This study explored how public health nurses (PHNs) work to address health inequities. Cultural safety was used as a theoretical lens. Methods for interpretive description were relied on for data collection and analysis. Data sources included interviews with 14 staff from an urban public health unit and document review of three policies. Two themes emerged: building relationships and working within a frame. Building relationships involved: delivering the message, taking the time, being present, the right nurse and learning from communities. The public health frame influenced the capacity of PHNs to address health inequities through: culture and stereotypes, public health standards, setting priorities, inclusion of priority populations, responding to change and (re)action through reorganization. Discursive formations of priority populations, and partnership and collaboration, were revealed. Findings highlighted downstream public health approaches to addressing health inequities. Importantly, embedding cultural safety as a framework for public health practice can guide upstream action.

This study explored how public health nurses (PHNs) work to address health inequities. Cultural safety was used as a theoretical lens. Methods for interpretive description were relied on for data collection and analysis. Data sources included interviews with 14 staff from an urban public health unit and document review of three policies. Two themes emerged: building relationships and working within a frame. Building relationships involved: delivering the message, taking the time, being present, the right nurse and learning from communities. The public health frame influenced the capacity of PHNs to address health inequities through: culture and stereotypes, public health standards, setting priorities, inclusion of priority populations, responding to change and (re)action through reorganization. Discursive formations of priority populations, and partnership and collaboration, were revealed. Findings highlighted downstream public health approaches to addressing health inequities. Importantly, embedding cultural safety as a framework for public health practice can guide upstream action.

Cubas provision of free health services to the entire population via neighborhood-based family doctors produced dramatic health gains and achieved a relative state of health equality. Since 1989, however, the termination of Soviet trade, a grave economic crisis, intensification of the US embargo, welfare reductions, and population aging have placed Cubas health successes and elder care services in jeopardy. Little independent research, though, has focused on the influence of post-Cold War circumstances on citizen attitudes about health programs and resources targeting Cubas older population. This research examined global and domestic factors since 1989 that have most influenced perceptions of the equitability and inequitability of health resources among older Cubans. Its multi-layered design drew on new International Political Economy, crystallization, and aspects of Grounded Theory. In-depth narrative interviews were conducted with Cubans age 60 years or older, their families and community support group members, family physicians and other medical personnel, and key health and government informants. Perceptions of health equity were found to correspond most with the geographic proximity and nearly unhindered physical access of older patients to their family doctors and the temporal availability of family physicians to their older patients. Conversely, perceptions of health inequity corresponded most with the older persons experience of medicine shortages and health resource rationing following global socio-political-economic change and domestic policy shifts after 1989. Furthermore, the life course influences of the pre- and post-revolutionary eras and pre-1989 and post-Cold War period were seminal in shaping the perceptions and expectations of the older participants regarding health care, the leadership, and Cuban socialism. The findings have added to the international health and cross-cultural gerontology literature. Decision-makers and health practitioners in Cuba and elsewhere have been informed about the importance of popular perceptions of the impact of health and elder policy change in an era of globalized social relations and capital. The research also has contributed a gerontological dimension and a narrative perspective to further the development of new International Political Economy.

Doctor of Philosophy / Department of Geography / Bimal K. Paul / This research set out to better understand the impact of socioeconomic characteristics, environmental risk, and the built environment on health in Mobile County, Alabama. A multilevel statistical analysis was used to identify those characteristics that had the greatest impact on health. The variables determined to be the most significant in defining health in Mobile County were used in the development of a health inequity index (HIQ). The index was used to identify the zip code tabulation areas (ZCTAs) in Mobile County that were likely to exhibit greater health inequality, and as a result, a higher potential for health inequity. In this study, a mailed survey on the built environment and health was conducted to gain a better understanding of the characteristics of individual residences, perceptions of individuals in regards to neighborhood health, citizen activism, and the environmental justice movement. Because there was a low response rate for the mailed surveys, fieldwork with face-to-face interviews was conducted in July, 2009. In conjunction with the survey data, mortality data obtained from the Alabama Department of Public Health was incorporated into the multilevel analysis. Using crude death rate, cause-specific death rate for cancer, and cause-specific death rate for heart disease as dependent variables and factors associated with socioeconomic status, environmental risk, and the built environment as independent variables, multiple linear regression was performed. The results of the multiple linear regression identified factors of socioeconomic status, environmental risk, and the built environment that had the greatest impact on health in Mobile County. Geographically weighted regression was performed to test local model strength by ZCTA in Mobile County. It was determined that the health inequity index developed as a result of the multilevel analysis was a reasonable measure of population health. Calculations of HIQ for each ZCTA in Mobile County helped to identify those ZCTAs most in need of intervention. The ZCTAs with high HIQ values were also those where the built environment was extremely poor, indicating that health is impacted by the places where people live.

Are health inequalities unjust, and if so, how should we measure and evaluate them? This thesis explores the central moral debates that underlie these sorts of questions about health inequalities, and it argues in support of one particular framework for measuring health inequalities. I begin by shedding light on the questions that need to be asked when attempting to determine which types of health inequalities are unjust. After explaining the complexities of several possible views of health inequity, I use these perspectives to inform my discussion of the debate about whether we ought to measure health inequalities in terms of individuals or groups. I evaluate the key tensions between these two opposing points of view. I then introduce a third possible view, which is Yukiko Asada’s idea that both individual and group-based measures of health inequality leave out important moral information, so it is therefore necessary to include both in order to get a full picture of a population’s health inequality. Next, I respond to objections that the proponents of using either a group or individual measurement of inequality on its own might make to the claim that neither measure is sufficient on its own. Finally, I propose some small changes to Asada’s measurement framework, which I believe will demonstrate why those opposed to her view actually ought to embrace it. I conclude that this approach is a promising solution to some of the difficulties defining health inequities that I have called attention to.

Estudo transversal com objetivo de estabelecer a relação entre condição bucal e impacto na qualidade de vida em 504 adultos de Chapecó, SC. Impacto Oral no Desempenho Diário (IODD), condição de saúde bucal, hábitos e cuidados, percepção de saúde e aspectos sociodemográficos foram coletados em exames clínicos e entrevistas domiciliares. Utilizou-se modelo de regressão logística múltipla, não condicional, hierarquizada na análise. O impacto foi referido por um quinto da população e apresentou baixa severidade. Comer e limpar os dentes foram as atividades mais afetadas. Morar em domicílios de maior aglomeração e nas áreas de pior condição de vida, ser mulher, ter sofrido com dor orofacial nos últimos seis meses e avaliar sua saúde como razoável ou ruim no último mês apresentaram associação independente com o impacto / The aim of this cross-sectional study was to establish a relationship between oral condition and its impact on quality of life in adults between 35 and 44 years-old (n=504) in Chapecó, State of Santa Catarina, Brazil. The Oral Impact on Daily Performances (OIDP), oral health condition, habits and care, self perception of health and socio-demographic aspects were collected during clinical examination and home interviews. Unconditional multiple logistic regression models were used in the analysis. Impact was found in a fifth of the population and was of low severity. Eating and cleaning teeth were the most affected performances. Households overcrowded, living in areas of poor conditions, being a woman, having sufered from orofacial pain in the last six months and individuals assessing their own health as reasonable or poor in the last month were independently associated with the impact

This thesis sets out to explore the extent to which health inequities experienced by Aboriginal youth living in Winnipeg are mediated by the urban environment. Between 2010 and 2011, Aboriginal youth associated with the GAPAYAC undertook a participatory action research process to create stories about the geography of health inequity, to share their ideas for positive change, and to support their social and political aspirations towards their right to a healthy city. The youth researchers (N=8) used participatory hip hop techniques involving visual art, photography, spoken word, music, and dance as tools to 'map' health inequities within and across the city. The results revealed several themes that speak to the youth researchers experiences of health inequity as they related to mobility, place, and exclusion. In turn, the youth researchers mobilized their knowledge through art and performances as vehicles for taking action against health inequity.

This thesis sets out to explore the extent to which health inequities experienced by Aboriginal youth living in Winnipeg are mediated by the urban environment. Between 2010 and 2011, Aboriginal youth associated with the GAPAYAC undertook a participatory action research process to create stories about the geography of health inequity, to share their ideas for positive change, and to support their social and political aspirations towards their right to a healthy city. The youth researchers (N=8) used participatory hip hop techniques involving visual art, photography, spoken word, music, and dance as tools to 'map' health inequities within and across the city. The results revealed several themes that speak to the youth researchers experiences of health inequity as they related to mobility, place, and exclusion. In turn, the youth researchers mobilized their knowledge through art and performances as vehicles for taking action against health inequity.

Estudo transversal com objetivo de estabelecer a relação entre condição bucal e impacto na qualidade de vida em 504 adultos de Chapecó, SC. Impacto Oral no Desempenho Diário (IODD), condição de saúde bucal, hábitos e cuidados, percepção de saúde e aspectos sociodemográficos foram coletados em exames clínicos e entrevistas domiciliares. Utilizou-se modelo de regressão logística múltipla, não condicional, hierarquizada na análise. O impacto foi referido por um quinto da população e apresentou baixa severidade. Comer e limpar os dentes foram as atividades mais afetadas. Morar em domicílios de maior aglomeração e nas áreas de pior condição de vida, ser mulher, ter sofrido com dor orofacial nos últimos seis meses e avaliar sua saúde como razoável ou ruim no último mês apresentaram associação independente com o impacto / The aim of this cross-sectional study was to establish a relationship between oral condition and its impact on quality of life in adults between 35 and 44 years-old (n=504) in Chapecó, State of Santa Catarina, Brazil. The Oral Impact on Daily Performances (OIDP), oral health condition, habits and care, self perception of health and socio-demographic aspects were collected during clinical examination and home interviews. Unconditional multiple logistic regression models were used in the analysis. Impact was found in a fifth of the population and was of low severity. Eating and cleaning teeth were the most affected performances. Households overcrowded, living in areas of poor conditions, being a woman, having sufered from orofacial pain in the last six months and individuals assessing their own health as reasonable or poor in the last month were independently associated with the impact

While tobacco use remains a leading preventable risk factor for mortality and morbidity in Canada (Patra, Rehm, Baliunas & Popova, 2007), the overall smoking prevalence rate of Canadians has decreased substantially from close to 50% of the population in 1965 to 16.1% of the population in 2012 (Canadian Tobacco Use Monitoring Survey (CTUMS) 2012; Reid, Hammond, Rynard & Burkhalter, 2014). However, up to 85% of individuals with a mental illness continue to use tobacco products (Harris, Parle & Gagne, 2007), contributing to an inequitable distribution of negative health outcomes for this population. Individuals with severe mental illness die an estimated twenty-five years earlier than the general population, with sixty per cent of these deaths due to cardiovascular, pulmonary and infectious disease (Parks, Svendsen, Singer, & Foti, 2006). A recent study that examined specific tobacco-attributable deaths in these populations found that tobacco accounted for 53% of deaths in individuals with schizophrenia, 50% of all deaths for those diagnosed with a depressive disorder, and 48% of all deaths for those with a diagnosis of bipolar disorder (Callaghan et al., 2014). This research project is intended to increase our understanding of what constitutes an effective intervention for smoking cessation and smoking reduction in a population of individuals with severe mental illness who are homeless or vulnerably housed, living in a large urban setting. Two areas of inquiry were proposed. The first inquiry examined data collected as part of a needs assessment to determine the overall prevalence rate of smoking and related behaviours for a population of individuals with severe mental illness receiving services from a community mental health agency. We found that the tobacco use prevalence was 72%, and 62% of smokers had high or very high levels of nicotine dependence; however almost half of respondents (47%) were interested in quitting or reducing tobacco within the next 6 months. Smokers were found to be over 9 times more likely to have a co-occurring substance use disorder (OR=9.44, 95%CI[6.33,14.08]). The second inquiry was a pilot study conducting a randomized controlled trial design to evaluate smoking cessation and smoking reduction outcomes for two groups of individuals (n=61) with severe mental illness receiving different smoking cessation interventions. Clients randomly assigned to the routine Smoking Cessation group (SC-R) received up to 24 weeks of no-cost Nicotine Replacement Therapy (NRT) and clients assigned to the Smoking Cessation Plus group (SC+) received up to 24 weeks of no-cost Nicotine Replacement Therapy (NRT) plus two initial individual sessions of motivational interviewing followed by weekly psychosocial group interventions for up to 24 weeks. Primary outcomes were levels of tobacco use at the 3-month and 6-month follow-up. The 7-day point prevalence abstinence rate measured at 3 months was 21.9% (n=7) for the SC+ group and 13.8% (n=4) for the SC-R group (OR=1.75,95%CI[.46,6.74]). At 6 months, the 7-day point prevalence abstinence rate was 12.5% (n=4) for the SC+ group and 6.9% (n=2) for the SC-R group (OR=1.93, 95%CI[.33,11.41]). Secondary outcomes included change in reported quality of life, physical health and mental health status functioning over the course of the study. We found that there were no statistically significant differences in the smoking quit or smoking reduction rates between the two treatment groups. At the 3-month time point the overall quit rate for both groups combined was 18% (n=11) and at the 6-month time point the quit rate was 10% (n=6). Reduction in the number of daily cigarettes smoked was statistically significant over time (F [1.68, 98.90] = 55.13, p < .001, η p 2 = 0.48) for both groups, as was the overall reduction of the FTND score (F [2, 94] = 17.98, p < .001, η p 2 = 0.28). This research demonstrates that collecting vital tobacco prevalence and dependency information is a straightforward and important task for community mental health agencies. Individuals with mental illness have both the interest and ability to quit or reduce their use of tobacco. Practitioners need to be aware of alternative smoking practices that may contribute to understanding tobacco use patterns and dependence in this population. Other factors such as co-morbid substance use disorder and level of community functioning may influence smoking status and, consequently, how treatment is provided. The findings of the pilot trial demonstrate the feasibility of conducting smoking cessation research with the population. Findings also suggest that a larger definitive trial is warranted to examine the effectiveness of the SC+ intervention. This research adds to the limited but growing knowledge base of how to address tobacco use and provide treatment to this vulnerable group, and will contribute to advances in population health by informing effective interventions with the attendant implications for program and policy development.