The susceptibility of individuals to illness and disease is greatly influenced by context specific social determinants of health (SDH), yet there is a dearth of literature pertaining to SDH among refugees, particularly those residing in urban areas. The purpose of this study was to identify and generate empirical evidence on SDH among female refugees in Malaysia. It focused specifically on Rohingya refugees, a stateless and persecuted Muslim minority from Myanmar. Intersectionality formed the theoretical foundation of the study, which utilized a qualitative research design and employed an exploratory, applied research approach. Document review provided background and contextual information for primary data, which were collected using semi-structured interviews and analysed using thematic analysis. The study was undertaken in affiliation with the United Nations High Commission for Refugees (UNHCR) and had two primary outputs: it provided UNHCR with information and recommendations to inform context-specific program and policy development, and it generated rich empirical findings that contribute to the nascent evidence base on SDH in the context of forced migration. Results indicate that key factors affecting the health and wellbeing of Rohingya women include: their journey from Myanmar to Malaysia, income, employment, food security, transportation, the physical environment, UNHCR, security issues, education, religion, healthcare, and social capital/the social safety net. These interacted, overlapped and compounded each other, forming a ‘web of interrelated factors’ that affected participants’ health. Findings provide insight into the instrumental role of the sociopolitical context in structuring the lives of urban refugee women, and emphasize the importance of extending current discourse beyond refugee women’s needs and vulnerabilities to consider their resilience and agency in situations of significant hardship. / Graduate / 2015-03-28 / 0573

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.

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.

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.

The social and structural determinants play a significant role in community health, and differences in the experience of these factors facilitate some of the health disparities that are seen in the US along racial and socioeconomic lines. In this manuscript, I propose a conceptual model of the social determinants of health hierarchy and discuss the positioning of the structural determinants of the built environment within that hierarchy. I discuss the research connecting some of the structural determinants to health outcomes. Finally, I review several opportunities for local government to alter the built environment in ways that can promote community health and mitigate health inequity. / Urban Bioethics