Advances in HIV care and treatment continue to prolong the lives of people diagnosed and living with HIV (PDLWH). The National HIV/AIDS Strategy mobilizes national, state, and local efforts toward ensuring equitable access to care, reducing disparities, and improving continuum of HIV care outcomes. A social/community-based factor that contributes to sub-optimal HIV outcomes for PDLWH – all of whom require regular visits to a medical facility – is access to accommodating, affordable, and acceptable HIV care providers. Employing case surveillance data to analyze relationships between social/community-based factors and HIV disease outcomes is an opportunity to identify underserved PDLWH. This analytic approach, linking individual case-level epidemiologic surveillance data with macro-level community measures, provides public health departments a more precise estimate of priority geographic zones and subpopulation clusters whereby limited public health resources can be directed for maximal impact and efficiency. This dissertation analyzed California HIV surveillance system (CHSS) data to characterize PDLWH in terms of residential census tract characteristics related to income, poverty, unemployment, vehicle access, population density, travel duration from residence to care facility, and access to care. The primary study population was 60,979 PDLWH as of 2014 who had recent, geocoded residential addresses collected in CHSS. Access to care was measured using a novel enhanced two-step floating catchment area (E2SFCA) method developed for this dissertation. We also assessed whether community characteristics, trip duration, and access to care were associated with suppressed viral load, an indicator of successful disease management. Several significant relationships were found between suppressed viral load and where people lived, how long they drove for care, and their E2SFCA-measured access to care. This analysis identifies new methods for state and local health jurisdictions to: investigate factors associated with HIV-specific health disparities, improve the capacity to direct resources for improving health outcomes for PDLWH, and enhance transmission prevention efforts.

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Research Question: This research adapted, tested, and evaluated a methodology to set priorities for systematic reviews topics within the Cochrane Collaboration that is sustainable and incorporates the social determinants of health and health equity into the analysis. Background: In 2008 a study was conducted to review, evaluate and compare the methods for prioritization used across the Cochrane Collaboration. Two key findings from that study were: 1) the methods were not sustainable and 2) health equity represented a gap in the process. To address these key findings, the objective of this research was to produce and test a method that is sustainable and incorporates the social determinants of health and health equity into the decision making process. As part of this research, the methods were evaluated to determine the level of success. Methodology: With assistance from experts in the field, a comparative analysis of existing priority setting methods was conducted. The Global Evidence Mapping (GEM) method was selected to be adapted to meet our research objectives. The adapted method was tested with assistance of the Cochrane Musculoskeletal Group in identifying priorities for Osteoarthritis. The results of the process and the outcomes were evaluated by applying the “Framework for Successful Priority Setting”. Results: This research found that the priority setting method developed is sustainable. Also, the methods succeeded in incorporating the social determinants of health and health equity into the analysis. A key strength of the study was the ability to incorporate the patients’ perspective in setting priorities for review topics. The lack of involvement of disadvantaged groups of the population was identified as a key limitation. Recommendations were put forward to incorporate the strengths of the study into future priority setting exercises within Cochrane and to address the limitations.

Although Fair Trade provides better trading mechanisms and a set of well-documented tangible benefits for small-scale coffee producers in the Global South, large inequities persist within Fair Trade certified cooperatives. In particular, gender equity and womens empowerment are considered to be integral considerations of this system but visible gender inequities within certified cooperatives persist. Responding to this apparent contradiction, local partners in Nicaragua articulated a need to better understand how gender equity is understood and acted upon and thus this research projectan exploration of implemented gender equity-promoting processes at three different organizational levels (a national association of small-scale coffee producers, a second-tier cooperative, and a base cooperative)emerged. Drawing on feminist and social determinants of health approaches to research, the study was informed by semi-structured key informant interviews and document revision. Both the interviews and the documents revealed that although gender work is being considered at all three levels, each organizations approach and interpretation is unique, which exposes different challenges, tensions, and experiences.<p> Notably, results indicate that there is no clear definition of gender equity amongst the different organizational levels. As a result, these groups appear to be interpreting gender equity, and therefore initiating equity-promoting processes based on different criteria. Interviews also revealed that although there is no evidence of active discrimination or exclusion of women within cooperatives, gender equity work is nonetheless constrained by a constellation of socio-cultural and organizational challenges that women face. Examples of socio-cultural challenges revealed through the interviews include illiteracy, ascribed child-rearing responsibilities, household chores, machista culture, land tenure arrangements and gendered power relations in terms of decision-making, while organizational challenges include the attitudes and influence of leaders, a lack of gender mainstreaming in the cooperatives work and the fact that becoming a member requires an input of resources that most women do not have access to.<p> In eliciting experiences and perspectives from various levels of organizations in the Fair Trade coffee sector, the research revealed numerous tensions between rhetoric and practice. These tensions reflect blind spots in Fair Trade marketing and research wherein existing rhetoric does not reflect the experiences of the women, cooperatives, and organizations shared in this research. The three most predominant tensions that are explored in this study are: empowerment and organizational autonomy versus standardization; the subordination of gender work to commercial interests and; the concentration of power within democratically-organized cooperatives. The study acknowledges that it is not the primary role of Fair Trade to solve gender inequities, but does suggest that through some basic changes, including most notably a stronger consideration of local contexts, Fair Trade and local cooperatives can effectively support local gender work and contribute to womens empowerment and health.

The disparity in tuberculosis rates between Indigenous and non-Indigenous people persists in Canada and New Zealand. The most common form of tuberculosis in humans is pulmonary tuberculosis so eliminating tuberculosis transmission is an important obstacle to decreasing the overall rates of the disease. In both Canada and New Zealand, social determinants of health such as housing conditions, access to health care and historical influences (including similar experiences with colonization) have been implicated in the high rates of tuberculosis. This thesis examines and compares the social determinants of tuberculosis transmission among Aboriginal people in the Canadian province of Alberta and Maori and Pacific people in New Zealand. In Alberta, ten Aboriginal individuals with smear-positive pulmonary tuberculosis participating in a larger prairie wide study were divided into two groups (transmitter and non-transmitter) based on transmission events identified through contact tracing and DNA fingerprinting. Interviews with the ten participants were analyzed and compared using an interpretive phenomenological perspective and informed by an Aboriginal framework of health. Survey data from the same individuals provided complementary descriptive statistics. In New Zealand, interviews with Maori and Pacific pulmonary TB participants that had been conducted as part of other studies were accessed and analyzed using an interpretive phenomenological perspective. Like in Canada, Indigenous frameworks of health specific to Maori and Pacific people informed the analysis. The Canadian analysis identified three factors of greater relevance within the transmission group: substance use, patient-delay-in-seeking-treatment, and number of contacts. These factors were also relevant for the Maori and Pacific experience of tuberculosis. The results of this cross-cultural comparative study highlight the complexity of the experience of tuberculosis for Indigenous people in both Canada and New Zealand. Future research and education and intervention programs must not only consider the proximal social determinants of health, such as poverty, unemployment, etc, but also the more distal social determinants of health and the causes of causes such as colonization and its multi-generational effects.

Research Question: This research adapted, tested, and evaluated a methodology to set priorities for systematic reviews topics within the Cochrane Collaboration that is sustainable and incorporates the social determinants of health and health equity into the analysis. Background: In 2008 a study was conducted to review, evaluate and compare the methods for prioritization used across the Cochrane Collaboration. Two key findings from that study were: 1) the methods were not sustainable and 2) health equity represented a gap in the process. To address these key findings, the objective of this research was to produce and test a method that is sustainable and incorporates the social determinants of health and health equity into the decision making process. As part of this research, the methods were evaluated to determine the level of success. Methodology: With assistance from experts in the field, a comparative analysis of existing priority setting methods was conducted. The Global Evidence Mapping (GEM) method was selected to be adapted to meet our research objectives. The adapted method was tested with assistance of the Cochrane Musculoskeletal Group in identifying priorities for Osteoarthritis. The results of the process and the outcomes were evaluated by applying the “Framework for Successful Priority Setting”. Results: This research found that the priority setting method developed is sustainable. Also, the methods succeeded in incorporating the social determinants of health and health equity into the analysis. A key strength of the study was the ability to incorporate the patients’ perspective in setting priorities for review topics. The lack of involvement of disadvantaged groups of the population was identified as a key limitation. Recommendations were put forward to incorporate the strengths of the study into future priority setting exercises within Cochrane and to address the limitations.

Although Fair Trade provides better trading mechanisms and a set of well-documented tangible benefits for small-scale coffee producers in the Global South, large inequities persist within Fair Trade certified cooperatives. In particular, gender equity and womens empowerment are considered to be integral considerations of this system but visible gender inequities within certified cooperatives persist. Responding to this apparent contradiction, local partners in Nicaragua articulated a need to better understand how gender equity is understood and acted upon and thus this research projectan exploration of implemented gender equity-promoting processes at three different organizational levels (a national association of small-scale coffee producers, a second-tier cooperative, and a base cooperative)emerged. Drawing on feminist and social determinants of health approaches to research, the study was informed by semi-structured key informant interviews and document revision. Both the interviews and the documents revealed that although gender work is being considered at all three levels, each organizations approach and interpretation is unique, which exposes different challenges, tensions, and experiences.<p> Notably, results indicate that there is no clear definition of gender equity amongst the different organizational levels. As a result, these groups appear to be interpreting gender equity, and therefore initiating equity-promoting processes based on different criteria. Interviews also revealed that although there is no evidence of active discrimination or exclusion of women within cooperatives, gender equity work is nonetheless constrained by a constellation of socio-cultural and organizational challenges that women face. Examples of socio-cultural challenges revealed through the interviews include illiteracy, ascribed child-rearing responsibilities, household chores, machista culture, land tenure arrangements and gendered power relations in terms of decision-making, while organizational challenges include the attitudes and influence of leaders, a lack of gender mainstreaming in the cooperatives work and the fact that becoming a member requires an input of resources that most women do not have access to.<p> In eliciting experiences and perspectives from various levels of organizations in the Fair Trade coffee sector, the research revealed numerous tensions between rhetoric and practice. These tensions reflect blind spots in Fair Trade marketing and research wherein existing rhetoric does not reflect the experiences of the women, cooperatives, and organizations shared in this research. The three most predominant tensions that are explored in this study are: empowerment and organizational autonomy versus standardization; the subordination of gender work to commercial interests and; the concentration of power within democratically-organized cooperatives. The study acknowledges that it is not the primary role of Fair Trade to solve gender inequities, but does suggest that through some basic changes, including most notably a stronger consideration of local contexts, Fair Trade and local cooperatives can effectively support local gender work and contribute to womens empowerment and health.

The disparity in tuberculosis rates between Indigenous and non-Indigenous people persists in Canada and New Zealand. The most common form of tuberculosis in humans is pulmonary tuberculosis so eliminating tuberculosis transmission is an important obstacle to decreasing the overall rates of the disease. In both Canada and New Zealand, social determinants of health such as housing conditions, access to health care and historical influences (including similar experiences with colonization) have been implicated in the high rates of tuberculosis. This thesis examines and compares the social determinants of tuberculosis transmission among Aboriginal people in the Canadian province of Alberta and Maori and Pacific people in New Zealand. In Alberta, ten Aboriginal individuals with smear-positive pulmonary tuberculosis participating in a larger prairie wide study were divided into two groups (transmitter and non-transmitter) based on transmission events identified through contact tracing and DNA fingerprinting. Interviews with the ten participants were analyzed and compared using an interpretive phenomenological perspective and informed by an Aboriginal framework of health. Survey data from the same individuals provided complementary descriptive statistics. In New Zealand, interviews with Maori and Pacific pulmonary TB participants that had been conducted as part of other studies were accessed and analyzed using an interpretive phenomenological perspective. Like in Canada, Indigenous frameworks of health specific to Maori and Pacific people informed the analysis. The Canadian analysis identified three factors of greater relevance within the transmission group: substance use, patient-delay-in-seeking-treatment, and number of contacts. These factors were also relevant for the Maori and Pacific experience of tuberculosis. The results of this cross-cultural comparative study highlight the complexity of the experience of tuberculosis for Indigenous people in both Canada and New Zealand. Future research and education and intervention programs must not only consider the proximal social determinants of health, such as poverty, unemployment, etc, but also the more distal social determinants of health and the causes of causes such as colonization and its multi-generational effects.

<p>Problem: The disparate health outcomes of African American mothers living with HIV functions at the intersection of gender-, race-, and class-inequality; HIV-related stigma; and motherhood, requiring multidimensional approaches to address the complex social and economic conditions of their lives, collectively known as the social determinants of health. African American women suffer significantly higher HIV infection rates and tend to die earlier from their infection than their White counterparts. Poverty is a significant precipitating factor for HIV infection and African American women are disproportionately poorer than other subpopulations in the United States. HIV-related stigma is linked to poorer mental and physical health outcomes across a broad range of demographic profiles. Being a mother adds an extra layer of social complexity to the lives of women living with HIV. This dissertation was designed to develop knowledge on the social determinants of health for African American mothers living with HIV by describing their social location at the intersection of gender-, race- and class – inequality; HIV-related stigma; and motherhood and exploring how their unique social identity influences their health-related experiences.</p><p>Methods: Using data from a literature review on intersectional approaches and other frameworks for examining vulnerable populations, an intersectional model for the study of the social determinants of health for African American mothers living with HIV was constructed. A pilot study exploring the methodological issues and ethical challenges of using photo elicitation with a highly stigmatized social group of women was conducted. The intersectional model and pilot study findings were then used to guide a qualitative descriptive study using storyline graphs, photo elicitation and in-depth qualitative interviewing as methods for exploring the intersection of the social determinants of health for eighteen (18) African American mothers living with HIV. Content, vector and frame analyses were used to describe the intersection of social determinants and identify potential process and structural level interventions. </p><p>Results: Findings from the pilot study include best practices for using visual methods with a highly stigmatized and potentially vulnerable group of women. Findings from the qualitative descriptive study include six additional social determinants of health - social support, religiosity, animal companions, physical environment, transportation and housing - not initially included in the conceptual model, a case for strength-based approaches, intersecting social determinants functioning as systems of oppression and the heterogeneous and fluid social locations as framed from the mother’s perspective. Three frames of social location for African American mothers living with HIV were proposed – emancipatory, situational, and internalized – as well as potential health implications and interventions. Each of the findings add to the literature on the configuration of intersecting social determinants health relevant to African American mothers living with HIV, expand the proposed intersectional model and help to generate hypotheses needed for intervention studies.</p> / Dissertation