The increase in the academic literature concerning the potential impacts that urban park systems can have over the life course of urban residents is beginning to be recognized by professionals in the fields of community quality of life studies, population health and in health geography. Typically urban spaces within Canada are designed to include a component of open space which can facilitate the recreation needs of residents. Within the City of Saskatoon neighbourhoods have such spaces in the form of neighbourhood parks, which are meant to facilitate passive or active recreation. Parks also provide open spaces of vegetation cover as opposed to the concrete and structural components of the city. Parks are meant to positively contribute to the residents lives and to the neighbourhood in which they are located. <p>In community quality of life studies, open spaces, such as parks along with other neighbourhood attributes, are often used to gauge residents perceptions of their immediate surroundings. The Saskatoon Quality of Life Project conducted by the Quality of Life Module at the Community-University Institute for Social Research (CUISR) conducted such a study in 2004 in which park spaces were related alongside other neighbourhood features such as transportation and social activities in order to capture residents perceptions of their community quality of life. <p>The purpose of this study is to look at how residents of differing socio-economic status (SES) neighbourhoods (one high SES and one low SES) perceive their neighbourhood park spaces and if their perceptions affect their perceived quality of life. In order to capture residents perceptions of their neighbourhood parks, face-to-face interviews were conducted with residents. In addition to the resident interviews, interviews were conducted with key informants as well as statistical analysis of secondary data from the 2004 Saskatoon Quality of Life Project was carried out. Results showed residents of different neighbourhood SES status shared common perceptions of their park spaces as well as how neighbourhood parks contributed to their quality of life.

Introduction: The distribution of the causes of maternal deaths, and the impact of facility-based obstetric care access (obstetric access) at the individual and population level in India have not yet been quantified. Objectives: (i) estimate the physician agreement for coding of maternal deaths; (ii) explain the distribution of maternal mortality in India; and (iii) quantify the effect of obstetric access on the probability of maternal death, accounting for effect modification of state level skilled attendant coverage. Methods: I used the nationally representative Million Death Survey (MDS) of the causes of death from 2001-3. I identified context-specific risk factors from the field reports to provide information on care patterns before deaths. The 1096 MDS maternal deaths were matched to 147 001 controls of non-fatal deliveries from a representative fertility survey. Findings: 1.Inter-rater reliability was substantial for two physicians assigning a cause of death. 2. Three-quarters of India's maternal deaths were clustered in rural areas of poorer states, although these regions have only half the estimated births in India. The distribution of major causes of maternal deaths (most notably hemorrhage, obstruction, sepsis, abortion) did not differ between poorer and richer states. Two-thirds of maternal deaths died seeking healthcare, most in a critical medical condition. 3. The probability of maternal death decreased with increasing skilled attendant coverage, among both women who had and had not accessed obstetric care. The risk of death among women who had obstetric access was higher (at 50% coverage, OR=2.32) than among those women who did not. However at higher population levels of coverage of safe birth, obstetric access had no effect. This effect appears to be driven partially by reverse causality, in which critical illness is shown to confound the association between care seeking and death. Conclusions: Simple MDS methods enable measurement of the levels, determinants of maternal deaths. Currently, obstetric access in India appears to be an indicator for inequitable access and poor quality even though it is a life-saving intervention. Reduction in maternal mortality in India will require expanded population-based coverage of skilled birth attendance and improved and early access to high quality obstetric care.

Introduction: The distribution of the causes of maternal deaths, and the impact of facility-based obstetric care access (obstetric access) at the individual and population level in India have not yet been quantified. Objectives: (i) estimate the physician agreement for coding of maternal deaths; (ii) explain the distribution of maternal mortality in India; and (iii) quantify the effect of obstetric access on the probability of maternal death, accounting for effect modification of state level skilled attendant coverage. Methods: I used the nationally representative Million Death Survey (MDS) of the causes of death from 2001-3. I identified context-specific risk factors from the field reports to provide information on care patterns before deaths. The 1096 MDS maternal deaths were matched to 147 001 controls of non-fatal deliveries from a representative fertility survey. Findings: 1.Inter-rater reliability was substantial for two physicians assigning a cause of death. 2. Three-quarters of India's maternal deaths were clustered in rural areas of poorer states, although these regions have only half the estimated births in India. The distribution of major causes of maternal deaths (most notably hemorrhage, obstruction, sepsis, abortion) did not differ between poorer and richer states. Two-thirds of maternal deaths died seeking healthcare, most in a critical medical condition. 3. The probability of maternal death decreased with increasing skilled attendant coverage, among both women who had and had not accessed obstetric care. The risk of death among women who had obstetric access was higher (at 50% coverage, OR=2.32) than among those women who did not. However at higher population levels of coverage of safe birth, obstetric access had no effect. This effect appears to be driven partially by reverse causality, in which critical illness is shown to confound the association between care seeking and death. Conclusions: Simple MDS methods enable measurement of the levels, determinants of maternal deaths. Currently, obstetric access in India appears to be an indicator for inequitable access and poor quality even though it is a life-saving intervention. Reduction in maternal mortality in India will require expanded population-based coverage of skilled birth attendance and improved and early access to high quality obstetric care.

An effective population health approach to cancer prevention for young adults requires an informed understanding of cancer-relevant factors for this distinct population. Such factors include the social context, modifiable health behaviours and intrapersonal factors which influence those behaviours. It is also necessary to understand how this population seeks out and uses health information. This descriptive study was carried out through an online questionnaire delivered to a sample of 484 university students in Nova Scotia aged 17 to 29. The study revealed that most students reported good health behaviours, students new to Nova Scotia reported better health behaviours, and while health was a priority, cancer was not. Students also described how intrapersonal factors and their broader social context influenced health behaviours. The results will advance a contemporary depiction of young adult health essential for developing tailored cancer prevention and health promotion strategies.

Background: Active transportation refers to methods of travel that involve physical activity, such as walking and bicycling. For students, characteristics of both individual and contextual environments are likely associated with active transportation to school. Furthermore, injury is one possible but overlooked outcome of active transportation to school. Objectives: To examine among urban Canadian youth in grades 6-10: 1) associations between individual- and area-level factors and active transportation to school and 2) the relationship between active transportation to school and active transportation injury. Methods: Individual-level data were obtained from the 2009/2010 Canadian Health Behaviour in School-Aged Children (HBSC) survey. Active transportation to school was measured via student’s report of their usual method of travel to school. Active transportation injury was assessed via self-report for a one-year recall period. Area-level data were obtained from a school administrators’ survey and from various geographical sources. Multi-level logistic regression was used to examine the associations of interest. Results: Multiple correlates of active transportation to school were identified from the individual/family, school, and neighbourhood. Correlates possessing a potential for intervention and a relatively high population impact were identified: gender (female: relative risk, RR=0.86, 95% CI: 0.80-0.91, population attributable risk, PAR: 7.1%), perception of neighbourhood safety (disagree vs. strongly agree: RR=0.83, 95% CI: 0.70-0.95, PAR: 2.3%), percentage of roads with sidewalks (quartile 3 vs. quartile 1: RR=1.17, 95% CI: 0.96-1.34, PAR: 9.5%), and the total length of streets (quartile 4 vs. quartile 1: RR=1.23, 95% CI: 1.00-1.42, PAR: 6.9%). A positive association between active transportation to school and active transportation injury was identified; the risk for injury increased as walking or bicycling increased (short distance: OR=1.17, 95% CI: 0.92-1.50; long distance: OR=1.56, 95% CI: 1.10-2.21). Conclusions: Many factors are associated with active transportation to school. While active transportation is associated with the potential for improved health, it also likely increases the risk for active transportation injuries. Interventions to increase active transportation to school should also consider potential negative outcomes. Future studies in this research area could focus on qualitative measures of the environment and school programs, in addition to the etiology of injuries experienced during school travel. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2012-08-12 15:11:48.409

The main purpose of this research is to describe how social and economic structures operating at different scales of influence have an impact on population overweight and obesity, and become manifest at the individual level. A mixed methods approach was used in this series of studies which facilitated a cross-scale analysis of the ecology of overweight and obesity, through linking of data at the individual and structural levels. Study one employed a cross-sectional retrospective analysis of overweight, obesity and socio-demographic indicators for 8,970,590 Canadian adults (25-64 years) using the 2005 Canadian Community Health Survey. Study two analyzed the trajectory of the energy gap (energy imbalance) in the Canadian population from 1976 to 2003, its temporal relationship to adult obesity, and estimated the relative contribution of energy consumption and expenditure to the increasing energy gap. It also assessed which foods contributed the most to changes in energy consumption over the study period. Study three used grounded theory to examine the etiology of working mothers’ food choice and food provisioning decisions. The research was informed by theoretical perspectives on the ecology of obesity, embodiment and structuration. The results of this series of studies show that: 1. There are significantly higher rates of overweight and obesity in some Canadian sub-populations. Despite these differences, the prevalence of overweight and obesity is very high in all socio-demographic groups, and focusing prevention interventions in the sub-populations with higher rates would do little to decrease overall population prevalence. 2. The energy gap in Canada has widened significantly in the past two decades along with population rates of obesity. Increased energy available through the food supply is a more important driver of obesity than decreased levels of physical activity. 3. Employed mothers, who are primarily responsible for family food, frequently make poor nutritional choices for themselves and their families which increase the risk of developing poor nutritional outcomes such as overweight and obesity. Despite their desire to provide more healthy food for their family, their decisions make sense in the context of their busy lives. Their actions are pragmatic and rational, and reinforced through an obesogenic environment which includes the industrial food system; social norms; and working conditions. This environment is dynamically co-created through their individual actions. This research concludes that influences at multiple scales create an obesogenic environment that affects the vast majority Canadians. Of particular importance are: the structure of the industrial food system (ubiquitous availability of calorie-dense processed, convenience foods); changing social norms regarding food; and working conditions. For this reason, public health interventions that focus only on education to improve lifestyle behaviours will do little to improve health outcomes, including overweight and obesity. Strategies need to focus on structural influences such as improving: food environments; social norms regarding gender, families and food; and working conditions.

There are growing calls for the involvement of multiple agencies to address health inequities. Many international non-governmental organizations (INGOs) working in health and development mention equity principles in their vision statements, missions, or strategic directions, and many authors view equity, including focusing on vulnerable populations, as an important role for these INGOs. However, there is a lack of in-depth empirical research on what influences INGOs’ implementation of equity principles in their work. The present study helps to fill this gap by using a case study to examine INGOs’ implementation of equity principles in their HIV/AIDS initiatives. In this case study, I focused on HIV/AIDS initiatives in Kenya to illustrate the nature of the implementation gap between the intent of INGOs to ensure equity in their work and actual practice, and to examine the various influences that affected the implementation of INGOs’ equity principles. I used HIV/AIDS as the exemplar because of the global epidemic of HIV/AIDS and the resulting large monetary investments made by donors to Southern countries and INGOs to address the disease. I conducted an in-depth case study of an INGO operating in Kenya. The research questions were: “What is the nature of the implementation gap between the intent of an INGO to ensure equity in its HIV/AIDS work and actual practice? What characterizes multi-level influences that affect an INGO’s implementation of equity principles in its HIV/AIDS work? How do multi-level influences affect an INGO’s implementation of equity principles in its HIV/AIDS work?” The case study design employed multiple methods including document reviews, interviews with staff of the INGO in Kenya, as well as its Northern INGO counterparts in Canada and the U.S., interviews with partners and clients of the INGO in Kenya, and participant observation with staff of the INGO in Kenya. I found that many players (e.g. Southern country government and the Northern donors) from different levels (e.g. in-country as well as Northern donor countries) shape INGOs’ implementation of equity principles in their HIV/AIDS work. Influences from donors include donor agendas and the focus of donor funding, as well as donor country policies. Influences from the Southern country government include government priorities and legislation. These influence INGOs’ implementation of equity principles in their HIV/AIDS work, and in some cases can outright contradict equity principles. However, since INGOs are often reliant on donor funding and need Southern governments’ permissions to work in-country, INGOs work within a system that is characterized by asymmetrical interdependence. They have to find a middle ground for implementing equity principles in their HIVAIDS work. Hence, these influences help give rise to an implementation gap between what INGOs intend to accomplish in implementing equity principles in HIV/AIDS work and actual practice. Implications for policy and practice include the need to: increase awareness of the roles various players have in implementing equity and the need for ongoing collaboration to achieve equity aims; continue work in capacity building on equity for INGO staff and its partners; and develop and refine tools for measuring and monitoring the implementation of equity. The present research clearly shows the significant role that INGOs play in equity, and the importance of understanding the multiple players and levels that influence INGOs’ implementation of equity principles in HIV/AIDS. The research can help INGOs, Southern country governments, and donors to better understand the system within which INGOs work in implementing equity principles, as multiple organizations continue to try to address health inequities around the globe.

With amateur athleticism on the rise in Canada, older Masters athletes have been promoted as exemplars of “successful aging” in governmental population health campaigns that encourage all seniors to be physically active. This study investigates the life experiences of a group of ‘successfully aging’ Masters athletes to better situate their circumstances against the backdrop of a discourse of health responsibilization enacted by the state in its efforts to improve the health of aging citizens. Data were obtained from 15 in-depth interviews with Masters athletes age 60 and over. The findings revealed Masters athletes to have had exceptional life-long involvement in athleticism with intense physical training debuting early in adult life with several participants having been high-ranking amateur athletes prior to their involvement in Masters athleticism. Belonging for the most part to a high socioeconomic status, these participants were able to afford the costs associated with participation in high calibre athletic training and events. While these athletes might be held as exemplars of successful aging, they did not perceive themselves as such nor are their lifestyles and athletic achievements typical of the older seniors population that is targeted by state funded population health promotion efforts. This study offers insight into the socially constructed nature of successful aging under neoliberalism. It highlights a trend whereby health and aging are responsibilized as successful personal endeavours rather than as the outcomes of determinants largely outside the control of any one individual. / Graduate / 0340 / 0615 / mcgowanb@uvic.ca

The main purpose of this research is to describe how social and economic structures operating at different scales of influence have an impact on population overweight and obesity, and become manifest at the individual level. A mixed methods approach was used in this series of studies which facilitated a cross-scale analysis of the ecology of overweight and obesity, through linking of data at the individual and structural levels. Study one employed a cross-sectional retrospective analysis of overweight, obesity and socio-demographic indicators for 8,970,590 Canadian adults (25-64 years) using the 2005 Canadian Community Health Survey. Study two analyzed the trajectory of the energy gap (energy imbalance) in the Canadian population from 1976 to 2003, its temporal relationship to adult obesity, and estimated the relative contribution of energy consumption and expenditure to the increasing energy gap. It also assessed which foods contributed the most to changes in energy consumption over the study period. Study three used grounded theory to examine the etiology of working mothers’ food choice and food provisioning decisions. The research was informed by theoretical perspectives on the ecology of obesity, embodiment and structuration. The results of this series of studies show that: 1. There are significantly higher rates of overweight and obesity in some Canadian sub-populations. Despite these differences, the prevalence of overweight and obesity is very high in all socio-demographic groups, and focusing prevention interventions in the sub-populations with higher rates would do little to decrease overall population prevalence. 2. The energy gap in Canada has widened significantly in the past two decades along with population rates of obesity. Increased energy available through the food supply is a more important driver of obesity than decreased levels of physical activity. 3. Employed mothers, who are primarily responsible for family food, frequently make poor nutritional choices for themselves and their families which increase the risk of developing poor nutritional outcomes such as overweight and obesity. Despite their desire to provide more healthy food for their family, their decisions make sense in the context of their busy lives. Their actions are pragmatic and rational, and reinforced through an obesogenic environment which includes the industrial food system; social norms; and working conditions. This environment is dynamically co-created through their individual actions. This research concludes that influences at multiple scales create an obesogenic environment that affects the vast majority Canadians. Of particular importance are: the structure of the industrial food system (ubiquitous availability of calorie-dense processed, convenience foods); changing social norms regarding food; and working conditions. For this reason, public health interventions that focus only on education to improve lifestyle behaviours will do little to improve health outcomes, including overweight and obesity. Strategies need to focus on structural influences such as improving: food environments; social norms regarding gender, families and food; and working conditions.

Background: We examined if it was possible to use routinely available, self-reported data on health behaviours to predict incident cancer cases in the Ontario population. Methods: This retrospective cohort study involved 43 696 female and 36 630 male respondents from Ontario, who were >20 years old and without a prior history of cancer, to the Canadian Community Health Survey (CCHS) cycles 2.1-4.1. The outcome of interest was malignant cancer from any site, termed all-cause cancer, determined from the Ontario Cancer Registry. Predictor variables in the risk algorithm were health behaviours including smoking status, pack-years of smoking, alcohol consumption, fruit and vegetable consumption and physical activity level. A competing-risk Cox proportional hazard model was utilized to determine hazard of incident cancer. The developed risk prediction tool was validated in the CCHS cycle 1.1 on 14 426 female and 11 970 male survey respondents. Results: Incident cancer was predicted with a high degree of calibration (differences between observed and predicted values for females 2.97%, for males 4.23%) and discrimination (C-statistic: females 0.76, males 0.83). Similar results were obtained in the validation cohort. Conclusions: Routinely collected self-reported information on health behaviours can be used to predict incident cancer in the Ontario population. This type of risk prediction tool is valuable for public health purposes of estimating population risk of incident cancer, as well as projection of future risk in the population over time.