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.

Chronic diseases such as cancer, diabetes, cardiovascular and respiratory diseases are a global concern. In recent decades, Canada has also experienced a major increase in immigration. Yet, a detailed profile of chronic disease and multimorbidity risk patterns across different immigrant populations has been lacking in Canada. The purpose of this dissertation is to identify knowledge gaps in the scientific literature on the development of chronic conditions and multimorbidity across immigrant populations in Ontario, using population-based immigrant and health data housed at ICES. The principal findings of this dissertation indicate that: 1. The risk of developing a chronic condition and multimorbidity was complex and varied by immigrants’ visa category and world region origin since: a. Refugees had the highest risk of developing a chronic condition and multimorbidity (two or more co-occurring chronic conditions) compared to long-term Ontario residents. b. There were differences in the risk of developing a chronic condition and multimorbidity by world regions of origin, when examined across different immigrant categories. 2. Hypertension and diabetes, and in combination with Chronic Obstructive Pulmonary Disease were the leading multimorbidity dyad and triad groups for all immigrant categories and long-term residents of Ontario. 3. The risk of developing a chronic condition increased among immigrants in more recent landing cohorts. The risk was highest among more recent refugees, and lower for family and economic class immigrants, when compared to long-term Ontario residents. These findings provide evidence to inform public health policy and planning by highlighting the complexity and heterogeneity of health outcomes across immigrant populations. Knowledge generated from this work will inform policies and evidence-based decision-making aimed to address the threat of chronic diseases and reduce health disparities.

Indiana University-Purdue University Indianapolis (IUPUI) / The United States spends more on healthcare than any other country in the world, but still trails most other countries when it comes to important health indicators. There has been an increasing recognition that in order to address this discrepancy, the U.S. health system must begin to address the underlying social determinants contributing to poor health outcomes. In light of this, the concept of “population health” has emerged as a framework and model for how to better address the social determinants contributing to unhealthy behaviors and increased rates of morbidity and mortality in the U.S. Various national initiatives, including reform related to how doctors and hospitals are paid, have been developed with the purpose of increasing the adoption of strategies to address population health among public and private organizations. In this dissertation I attempt to assess how these national policies are driving behavior and outcomes related to improving population health in private and public sectors. It is comprised of three papers focused on 1) a systematic review of literature to assess how hospitals are responding to policies that encourage them to form partnerships to address population health, 2) a quantitative analysis of how the Affordable Care Act has impacted population health by addressing tobacco use with policies to increase Medicaid coverage for tobacco cessation services, and 3) an empirical examination to identify hospital strategic partnerships to address population health and determine hospital and market characteristics associated with these partnerships. The main findings of this study indicate that while there is a growing amount of peer reviewed literature focused on hospital partnerships for population health there is still a need for more generalizable studies with rigorous study designs in this area; Medicaid Expansion as a part of the Affordable Care Act is associated with lower prevalence of tobacco use; and policies, such as Accountable Care Organization and Bundled Payment models, may be influencing hospitals to engage with a broad set of partners to support population health activities. Collectively these studies provide new evidence to suggest that national policies may be driving behavior in private and public sectors related to population health. / 2022-04-06

Research, primarily based out of the United States, has shown that incarceration is related to a variety of negative outcomes for individuals, families, communities, and even broader populations. For example, studies have highlighted primarily negative physical and mental health effects of incarceration at multiple levels. However, we know little about societal consequences of incarceration, even as the global imprisoned population reaches its highest number yet. This dissertation aims to add to the small existing body of cross-national research on nation-level outcomes of imprisonment by examining the effect of incarceration rates on population health. To do so, I have collected, cleaned, and compiled longitudinal data from 1990-2019 from a range of sources, including datasets from the United Nations’ Office on Drugs and Crime and the World Bank. Using multilevel models with repeated measures within countries, this dissertation examines the overall relationship between incarceration and five population health outcomes – life expectancy, infant mortality, suicide rate, HIV prevalence, and TB incidence – for over 100 nations. In addition, models explore factors suggested by the literature to moderate or mediate these relationships, including prison conditions, welfare support, and racial diversity for the former and social capital for the latter.The findings from this research partially support hypotheses that incarceration levels relate to negative health outcomes at the population level. Bivariate and simple multivariate analyses of around 200 countries show that incarceration can be protective, especially at lower levels of country wealth, but high-income countries are often negatively affected by high levels of incarceration. When looking at a smaller sample of around 130 countries with available data for a range of relevant variables in this 30-year time period, most of these overarching relationships between incarceration and health do show negative effects – the one consistent outlier is infant mortality rate. Moderation analyses showed many of the direct effects to be moderated by country contexts such as racial diversity and exclusion, social protection expenditure, and prison conditions. Adding in these interactions revealed some relationships that were obscured in the direct effect models; sometimes, these were relationships that supported the narrative suggested by the literature, such as infectious disease outcomes being exacerbated by high racial diversity (HIV prevalence) or harsh prison conditions (TB incidence), but other times these were in the opposite, or an unexpected, direction. Subsample analyses allowed examination of subgroups of countries that were driving overall effects. For example, the negative effect of incarceration on life expectancy over time was found to be present only in the subsample of countries with above average racial diversity and/or exclusion, below average social protection expenditure, and worse than average prison conditions. Mediation analyses within a smaller sample of countries and years (2007-19) showed some evidence of partial mediation through civic participation and social networks, but also evidence of a suppressive effect of social capital variables on the relationship between incarceration and both infant mortality rates and HIV prevalence. While there are limitations to this research due mainly to characteristics and availability of comparative international data, there are also implications for theory, research, policy, and practice. Hopefully this work will promote more theory and research on the effects of incarceration at the country level, as negative consequences are not confined to the U.S., and encourage policymakers and practitioners to better understand how incarceration levels are affecting the health of the whole population. / Criminal Justice

No description available.

The purpose of this thesis was to develop an approach that could evaluate the burden of unhealthy behaviours over a lifetime through linked population-based health surveys. The Canadian Community Health Survey (CCHS) is one such cross-sectional survey that is routinely administered to the household population and has been linked to a multitude of administrative healthcare databases. Utilizing the linked CCHS to evaluate the burden of unhealthy behaviours over a lifetime is challenging. Health behaviours naturally change over a lifetime due to many factors, and the burden of unhealthy behaviours has many different dimensions (e.g., mortality, disability, and healthcare costs) that are interconnected with each other. The degree to which lifetime disability and healthcare costs vary in relation to differences in life expectancy remains an area of debate. It is unclear whether individuals with healthy behaviours actually experience less lifetime disability and healthcare costs than individuals with unhealthy behaviours since they typically live much longer. Through several studies, this thesis developed various components that can be potentially combined into a lifetime approach which incorporates multivariable transitions. The first two studies assessed the burden of unhealthy behaviours on period life expectancy and period lifetime healthcare costs. In the first study, CCHS-based multivariable risk algorithms were constructed to provide estimates of the causal associations between each unhealthy behavior (smoking history, leisure physical inactivity, non-active transport, leisure sedentary activity, and poor diet) and mortality. The burden of unhealthy behaviours on period life expectancy was estimated to be 7.5 (6.5-8.3) life years in 2000-2004 and 6.7 (5.8-7.4) life years in 2010-2014. The largest burdens were attributed to non-active transport and smoking. In the second study, CCHS-based multivariable risk algorithms were constructed to provide estimates of the causal associations between each unhealthy behavior and healthcare costs within different phases of life (i.e., defined by proximity to death). Unhealthy behaviours were attributed with 10.2% (2.5%-17.7%) of the period lifetime healthcare costs in 2000-2004, and 12.9% (5.6%-19.8%) in 2010-2014. Leisure sedentary activity and non-active transport were responsible for almost this entire burden, while the other unhealthy behaviours appeared to actually reduce period lifetime healthcare costs. The degree to which these estimates are accurate is unclear given the limitations of period life tables and the potential for unhealthy behaviours relating to physical activity to be a product of aging and prior illness. The third study focused on developing methods by which to derive CCHS-based multivariable transition risk algorithms, which would allow for the creation of cohort life tables rather than period life tables. Novel methods involving multiple imputation models were utilized to create quasi-longitudinal CCHS cohorts from multiple cycles of the CCHS. These quasi-longitudinal cohorts were leveraged to develop multivariable risk algorithms for transitions towards different levels of immobility, an exposure that had been included in the prior algorithms for mortality and healthcare costs. Transitions towards moderate immobility were predicted by all unhealthy behaviours except poor diet, and transitions towards severe immobility were predicted by all unhealthy behaviours except sedentary activity. This approach can also be utilized to develop multivariable transitions for the unhealthy behaviours, which were simultaneously allowed to transition in the quasi-longitudinal CCHS cohorts. Such multivariable transition algorithms could potentially be combined with the previously derived algorithms for mortality and healthcare costs to generate more realistic estimates of life expectancy and lifetime healthcare costs. Large variability in the imputed quasi-longitudinal CCHS cohorts requires further examination, and may be reduced by including comorbidities, healthcare costs, and other information from linked administrative healthcare databases. The last two studies evaluated the representativeness of linked CCHS respondents for population-based studies. Response and consent (to linkage) rates in the CCHS have been declining since its introduction raising concerns surrounding the comparability of CCHS samples over time. Similar to other population-based surveys, survey weights are provided that are designed address biases that may arise from non-response and non-consent to linkage. Unfortunately, these survey weights are not necessarily appropriate for many linked health outcomes that are rare. As a result, CCHS-based multivariable health risk algorithms are frequently derived from pooled unweighted CCHS samples. Fortunately, relative to wider sampling frames, unweighted linked CCHS samples were observed to be comparable over time. Nevertheless, linked CCHS respondents were observed to be healthier than comparable individuals in the community-dwelling and general populations at older ages, where they demonstrated lower risks of mortality, long-term care admission, and healthcare costs. This was not unexpected given that important segments of the population (e.g., residents of retirement homes and long-term care care) are excluded from the CCHS sampling frame. These studies highlighted the difficulties of estimating life expectancy and corresponding lifetime healthcare costs from the household population, and the necessity to ensure that such estimates realistically incorporate the time individuals may live outside of the household population over a lifetime. These series of studies therefore resulted in mortality, healthcare cost, and transition risk algorithms that could potentially be combined to generate lifetime estimates of life expectancy, disability, and healthcare costs for a CCHS respondent. The development of transition risk algorithms requires further research. Once these methods are optimized and transition risk algorithms for all exposures of interest are generated, all the components required for this framework will be complete. At that point, explicit methods by which to combine the algorithms and validate projections will be required. This framework will enable a cause-deleted approach to be applied that simultaneously considers the impact of unhealthy behaviours on mortality, disability, transitions, and healthcare costs. This thesis represents an initial first step towards creating a framework that has the potential to generate lifetime estimates, as well as counterfactual estimates, which better reflect the complex nature of lifetime trajectories.

Background: Diet is an important modifiable risk factor for cardiovascular disease. Numerous studies have examined the association between dietary intake and cardiovascular disease in North America and Europe, but little information is available on potential associations in many geographic regions including South Asia, South America, Africa, China, and the Middle East. Presently, it is unclear whether the findings from Western countries are applicable to these regions where population characteristics, background diet, and disease risk differ. This thesis aims to investigate the relationship between diet and cardiovascular disease and mortality in a heterogeneous, international population. Methods: Baseline data from the Prospective Urban Rural Epidemiology (PURE) study was used to investigate the availability, affordability, and consumption of fruits and vegetables. Additionally, PURE baseline and follow-up was used to examine the association between foods (fruits, vegetables and legumes) and macronutrients (total and fat subtypes, carbohydrate and protein) and cardiovascular outcomes and mortality. PURE is a prospective cohort study in individuals aged 35 to 70 years in 18 high-income middle-income and low-income countries on five continents. Availability and affordability of fruits and vegetables was collected from centrally located grocery stores and market places in each PURE community. Diet was measured using country and region-specific food frequency questionnaires at baseline. Case-report forms, death certificates, medical records and verbal autopsies were used to capture data about major cardiovascular events, and death during follow-up. The cost and diversity of fruits and vegetables was documented and mean fruit and vegetable intake by their relative cost was assessed. Associations between fruit, vegetable and legume consumption with risk of cardiovascular outcomes and mortality were examined. We investigated the association between macronutrients and risk of mortality and modeled nutrient replacement using energy-adjustment and joint effect models. Results: Results from the PURE study indicate that consumption of fruits and vegetables is low worldwide, particularly in low-income countries, and this is associated with low affordability. Higher fruit, vegetable and legume consumption was associated with a lower risk of non-cardiovascular, and total mortality and benefits appear to be maximal at three to four servings per day. This finding indicates that health benefits can be achieved at intake lower than most dietary recommendations, an approach that is likely to be more affordable in poor countries. Higher carbohydrate intake was positively associated with an increased risk of mortality, while total and fat subtypes, and protein was inversely associated with death. For the nutrient replacement analysis, the joint effect method demonstrated higher agreement with the single nutrient results compared to the conventional energy-adjustment method. This result suggests that traditional nutrient replacement modeling is not appropriate for international populations with diverse nutrient intake. Conclusions: Dietary intake varies across geographic regions and interventions to improve diet and nutrition recommendations should be tailored to the geographic setting. / Thesis / Doctor of Philosophy (PhD)

Background: Radon is a high impact environmental pollutant and is the second leading cause of lung cancer in Canada. Despite the gravity of the health risk, residents have inadequate awareness and have taken minimum preventive actions. The success of any population-level health awareness program is contingent on the views and actions of key decision makers at the household level. People's perceptions of the risk should inform health communication messaging that aims to motivate them to take preventive measures. The objective of this study was to measure the quantifiable associations and predictions between perceptions of radon health risk and their preventive actions; to explore and examines the social determinants that enable and hinder the adoption of preventive measures. Additionally, the best effective radon control systems for both the new and existing houses and relevant policy implications have been examined. Methods: A mixed methods study consisting of surveys (n=557) and qualitative interviews (n=35) was conducted with both homeowners and tenants of Ottawa-Gatineau areas. Descriptive, correlation and regression analyses addressed the quantitative research questions. Thematic, inductive analysis identified themes in the qualitative data. A mixed methods analysis triangulate both results. A registered systematic review of radon interventions around the world was conducted and radon policy analysis was done by applying interdisciplinary frameworks. Results: Residents’ perceptions of radon health risk, smoking at home, social influence, and care for family significantly correlated with their intention to test for radon; the same variables predicted their protection behaviours. Residents obtained information on radon from the media, individual search, workplace and social networks. Residents who had dual - cognitive and emotional awareness of the risk, were motivated enough to take action. Having an understanding of the risk, caring for family, knowing others who contracted lung cancer and being financially capable were enablers for action. Obstacles included lack of awareness, cost of mitigation, lack of home ownership and potential stigma in selling the house. Residents attributed primary responsibility to public agencies for disseminating information and suggested incentivizing and mandating actions to promote preventive measures. Indoor radon is best controlled by installing an active SSDS with additional measures to seal any entry points in the foundation. The policy analysis generated a list of recommendations that can be implemented through multisectoral systems level actions to address the social determinants of risk distribution. Conclusions: Residents do not get the crucial information on radon health risk and report barriers in testing and engaging in protective action. Risk perceptions are subjective and influenced by micro and macro level factors. Inducing protective action to reduce risk requires comprehensive interventions taking into account dual perceptions of the threat. Future research can explore the dual aspects of risk perception and examine the contents of the risk communication message. Policy should address the shared responsibility of both governments and residents in tackling the issue with reasonable incentives and mandatory regulations.

Background: Lung cancer was the fifth leading cause of mortality globally in 2010, and the leading cause of cancer mortality in Canada, representing 26% of all cancer deaths for both men and women in 2017. Radon is a very modifiable environmental exposure that is the second most important cause of lung cancer. Objectives: The objectives of this thesis are to quantify the lung cancer burden associated with residential radon and to identify the most cost effective mitigation options to reduce residential radon in Canada. Methods: The global burden of lung cancer mortality attributable to radon in 2012 was estimated from the 66 countries for which a representative national radon survey was available, using several different models for excess relative risk (ERR) of lung cancer from radon studies. Cost-utility analyses are conducted for 20 practical radon interventions scenarios to reduce residential radon exposures in new and existing housing in Canada, each province/territory and 17 census metropolitan areas. A societal perspective and a lifetime horizon are adopted. A Markov cohort model and a discrete event simulation are used to model residents by household, based on a period-life table analysis, at a discount rate of 1.5%. Results: The estimates of the global median PAR were consistent, ranging from 16.5% to 13.6% for the three ERR models based on miners, and the mean estimates of PAR for Canada ranged from 16.3% to 14.6%. It is very cost effective to install radon preventive measures in new construction compared to no radon control in all regions across Canada. At a radon mitigation threshold of 100 Bq/m3, the sequential analysis recommends the combination of the activation of preventive measures in new housing with the mitigation of existing housing at current testing and mitigation rates for cost effectiveness thresholds between 51,889 and 92,072 $/QALY for Canada, between 27,558 and 85,965 $/QALY for Manitoba, and between 15,801 and 36,547 $/QALY for the Yukon. The discounted ICER for screening and mitigation of existing housing at current rates relative to no radon control measures is 62,451 (66,421) $/QALY using a Markov cohort model (discrete event simulation model) for mitigation of housing above a threshold of 200 Bq/m3, and is 58,866 (59,556) $/QALY using a Markov cohort model (discrete event simulation model) for mitigation of housing above a threshold of 100 Bq/m3. Conclusions: Cost effective residential radon interventions should be implemented across Canada to reduce exposures to this very modifiable cause of lung cancer and to help reduce the increasing lung cancer burden in an ageing Canadian population.

acase@tulane.edu / Health systems globally are faced with failed ethical commitment to their patients and financial extinction if they fail to consistently provide clinically efficacious, societally equitable, cost-effective healthcare. Despite the known causal link between the nutrition-related chronic disease epidemics and the world’s top morbidity cause, cardiovascular disease, there is no evidence-based, cost effective, scalable model of nutrition education intervention for and with medical trainees and professionals and their patients. Similarly, there is no known demonstrated case successfully applying artificial intelligence (AI)driven Big Data within a population health management framework for such an intervention to optimally refine it. Therefore, the medical school-based teaching kitchen, The Goldring Center for Culinary Medicine (GCCM) at Tulane University School of Medicine, launched the largest known multi-site cohort study with nested Bayesian adaptive randomized controlled trial (BA-RCTs) across 30 medical centers and 3,785 medical trainees/professionals. Cooking for Health Optimization with Patients (CHOP) with its four sub-studies features not only the first known systematic review and metaanalysis on this subject to determine best practices. CHOP also serves as the first known nutrition education study utilizing the latest AI-based machine learning (ML) techniques to complement the traditional statistical approaches to provide real-time, precise treatment estimates for causal inference and assessment of hands-on cooking and nutrition education for medical professionals and trainees’ patient counseling competencies, and improved patient psychometric and biometric outcomes. (1) The first sub-study, CHOP-Meta-analysis, demonstrated that though the average effect size (ES) across the 10 eligible nutrition education studies among medical trainees was 10.36 (95%CI 6.87-13.85; p<0.001), the only study meeting the STROBE criteria for high quality, the phase I sub-study of CHOP-Medical Students below, had significantly triple the ES (31.67; 95%CI 29.91-33.43). (2) CHOP-Medical Students demonstrated in inverse variance-weighted fixed effects meta-analysis of propensity score-adjusted fixed effects multivariable regression across 2,982 students that GCCM versus traditional clinical education significantly improved trainees’ total mastery counseling patients in 25 nutrition topics (OR 1.64; 95%CI 1.53-1.76; p<0.001). (3) CHOP-CME demonstrated that among 230 medical professionals, GCCM education significantly increased these odds, but by 159% more than the trainees’ improvement (OR 2.66; 95%CI 2.26-3.14; p<0.001) in addition to significantly increasing the odds of counseling most patients on nutrition in their clinical practices (OR 5.56; 95%CI 2.124-14.18; p<0.001). (4) CHOPCommunity demonstrated that GCCM education versus the standard of care significantly increased patient adherence to the Mediterranean diet (MedDiet) (OR 1.94; 1.04-3.60; p=0.038) and greater connectedness in their social networks (p=0.007). The pilot RCT for diabetes patients, CHOP-Diabetes, nested in this sub-study demonstrated superior improvements in diastolic blood pressure (-4 versus 7 mmHg, p=0.037) and cholesterol (14 versus 17 mg/dL, p=0.044) for patients randomized to GCCM versus the standard of care. The nested Phase II BA-RCT, CHOP-Family, demonstrated that GCCM versus standard of care had significantly greater MedDiet adherence based on their grocery receipts (OR 4.92; 95%CI 1.78-13.56; p=0.002). Using the Random Forest Multiple Imputation ML algorithm, the simulated Phase III BA-RCT predicted 93 hospital admissions and $3.9 million would be saved providing GCCM versus standard of care for congestive heart failure (CHF) exacerbation-risk patients primarily from underserved communities. Among 41 tested ML algorithms, the top performing Iterative Classifier Optimizer was comparable to the estimated traditional statistical model for the trainees’ primary endpoint for (1) (RMSE 0.314 versus 0.282), and the top performing Kstar was superior to the traditional model for the professionals’ primary endpoint (RMSE 0.431 versus 0.414). The four sub-studies within CHOP taken together provide the first known multi-site cohort and BA-RCT evidence for superiority of hands-on cooking and nutrition education compared to the standard of education and medical care for improved trainee/professional nutrition counseling competencies and patient outcomes. CHOP utilized the state-of-the-art in causal inference-based statistics, randomized trials for causal assessment, and ML to provide robust, precise estimates of comparative treatment effectiveness. This research infrastructure was scaled up to meet GCCM’s growing programmatic needs as it has since grown over 5 years to 30+ medical centers providing 53,674+ teaching hours to 4,171+ medical trainees/professionals and patients. CHOP has utilized the latest rigorous study design and analysis methodologies to provide a blueprint to optimize health systems through sustainable improvements as population health management that is clinically and cost effective, reducing health inequities while improving individual outcomes. / 1 / Dominique J Monlezun Jr