Introduction: In the new century, worldwide health professionals face new pressures for changes towards more cost-effective and sustainable health care for all populations. Globalization creates daunting challenges as well as new opportunities for institutions and health professionals being more connected and rethink their strategies toward an interprofessional practice. Although Health professionals are paying increased attention to issues of global health, there are no current competency assessment tools appropriate for evaluating their competency in global health. This study aims to assess global health competencies of family medicine residents, nursing, physiotherapy and occupational therapy students in five universities across Ontario, Canada Methods: A total of 429 students participated in the Global Health Competency Survey, drawn from family medicine residency, nursing, physiotherapy and occupational therapy programs of five universities in Ontario, Canada. The surveys were evaluated for face and content validity and reliability. Results: Factor analysis was used to identify the main factors to be included in the reliability analysis. Content validity was supported with one floor effect in the “racial/ethnic disparities” variable (36.1%), and few ceiling effects. Seven of the twenty-two variables performed the best (between 34% and 59.6%). For the overall rating score, no participants had floor or ceiling effects. Five factors were identified which accounted for 95% of the variance. Cronbach’s alpha was >0.8 indicating that the survey items had good internal consistency and represent a homogeneous construct. The results of the survey demonstrated that self-reported knowledge confidence in global health issues and global health skills were low for family medicine residents, nursing, physiotherapy and occupational therapy’ students. The percentage of residents and students who self-reported themselves confident was less than 60% for all global health issues. Conclusion: The Global Health Competency Survey demonstrated good internal consistency and face and content validity. The new century requires professionals competent in global health. Improvements in the core competencies in global health can be a bridge to a more equal world. Institutions must offer interprofessional approaches and a curriculum that exposes them to a varied learning methods and opportunities to improve their knowledge and skills in global health.

Population health is concerned with analyzing the factors that determine the uneven distribution of health in a population and it also proposes interventions to narrow health inequalities. Kindig has proposed a population health management strategy that would engage the health and other sectors on population health improvement through a financial incentive linked to health outcomes. Proposed elements of a population health approach in health care at the patient encounter level include paying attention to health determinants for the patient and ensuring interprofessional collaboration; at the system level the approach includes developing and advocating for interventions that address health inequalities, such as delivering services to under-serviced areas and vulnerable populations. There has been virtually no research among frontline clinicians on the awareness and salience of a population health approach. In order to address this gap an exploratory study was conducted among family physicians in Primary Care Networks (PCNs) in Alberta, Canada. PCNs include capitation funding that is used to purchase services such as nursing, pharmacy and dietetics. The physicians were able to describe their patient populations in terms of a full range of social determinants and the health status inequalities they produce. They emphasized the importance of preventive screening and counseling in contributing to the health of their patients, and cited the key contributions of other team members to these activities, as well as the electronic medical record (EMR). They reported ambivalence toward the effectiveness of financial incentives for population health improvement, and while there was some collaboration with schools, inter-sectoral collaboration has yet to develop outside the health sector. This thesis has demonstrated the potential for primary care physicians to adopt a population health approach. However, there is a considerable distance to go in introducing an incentive approach for outcome-based population health management, as envisioned by Kindig.

Thesis advisor: Andrew Jorgenson / In 2015, the United Nations implemented the Sustainable Development Goals (SDGs), which cover a wide range of social, economic and environmental issues. While there is a virtual international consensus regarding the importance of these goals, and reconsidering the ecological costs of human development, there are disagreements on the best approaches to actually achieving sustainability. Mainstream perspectives argue that the most feasible and effective path to sustainable development is to decouple economic growth from its environmental impacts, largely through the advancement and implementation of green technologies. In this framework, economic growth is seen as synonymous with development and a necessary prerequisite for improving human wellbeing. On the other hand, many scholars are critical of this approach to sustainable development and argue that economic growth is not only antithetical to achieving environmental sustainability, it also has limited appeal for improving social and economic wellbeing in developed countries. With this in mind, in this dissertation I examine alternative pathways to sustainable development that move beyond the growth-consensus. Previous studies argue that a working time reduction potentially represents a multi-dividend sustainability policy that could improve social, economic and environmental outcomes. Similarly, previous research also indicates that inequality is negatively associated with human wellbeing and can lead to increased environmental pressures. Across three empirical chapters, I investigate the effects of working hours and inequality, and their interaction, on measures of environmental and human wellbeing across US states over time. In the first chapter, I assess the relationship between average working hours and CO2 emissions from 2007 to 2013. This chapter is the first examination of this relationship at the US state level and finds that longer working hours are associated with increased emissions over time. The second empirical chapter takes this research one step further and examines how inequality shapes the relationship between working hours and emissions from 2005 to 2015. The results of these analyses again find that longer working hours are associated with increased emissions but that the relationship becomes more intense at higher levels of inequality. The third empirical chapter investigates the claim that a working time reduction could be a multi-dividend sustainability policy by examining the relationship between work hours and life expectancy from 2005 to 2015. I also examine how inequality shapes this relationship as well. Results indicate that longer working hours are associated with decreases in life expectancy, and that this effect is larger at higher levels of inequality. In all, these studies provide more evidence that reducing working hours could potentially be an effective sustainability policy that could contribute to achieving multiple sustainable development goals. Further, they show that inequality is an important factor shaping socio-environmental relationships and population health relationships. / Thesis (PhD) — Boston College, 2020. / Submitted to: Boston College. Graduate School of Arts and Sciences. / Discipline: Sociology.

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.

The purpose of this study was to explain how public health renewal has shaped public health nursing practice, how public health nurses have managed these changes, and the perceived impact of such changes on health outcomes. I used the grounded theory method to develop a theoretical explanation of how public health nurses navigated the changing organizational milieu in British Columbia. I interviewed 29 public health nurses and three public health nursing managers in three health authorities to explicate the impact of healthcare reform initiatives on public health nurses and public health nursing practice. Over the last few decades, there have been several organizational and policy changes in British Columbia, intended to strengthen the health system and health service delivery. These changes have eroded the nature of the public health nurse role and negatively influenced public health nursing practice, undermining the ability of public health nurses to improve population health and health equity. Many participants were concerned about changes in their practice and reported that leaders restricted their role, particularly in their broad health promotion and community development efforts. Nurses in this study highlighted specific organizational and policy changes that have undermined their effectiveness. For example, nurses talked about cuts to the public health budget, the disbanding of health unit structures, the appointment of leaders who lacked public health or public health nursing knowledge and experience, and the increase in mandated targeted public health nursing programs with a corresponding decrease in universal programs. As a result, participants engaged in the process of managing the eroding of the public health nurse role, which comprises five strategies. In standing tall, a number of nurses in this study advocated for their practice and pushed back against decisions that jeopardized the quality of public health nursing programs and services with varying degrees of force. Public health nurse participants also worked within organizational expectations and constraints in the process of getting by. In going underground, several public health nurses engaged in various activities in secret by harnessing their community connections and attended to community issues they believed went unaddressed. A number of nurses, dissatisfied by the state of their role, were contemplating getting out and considered other employment possibilities. Throughout the process of navigating external changes affecting practice, many nurses restored their dedication to the public health nurse role in reaffirming commitment. Given the limited research exploring the impact of healthcare reform and public health renewal on public health nursing practice, this research helps to provide an initial glimpse into the effects of such change on public health nurses in British Columbia. / Graduate

Since 2018, the Provincial Government of Ontario has begun transformation within the public health sector, which emphasizes the increased application of a population health approach. The goal of this transformation is to maximize the contribution of public health in improving the health of Ontarians by moving from a reactive to a proactive model that is focused on prevention. To support this transformation the standards that guide the programs and services provided through public health units underwent modernization in 2018. The emphasis of the modernized standards is about expanding the scope and reach of public health, by supporting the role of population health in the development and delivery of programs and services. This thesis used quantitative data to examine the extent that a population health approach was implemented in sexual health programs and services in public health units across Ontario. Qualitative data was gathered to explore public health managers’ and supervisors’ perceptions of barriers and facilitators that influenced the implementation of this approach. A mixed-methods study was used to determine if the qualitative findings helped our understanding of the quantitative results. This multi-phase mixed methods study involved four sequential phases. Phase 1 and 2 involved instrument development which included a literature review, input from experts, and testing; in phase 3 instrument administration was conducted; and phase 4 involved interviews with sexual health managers and supervisors. A qualitative descriptive approach was used as part of phases 1, 2, and in phase 4 for data collection and analysis using focus groups and semi-structured interviews with sexual health managers and supervisors delivering sexual health programs and services. The instrument was developed based on Health Canada’s Population Health Key Elements Template with multiple activities listed under each element and was administered in phase 3. Descriptive statistics were used to analyze this data. The Consolidated Framework for Implementation Research (CFIR) guided the development of the interviews for phase 4 and the qualitative analysis. Quantitative data showed that some population health elements were implemented more than others. For example, Address Determinants of Health and their Interactions was implemented by most health units while Employ Mechanisms for Public Involvement was implemented by a few. Qualitative data revealed that most factors influencing the implementation of a population health approach fit within CFIR’s domains of the inner and outer setting. For example Address Determinants of Health and Their Interactions and Focus on the Health of Populations were highly implemented by health units, due to factors such as organizational culture, and access to data. On the other hand, the elements Collaborate Across Sectors and Levels and Employ Mechanism for Public Involvement were less often implemented which were influenced by resources (e.g., human and financial) that were available to the health unit. This study fills an existing gap in the research and offers evidence of how to implement a population health approach within sexual health programs and services in public health. / Thesis / Candidate in Philosophy / Traditionally, sexual health programs and services provided by Ontario public health units have focused on providing services for individuals, such as clinic services. More recently, there has been a shift in public health to apply a population health approach, which focuses attention on addressing the broader social and economic influences on health. This is viewed as important to improving the health of communities and disadvantaged groups within those communities. It is not known to what extent this shift in the approach to sexual health services or programs is being implemented within Ontario public health units. Therefore, it is important to understand how public health units have moved towards a broader approach in sexual health and what challenges they have faced. This thesis examines how much sexual health programs and services have implemented a population health approach within sexual health programs and services in public health units. It also explores what helped or hindered this change. Some key population health activities (e.g., using evidence to plan programs, offering clinic services) have been implemented but not all (e.g., working with community partners, participating in primary research). An example of a barrier to implementation is having a lack of resources (human and financial). New knowledge from this study can support public health organizations to apply a broader population health approach in sexual health programs and services.

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Asthma is one of the most common respiratory diseases in Canada. It not only brings pain to more than 7.8% of Canadians but it also costs millions of dollars every year. In this project we study the influence that environmental factors have on asthma based on the data from the National Population Health Survey (NPHS) conducted by Statistics Canada. A descriptive analysis is done first to get an initial understanding of the environmental factors' effects on asthma. Then we do a x2-test to test for the homogeneity of asthma distribution across the levels of each environmental factor. Most of the factors included in our study are significant except those representing whether living in the metropolitan areas of Montreal or Vancouver, the number of persons living in the household, and whether there are small children in the household. For ordinal variables we test for trend on asthma prevalence. The trend tests indicate that there are significant trends between asthma and most of the ordinal factors except for a few, including the number of bedrooms in the household and the number of cigarettes smoked daily by the daily smokers. Then odds ratio and relative risk analyses are done to obtain statistical insights on the relative risk of the factors. The result shows that living in Nova Scotia, Ontario and Quebec, urban areas, engaged in finance, community services, personal service, young, attend physical activities, born in Canada, white, single or widowed, separated, divorced, start smoking early, do not own the dwelling living in, female adult, male children, and overweight and underweight adult, are all contributing factors for asthma. To model and investigate the joint effect of factors on asthma prevalence, we use logistic and log-linear regression models. To avoid collinearity problems, a reduced number of predictors is used. The results suggest that environmental factors have a significant joint influence on asthma prevalence. / Thesis / Master of Science (MS)

Amphibian populations are declining on a global scale and although disease outbreaks are a commonly accepted hypothesis they are not the only one. My aims for my thesis were to study the home range of Leiopelma hamiltoni, to determine whether a photographic database could be used to individual identified them and monitor the health status of the population. Habitat loss is a possible cause. For this reason monitoring an animals' home range is a possible method to detect early impacts the population is facing. By tracking 12 L. hamiltoni within a 12 m x 6 m grid on Maud Island, it was shown that the home range size can vary from 0.5 m2 to 25 m2 based on the minimum convex polygon method. However, to track multiple individuals it is important to be able to distinguish among frogs. The commonly used methods of identification, such as toe clipping, pose potentially detrimental effects. Therefore, non-invasive methods based on natural markings need to be established. Through the use of the dark pigmented patterns found on the skin of L. hamiltoni individuals can be identified on recapture with a mean accuracy of 93%. By developing a database to maintain the photographs used for individual identification, the database can also be used to monitor the status of the population. During 2003 numerous L. hamiltoni were observed with denuded patches predominantly on the facial region. By monitoring five individuals within the captive facility at the University of Canterbury it was discovered that frogs appear to be able to cure themselves. Through researching the home range requirements and developing a photographic database to monitor the population status of L. hamiltoni, it will aid in the management of ensuring the long-term survival of this archaic species of frog.

Since the early 1990s, the Estonian health sector has been undergoing a number of reforms. At the same time, a number of legislative acts have also been established, forming a new legal basis for the health system. The introduction of a social health insurance in 1992 was the first reform in the Estonian health sector reorganisation, followed by a primary health care (PHC) reform, a hospital reform and a number of public health reforms. The aim of this thesis is to analyse these health sector reforms in Estonia, focusing on the outcomes of the health system from the population’s perspective. Proceeding from this general aim, the specific objectives of the thesis are as follows: 1) To analyse the PHC reform in terms of the access to the health services and the acceptability and satisfaction with these services. 2) To analyse the health insurance reform in terms of the acceptability and satisfaction with the new system. 3) To analyse the public health reforms and their impact on the health of the population. The empirical data were gathered with the following research methods: reviews of official health statistics and population surveys in 1998, 2002 and 2005 based on face-to-face interviews using structured questionnaires. The main results can be summarised in relation to the objectives of the thesis: 1) The primary health care reform has been implemented and most of the objectives have been achieved. In general, people accept the changes in the PHC system and the satisfaction with the family doctors has increased. Access to the PHC services is good. Based on the results of a population study in 2002 and 2005, more than half of the respondents could see the family doctor on the same day they made an appointment. Almost a half of the respondents (49%) were satisfied with the access to the health services. Satisfaction with the PHC services and family doctors were found to have positive effects on satisfaction with access to health services. Although people with chronic conditions were less satisfied with the access to the health services they did not experience organisational barriers in their access to such services. 2) The health insurance reform has been implemented and a high level of financial protection has been maintained. The solidarity principle of the health insurance system guarantees access to health services for all the insured people. About half of the population is satisfied with the present system. Compared to 2002, the percentage of satisfied people has increased in 2005, while the percentage of very dissatisfied persons has decreased. The most important predictor of satisfaction with the health insurance was the satisfaction with the existing PHC system. The satisfaction with the health insurance was higher in 2002 as well as 2005 among those respondents who had visited a family doctor or a specialist or were admitted in a hospital during the last 12 months before the survey, but lower among those who had visited a dentist. A small majority preferred the solidarity principles and comprehensive financing of health service by health insurance. The attitudes regarding financing principles were related to the personal contacts with the health services. The respondents who had used the PHC or ambulance services preferred a more comprehensive financing of health services, while those who had had contacts with a specialists or dentists would prefer less comprehensive financing if the waiting lists were short. More than three quarters of the respondents were informed about their rights concerning the access to the health services. Personal contacts with family doctors and specialists had positive impact on the level of awareness. 3) Some progress has been made in connection with the public health reforms. A number of national programs and projects to prevent the most essential health risks have been initiated. As a result, there is some evidence of a positive impact on the health of the population – positive trends in dietary habits and decreasing infant mortality, number of abortions, and incidences of sexually transmitted infections and tuberculosis. At the same time, however, the proportion of smokers and consumers of strong alcohol has not decreased. Moreover, there has been an explosive increase of new cases of HIV-infections in 2000, which is one of the most serious public health problems today. Greater progress has been achieved in the areas where health promotion and health education activities have been supported by political decisions to make a healthy choice for the population easier. However, a comprehensive national health policy and strategy is still lacking in Estonia. In public health, this is evidenced by a lack of long-term planning and understanding of the significance of intersectoral co-operation. Discussion. Up to now, the major reforms in the Estonian health system have been implemented. However, the environment is changing and the health system has to respond to these changes. The next step should therefore be to reach a public agreement about the common values of the health system and setting long-term health policy goals. To improve the effectiveness of policy implementation and reform, the importance of systematic research and evaluation should also be stressed.