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.

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.

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.