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)

Social Determinants of Health (SDOH) play a crucial role in healthcare outcomes, yet identifying them from unstructured patient data remains a challenge. This research explores the potential of Large Language Models (LLMs) for automated SDOH identification from patient notes. We propose a general framework for SDOH screening that is simple and straightforward. We leverage existing SDOH datasets, adapting and combining them to create a more comprehensive benchmark for this task, addressing the research gap of limited datasets. Using the benchmark and proposed framework, we conclude by conducting several preliminary experiments exploring and comparing promising LLM system implementations. Our findings highlight the potential of LLMs for automated SDOH screening while emphasizing the need for more robust datasets and evaluation frameworks. / Master of Science / Social Determinants of Health (SDOH) have been shown to significantly impact health outcomes and are seen as a major contributor to global health inequities. However, their use within the healthcare industry is still significantly under emphasized, largely due to the difficulty of manually identifying SDOH factors. While previous works have explored automated approaches for SDOH identification, they lack standardization, data transparency and robustness, and are largely outdated compared to the latest Artificial Intelligence (AI) approaches. Therefore, in this work we propose a holistic framework for automated SDOH identification. We also present a higher quality SDOH benchmark, merging existing publicly available datasets, standardizing them, and cleaning them for errors. With this benchmark, we then conducted experiments to gain greater insights into the best performance across different state-of-the-art AI approaches. Through this work, we contribute a better way to think about automated SDOH screening systems, the first publicly accessible multi-clinic and multi-annotator benchmark, as well as greater insights into the latest AI approaches for state-of-the-art results.

Yes / If global palliative care is to successfully address challenges of unequal access, continuity of care, and health services reductionism, new practice models to address these issues need to be identified, debated and tested. This paper offers one such practice model based on a public health approach to palliative care that has so far shown promising evidence of effectiveness. Methods: We describe how four essential elements within a public health model can work together to address quality and continuity of care as well as addressing the numerous barriers of access. These elements are: (I) specialist, and (II) generalist palliative care services working with (III) communities and neighbourhoods, working in their turn with their (IV) key civic institutions. Results: The positive and negative impact and advantages of each of these elements is described and discussed. Conclusions: A solely clinical model of palliative care is inadequate to addressing the multiple comorbidities and access issues characteristic of modern palliative care. A public health approach based on a close partnership between clinical services and communities/civic institutions is the optimal practice model.

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.

Purpose: The purpose of this study is to examine the social determinants of CHIP (Child Health Investment Partnership) of Roanoke Valley children who participated in the preventive oral health program compared to those who did not. Methods: This is a retrospective cohort study of children (n=2,425) enrolled in CHIP of Roanoke Valley from September 2008-September 2014. Bivariate analysis and multivariable logistic regression models were used to compare age, gender, race, locality, parents’ education level, age at enrollment, and length of enrollment for oral health program participants versus those who did not participate. Results: Children who were Hispanic as well as children who enrolled in CHIP at an earlier age were more likely to enroll in the oral health program. Conclusions: By focusing on enrolling children at earlier ages, there is the potential to increase the use of dental care to match the recommended periodicity of dental care for young children.

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.