Aboriginal community centric research and data systems, specifically in the area of mental health and substance misuse. The goal of this research was to address these knowledge gaps. The three linked studies being presented were nested in the Our Health Counts (OHC) project, a multi-partnership study aimed at developing a baseline population health database for urban Aboriginal people living in Ontario. In the first study, concept mapping was used to engage urban Aboriginal stakeholders from three culturally diverse communities in identifying health priorities. After completing brainstorming, sorting and rating, and map interpretation sessions, three unique community specific maps emerged. Map clusters and their ratings reflected First Nations, Inuit, and Métis understandings of health. Concept mapping encouraged community participation and informed the development of three health assessment surveys. The second study generated a representative sample of First Nations adults and children living in Hamilton, Ontario by utilizing Respondent Driven Sampling (RDS), a modified chain-referral sampling approach. Population estimates were generated for household and personal income, mobility, over-crowding and food availability. Results revealed striking disparities in social determinants of health between First Nations and the general population. The third study used the RDS generated sample to examine mental health and substance misuse among First Nations adults living in Hamilton. Prevalence estimates were generated for diagnosis and treatment of a mental illness, depression, anxiety, post-traumatic stress disorder (PTSD), suicide, alcohol and substance misuse, and access to emotional supports. Findings indicated that First Nations adults living in Hamilton experience a disproportionate burden of mental health and substance misuse challenges. The three linked studies make innovative contributions to Aboriginal health research. Results clearly exemplify the effective application of community-based research methods that are grounded in local knowledge and built on existing community strengths and capacities. Representative population health data for urban First Nations will contribute to current deficiencies in health information; will shape policy and programming priorities as well as future research directions, particularly with respect to health and social disparities among this population.