Despite the development of an Aboriginal Healing and Wellness Strategy (AHWS), which implemented Aboriginal Health Access Centres (AHACs) to provide integrated healthcare including both mainstream and traditional services, health inequalities persist among the urban Aboriginal population in Ontario. There are multiple social determinants of health (SDOH) besides access to healthcare that affect Aboriginal health. The objectives of this study were to describe the past and current policy strategies to address Aboriginal health in Ontario, and to investigate the ways that service providers perceive health inequalities, demonstrating whether the SDOH are considered in service provision to urban Aboriginal clients. In addition to a document review, interviews were held with representatives from three provincial ministries involved with the AHWS. Through a community engagement research strategy, nine semi-structured interviews were conducted with service providers from various departments within an urban AHAC. Interviews were analyzed using a modified grounded theory, which was guided by the SDOH framework. In understanding policy development, themes included: collaboration with Aboriginal communities and improving access to holistic care. In approaching service provision, themes included: perceived health inequalities and their determinants, what is being done and what must be done to address health inequalities and the use of the SDOH framework in practice. Findings suggest that service providers accurately identify the health needs of their clients, and utilize the SDOH to understand the causes of inequalities, however the SDOH cannot be fully addressed at the service provision level. The SDOH framework must be utilized at the policy level, in order to effectively address the wider determinants of health through intersectoral collaboration between provincial ministries and Aboriginal communities. / Thesis / Master of Arts (MA)

This submission for the award of PhD by Published Work includes a range of single, joint and multiple-authored publications that were published between 2005 and 2016. The publications cover a range of issues relevant to social work with a particular emphasis on mental health and health inequalities. The statement provides an underpinning conceptual framework that demonstrates interwoven themes of power, partnership and marginality. These are explored in relation to the published work, demonstrating an original and coherent contribution to the social work knowledge and practice base. The discussion draws on a reflexive journey through social work practice, education and research. The conclusion proposes that considerations of power and partnership are crucial elements of the potential for creative work ‘on the margins’.

yes / Efforts to reduce the widening gap between the health and social well-being of people within and between countries have become an urgent priority for politicians and policymakers. The Rio Declaration called on governments worldwide to promote and strengthen universal access to social services and to work in partnership to promote health equity and foster more inclusive societies. This paper contributes to international debates about the role of social work in promoting social justice by reducing social and health inequalities. Despite clear commitments to promote good health, there is a notable absence of a social determinants of health perspective in international social work curricula standards. The current review of social work education in England presents a timely opportunity to integrate such a perspective in teaching and learning and to disseminate this more widely. Employing the concepts of downstream and upstream interventions, the first part of the paper examines the distinctiveness of the social work contribution to this global agenda. In the second part of the paper, we consider how the content of learning activities about health inequalities can be incorporated in international social work curricula, namely, human rights, using Gypsy and Traveller families as an exemplar, inter-professional education and international perspectives.

No / Lay involvement in public health programmes occurs through formalised lay health worker (LHW) and other volunteer roles. Whether such participation should be supported, or indeed rewarded, by payment is a critical question. With reference to policy in England, UK, this paper argues how framing citizen involvement in health only as time freely given does not account for the complexities of practice, nor intrinsic motivations. The paper reports results on payment drawn from a study of approaches to support lay people in public health roles, conducted in England, 2007e9. The first phase of the study comprised a scoping review of 224 publications, three public hearings and a register of projects. Findings revealed the diversity of approaches to payment, but also the contested nature of the topic. The second phase investigated programme support matters in five case studies of public health projects, which were selected primarily to reflect role types. All five projects involved volunteers, with two utilising forms of payment to support engagement. Interviews were conducted with a sample of project staff, LHWs (paid and unpaid), external partners and service users. Drawing on both lay and professional perspectives, the paper explores how payment relates to social context as well as various motivations for giving, receiving or declining financial support. The findings show that personal costs are not always absorbed, and that there is a potential conflict between financial support, whether sessional payment or expenses, and welfare benefits. In identifying some of the advantages and disadvantages of payment, the paper highlights the complexity of an issue often addressed only superficially. It concludes that, in order to support citizen involvement, fairness and value should be considered alongside pragmatic matters of programme management; however policy conflicts need to be resolved to ensure that employment and welfare rights are maintained. / National Institute for Health Research Service Delivery and Organisation Programme (project number 08/1716/206).

Background: Perinatal depression disproportionately affects asylum seeking and refugee (AS&R) women, but they are less likely to receive support than other women. There is no published research which considers the assessment and support for symptoms of perinatal depression provided by midwives for AS&R women navigating England’s maternity services. Aim: To investigate how midwifery practice can be developed to support asylum seeking and refugee women with symptoms of perinatal depression. Methods: A post-colonial feminist inquiry consisting of a scoping survey (study one) and a qualitative research study (study two) using remote interviews with AS&R women and midwives. Qualitative data was analysed using reflexive thematic analysis. Findings: Study one demonstrated that midwives who care for AS&R women work within diverse roles and service structures across England. Study two identified that midwives lack the resources and support structures required to effectively recognise and support symptoms of perinatal depression in AS&R women. These factors were sometimes invisible to AS&R women, but still negatively affected their ability to effectively discuss perinatal depression with a midwife and access help for any symptoms. The lack of appropriate resources was harmful to both AS&R women and midwives. Conclusion: AS&R women and midwives who care for them navigate an inequitable maternity system in England. Midwives do not have the appropriate resources to provide a level of care which is equitable to women in the general maternity population. This leaves AS&R women’s perinatal mental health needs unrecognised and unmet, acting as a barrier to receiving effective support. / Mary Seacole research development scholarship

No / Bradford, in northern England, has attracted migrants since the nineteenth century. The most recent group, from Pakistan, began to arrive in the 1950s. There is now a three-generational Muslim community of Pakistani origin. The interaction of migration, ethnicity and deprivation in Bradford is considered by focusing on infant mortality. This is higher in Bradford than overall UK averages. The highest rates are in babies of first-generation migrant mothers. Migration theory, in particular, macro-economic models explaining choice to migrate, is critically reviewed. In addition to economic factors, family reconstitution is a key motivation for migration. The resulting characteristics of migrants and of the hybrid community they constitute display a complex clustering of risk factors relevant to infant health. An understanding of individual and social characteristics of the migrant community are needed to augment conventional theories of health disadvantage, which do not explain the inequality of life chances evident in this city.

Introdução - A exposição à poluição do ar é responsável por diversos efeitos à saúde e se distribui de forma diferenciada na população conforme o nível sócio-econômico. Objetivos - Explorar relações entre internações hospitalares por tipos de câncer e indicadores ambientais e sócioeconômico, na escala de áreas de pequeno tamanho, no município de São Paulo. Métodos - Revisaram-se estudos ecológicos sobre desigualdades sócio-econômicas em câncer e estudos sobre os efeitos da poluição ambiental do ar relacionada ao tráfego sobre o risco de câncer, publicados entre 1998 e 2008. Empreendeu-se a seguir estudo ecológico, com uso de unidade delimitada por grid (500 por 500 metros) e setor censitário, englobando todos os indivíduos internados em hospitais públicos ou privados com diagnóstico principal de neoplasia primária invasiva, no período de 2004 a 2006. As internações foram georreferenciadas e alocadas às unidades de estudo, sendo cada caso contado apenas uma vez. A densidade de tráfego foi calculada para cada unidade da grid a partir de dados de contagem veicular. Utilizaram-se modelos de regressão logística para explorar as associações entre densidade de tráfego, Índice de Desenvolvimento Humano e taxas de internação hospitalar. Resultados - O estudo de revisão mostrou que o nível sócio-econômico se associou de modo distinto de acordo com o tipo de neoplasia maligna. A maioria dos estudos observaram associação positiva da poluição ambiental do ar com câncer, com achados mais consistentes para exposição a material particulado inalável e câncer de pulmão. Do estudo ecológico verificou-se risco aumentado de internação por neoplasias respiratórias em adultos e hematológicas em crianças e adolescentes associado a morar em áreas com maior densidade de tráfego por veículos totais, movidos a gasolina e a diesel, com claro gradiente dose-resposta. O nível sócio-econômico da área 6 de moradia esteve associado positivamente e em gradiente com as medidas de densidade de tráfego e com os cânceres de mama e de próstata. Conclusões - Investigações se fazem necessárias em megacidades de países em desenvolvimento sobre os riscos à saúde relacionados à poluição ambiental do ar devida ao tráfego e sobre o modo como se desenvolveu a rede viária e o tráfego de veículos em sua relação com os locais ocupados historicamente pelas diferentes classes sociais. Estudos que contornem as limitações aqui encontradas poderão fornecer estimativas mais precisas e acuradas / Introduction - Exposure to air pollution is responsible for various health effects and is distributed differently in the population according to socioeconomic status. Objectives - To explore relationships between hospital admissions for cancers and socio-economic and environmental indicators, on a small-area scale, in São Paulo city. Methods - First we reviewed ecological studies on socioeconomic inequalities in cancer and studies on the effects of traffic-related air pollution on the risk of cancer, published between 1998 and 2008. Then an ecological study was undertaken, using a unit defined by grid (500 by 500 meters) and census tract, and embraced all individuals admitted to public or private hospitals with a main diagnosis of primary invasive cancer during the period 2004 to 2006. Hospitalizations were georeferenced and allocated to units of study, each case counted only once. The traffic density was calculated for each grid unit from vehicle count data. We used logistic regression models to explore the associations between traffic density, Human Development Index and rates of hospitalization. Results - The review showed that the socioeconomic status was associated differently according to the type of malignancy. Most studies found a positive association of environmental air pollution with cancer, the most consistent findings for exposure to inhalable particulate matter and lung cancer. The ecological study found an increased risk of hospitalization for respiratory cancers in adults and for hematologic cancers in children and adolescents associated with living in areas with higher total, gasoline and diesel traffic density, with a clear dose-response gradient. The socioeconomic status of the living area was positively associated in gradient with measures of traffic density and with breast and prostate cancers. 8 Conclusions - Investigations are necessary in megacities of developing countries about the health risks of traffic-related environmental air pollution and about how the development of the road network and vehicle traffic relates to sites historically occupied by different social classes. Studies that circumvent the limitations found here may provide more precise and accurate estimates

Cette thèse a pour but d'améliorer les connaissances concernant les techniques d'analyse de données et certains modèles bayésiens dans le domaine de l'étude des inégalités sociales et environnementales de santé. À l'échelle géographique de l'IRIS sur les agglomérations de Paris, Marseille, Lyon et Lille, l'événement sanitaire étudié est la mortalité infantile dont on cherchera à expliquer le risque avec des données socio-économiques issues du recensement et des expositions environnementales comme la pollution de l'air, les niveaux de bruit et la proximité aux industries polluantes, au trafic automobile ou aux espaces verts. Deux volets principaux composent cette thèse. Le volet analyse de données détaille la mise au point d'une procédure de création d'indices socio-économiques multidimensionnels et la conception d'un package R l'implémentant, puis la création d'un indice de multi-expositions environnementales. Pour cela, on utilise des techniques d'analyse de données pour synthétiser l'information et fournir des indicateurs composites utilisables directement par les décideurs publics ou dans le cadre d'études épidémiologiques. Le second volet concerne les modèles bayésiens et explique le modèle « BYM ». Celui-ci permet de prendre en compte les aspects spatiaux des données et est mis en oeuvre pour estimer le risque de mortalité infantile. Dans les deux cas, les méthodes sont présentées et différents résultats de leur utilisation dans le contexte ci-dessus exposés. On montre notamment l'intérêt de la procédure de création d'indices socio-économiques et de multi-expositions, ainsi que l'existence d'inégalités sociales de mortalité infantile dans les agglomérations étudiées / The purpose of this thesis is to improve the knowledge about and apply data mining techniques and some Bayesian model in the field of social and environmental health inequalities. On the neighborhood scale on the Paris, Marseille, Lyon and Lille metropolitan areas, the health event studied is infant mortality. We try to explain its risk with socio-economic data retrieved from the national census and environmental exposures such as air pollution, noise, proximity to traffic, green spaces and industries. The thesis is composed of two parts. The data mining part details the development of a procedure of creation of multidimensional socio-economic indices and of an R package that implements it, followed by the creation of a cumulative exposure index. In this part, data mining techniques are used to synthesize information and provide composite indicators amenable for direct usage by stakeholders or in the framework of epidemiological studies. The second part is about Bayesian models. It explains the "BYM" model. This model allows to take into account the spatial dimension of the data when estimating mortality risks. In both cases, the methods are exposed and several results of their usage in the above-mentioned context are presented. We also show the value of the socio-economic index procedure, as well as the existence of social inequalities of infant mortality in the studied metropolitan areas

O estudo dos determinantes sociais dos processos de saúde e doença da população é um importante campo da Saúde Coletiva, indicando que o entendimento desses fatores favorece ações concretas de cuidado e respostas às necessidades de saúde, principalmente na promoção, prevenção, tratamento e recuperação da saúde, aumenta a redução de vulnerabilidades, de iniquidades em saúde e promove justiça social. A presente pesquisa teve como objetivos verificar a evolução dos indicadores socioeconômicos e de cárie dentária, ocorrida no Brasil entre os anos 2000 e 2010, e a influência dos determinantes socioeconômicos na ocorrência de cárie dentária no Brasil, no ano de 2010. Trata-se de um estudo do tipo ecológico de caráter exploratório envolvendo dados secundários oficiais coletados dos inquéritos populacionais em Saúde Bucal, dos anos de 2003 e 2010, e do Atlas do Desenvolvimento Humano no Brasil 2013. O teste de correlação de Spearman foi utilizado para avaliar as diferenças encontradas entre os indicadores socioeconômicos e de cárie dentária entre os anos 2000 e 2010 e as técnicas de análise exploratória multivariada, denominadas Análise de Agrupamentos e Análise do Componente Principal, utilizadas para verificar a similaridade e influência entre os indicadores socioeconômicos e de cárie dentária no ano de 2010. Os resultados mostraram que entre os anos 2000 e 2010 houve melhora significativa em todos os indicadores socioeconômicos estudados em todas as regiões administrativas. Neste mesmo período, também houve melhora significante nos índices de ocorrência de cárie dentária em todas as faixas etárias (5, 12, 15 a 19, 35 a 44 e 65 anos ou mais) e em todas as regiões do Brasil. Todas as variáveis de ocorrência de cárie dentária (Prevalência de Cárie, ceod/CPOD e número de dentes cariados, restaurados e perdidos por cárie) relativos aos grupos etários de 5, 12 e 15 a 19 anos, foram influenciados pelo determinante socioeconômico compreendido pela desigualdade de renda. Entre os adultos (35 a 44 anos) e idosos (65 a 74 anos) as variáveis de ocorrência de cárie dentária sofreram influencia dos aspectos físico-materiais na produção da saúde e da doença, das desigualdades de renda e das relações entre a saúde das populações e as condições nas quais ela vive. Os indicadores analisados podem contribuir na elaboração de modelos de decisão em saúde, na explicação dos processos organizativos e da desigualdade na oferta de serviços e recursos humanos em saúde bucal no Brasil. / Analysis of the social determinants of health and disease processes in the population is an important field in Public Health, indicating that understanding on these factors favors concrete actions of care and responses to the health needs, especially for health promotion, prevention, treatment and recovery; it reduces the vulnerabilities and health inequalities and promotes social justice. This study analyzed the evolution of socioeconomic indicators and dental caries in Brazil between the years 2000 and 2010, as well as the influence of socioeconomic determinants on the occurrence of dental caries in Brazil in the year 2010. This ecological exploratory study involved official secondary data collected from population oral health surveys in the years 2003 and 2010, and from the Human Development Atlas in Brazil 2013. The Spearman correlation test was used to evaluate the differences observed in socioeconomic indicators and dental caries between the years 2000 and 2010, and techniques of multivariate exploratory analysis, called Group Analysis and Main Component Analysis, were used to verify that similarity and the influence between socioeconomic indicators and dental caries in the year 2010. The results revealed that, between the years 2000 an there was significant improvement in all socioeconomic indicators analyzed in all administrative regions. In the same period, there was also significant improvement in rates of occurrence of dental caries in all age groups (5, 12, 15 to 19, 35 to 44 and 65 year and in all Brazilian regions. All variables of dental caries (caries prevalence, dmft/DMFT and number of teeth decayed, restored and lost due to caries) related to the age groups of 5, 12 and 15 to 19 years were influenced by the socioeconomic determinant related to income inequality. Concerning the adults (35 to 44 years) and elderly individuals (65 to 74 years), the variables of dental caries were influenced by physical-material aspects related to health and disease processes, income inequalities and relationships between population health and living conditions. The indicators analyzed may contribute to the establishment of health decision models, explanation of organizational processes and inequality in service providing and human resources in oral health in Brazil.

O estudo dos determinantes sociais dos processos de saúde e doença da população é um importante campo da Saúde Coletiva, indicando que o entendimento desses fatores favorece ações concretas de cuidado e respostas às necessidades de saúde, principalmente na promoção, prevenção, tratamento e recuperação da saúde, aumenta a redução de vulnerabilidades, de iniquidades em saúde e promove justiça social. A presente pesquisa teve como objetivos verificar a evolução dos indicadores socioeconômicos e de cárie dentária, ocorrida no Brasil entre os anos 2000 e 2010, e a influência dos determinantes socioeconômicos na ocorrência de cárie dentária no Brasil, no ano de 2010. Trata-se de um estudo do tipo ecológico de caráter exploratório envolvendo dados secundários oficiais coletados dos inquéritos populacionais em Saúde Bucal, dos anos de 2003 e 2010, e do Atlas do Desenvolvimento Humano no Brasil 2013. O teste de correlação de Spearman foi utilizado para avaliar as diferenças encontradas entre os indicadores socioeconômicos e de cárie dentária entre os anos 2000 e 2010 e as técnicas de análise exploratória multivariada, denominadas Análise de Agrupamentos e Análise do Componente Principal, utilizadas para verificar a similaridade e influência entre os indicadores socioeconômicos e de cárie dentária no ano de 2010. Os resultados mostraram que entre os anos 2000 e 2010 houve melhora significativa em todos os indicadores socioeconômicos estudados em todas as regiões administrativas. Neste mesmo período, também houve melhora significante nos índices de ocorrência de cárie dentária em todas as faixas etárias (5, 12, 15 a 19, 35 a 44 e 65 anos ou mais) e em todas as regiões do Brasil. Todas as variáveis de ocorrência de cárie dentária (Prevalência de Cárie, ceod/CPOD e número de dentes cariados, restaurados e perdidos por cárie) relativos aos grupos etários de 5, 12 e 15 a 19 anos, foram influenciados pelo determinante socioeconômico compreendido pela desigualdade de renda. Entre os adultos (35 a 44 anos) e idosos (65 a 74 anos) as variáveis de ocorrência de cárie dentária sofreram influencia dos aspectos físico-materiais na produção da saúde e da doença, das desigualdades de renda e das relações entre a saúde das populações e as condições nas quais ela vive. Os indicadores analisados podem contribuir na elaboração de modelos de decisão em saúde, na explicação dos processos organizativos e da desigualdade na oferta de serviços e recursos humanos em saúde bucal no Brasil. / Analysis of the social determinants of health and disease processes in the population is an important field in Public Health, indicating that understanding on these factors favors concrete actions of care and responses to the health needs, especially for health promotion, prevention, treatment and recovery; it reduces the vulnerabilities and health inequalities and promotes social justice. This study analyzed the evolution of socioeconomic indicators and dental caries in Brazil between the years 2000 and 2010, as well as the influence of socioeconomic determinants on the occurrence of dental caries in Brazil in the year 2010. This ecological exploratory study involved official secondary data collected from population oral health surveys in the years 2003 and 2010, and from the Human Development Atlas in Brazil 2013. The Spearman correlation test was used to evaluate the differences observed in socioeconomic indicators and dental caries between the years 2000 and 2010, and techniques of multivariate exploratory analysis, called Group Analysis and Main Component Analysis, were used to verify that similarity and the influence between socioeconomic indicators and dental caries in the year 2010. The results revealed that, between the years 2000 an there was significant improvement in all socioeconomic indicators analyzed in all administrative regions. In the same period, there was also significant improvement in rates of occurrence of dental caries in all age groups (5, 12, 15 to 19, 35 to 44 and 65 year and in all Brazilian regions. All variables of dental caries (caries prevalence, dmft/DMFT and number of teeth decayed, restored and lost due to caries) related to the age groups of 5, 12 and 15 to 19 years were influenced by the socioeconomic determinant related to income inequality. Concerning the adults (35 to 44 years) and elderly individuals (65 to 74 years), the variables of dental caries were influenced by physical-material aspects related to health and disease processes, income inequalities and relationships between population health and living conditions. The indicators analyzed may contribute to the establishment of health decision models, explanation of organizational processes and inequality in service providing and human resources in oral health in Brazil.