Theses (Social Dimensions of Health)

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    An Intersectionality-Informed Analysis of Loneliness and Discrimination Experienced by 2S/GBTQ+ People Living With Disabilities Before and During the COVID-19 Pandemic
    (2024) Amato, Anthony Theodore; Lachowsky, Nathan; Card, Kiffer
    Introduction: Social inequities such as loneliness and discrimination due to sexual orientation (herein, discrimination) are prevalent across disabled people and Two-Spirit, Gay, Bisexual and Trans men, Queer and Non-Binary (2S/GBTQ+) communities. However, little is known about how loneliness and discrimination were experienced in Canada at the intersection of disability and 2S/GBTQ+ communities, especially before and during the COVID-19 pandemic. Method: To address this knowledge gap, four cycles (2019, 2020, 2021, 2022) of cross-sectional, bilingual, community-based Sex Now survey data were used, which included 2S/GBTQ+ people aged 15 years or older and living in Canada. A total of 12,355 2S/GBTQ+ participants responded to loneliness outcomes, and 11,575 to discrimination outcomes. A multi-stage data analysis was conducted. First, crosstabulations and chi-square tests were used to describe and test for differences across outcomes across the four survey cycles. Second, pooled data were analyzed to describe and test for differences in outcomes based on social determinants of health. Third, stratified analyses were repeated for participants living with and without a disability. Finally, only among 2S/GBTQ+ participants living with disabilities, multivariable logistic regression models of each outcome identified 1) temporal trends by survey year, and 2) social determinants of health correlates. Results: There were statistically significant differences in outcomes across survey cycles, which were greater among 2S/GBTQ+ participants living with a disability. Compared with 2019 (before COVID-19), the odds of reporting loneliness were greater for 2S/GBTQ+ participants living with disabilities in 2020 and 2021 (but not 2022). 2S/GBTQ+ participants living with a disability who reported a racialized identity, financial strain, or a gender-expansive identity had greater odds of reporting loneliness. Compared with 2019 (before COVID-19), decreased odds of reporting discrimination were found in 2021 and 2022 (but not 2020). Generally, older 2S/GBTQ+ participants living with a disability were less likely to experience discrimination. 2S/GBTQ+ participants living with disabilities who were racialized, queer versus bisexual identified, and gender-expansive reported greater odds of discrimination. Conclusions: These findings suggest that 2S/GBTQ+ people living with disabilities were impacted by greater loneliness and lesser discrimination during COVID-19. However, social inequities were also present among 2S/GBTQ+ people living with disabilities. Equitable policy planning is needed to ensure that underserved yet deserving communities are not disproportionally affected by future pandemics and associated public health responses.
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    BLOOD DONATION IN THE ERA OF BIOMEDICAL HIV PREVENTION AND GENDER-NEUTRAL DONOR SCREENING
    (2024-01-29) Higgins, Robert; Lachowsky, Nathan; Card, Kiffer
    Objective. Canada’s implementation of gender-neutral sexual behaviour screening allows sexually active men who have sex with men to donate blood for the first time. Public health campaigns promoting effectiveness of pre-exposure prophylaxis (PrEP) and undetectable = untransmittable (U=U) for HIV prevention heavily target sexual and gender minorities. Donor deferral policies remain in place for both methods. This thesis explores the tension between the effectiveness of these HIV prevention methods and donor policies considering them indicators of HIV risk. Methods. I wrote an algorithm approximating donor eligibility producing two analytic samples; one including PrEP use, one including HIV-negative men using U=U. I then estimate the proportion of donors who would be deferred for each prevention method. Chapter Two uses logistic regression to investigate PrEP use as a motivator for blood donation. Chapter Three describes HIV risk and protective factors for HIV and compares these observations to population health estimates of HIV incidence risk. Results. The algorithm identified n = 2,301 potential donors when PrEP users were included. Of these n = 85 (3.7%) would have been deferred for PrEP use. When repeated with HIV-negative donors using U=U, n= 2,354 donors were identified and n = 53 (2.3%) would have been deferred. PrEP use was not associated with willingness to donate. Estimates of HIV acquisition risk observed in the U=U analytic sample showed high risk of HIV acquisition. Contradictorily, a high number of combination HIV prevention strategies were also observed in the sample. Conclusion. It is likely donors are deferred solely for their choice of HIV prevention method. Having made a past donation was the best predictor of willingness to donate blood. Observed combination HIV prevention strategies employed by the U=U analytic sample did not support high public health estimates of HIV acquisition risk. Future research should explore PrEP adherence in samples of donors deferred for PrEP use and adjusting estimates of HIV acquisition risk to consider PrEP and U=U in risk estimates.
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    Pockets of Safety: Implementing an Overdose Prevention Site into an Emergency Shelter During a Public Health Emergency
    (2023-12-19) Elbassiouny, Katrina; Pauly, Bernadette; Wallace, Bruce
    Background: In April 2016, after several months of increased numbers of unintentional drug toxicity deaths, British Columbia’s Provincial Health Offer declared a public health emergency in response to this prolonged spike. In December 2016, the BC Minister of Health released Ministerial Order 488, supporting the implementation and expansion of overdose prevention services. In response to the toxic drug policy crisis in BC, one such overdose prevention site (OPS) was implemented within an emergency shelter, in Victoria, BC, in December 2016. This research sought to understand the role of OPS in responses to substance use and harms for people who use drugs and alcohol from the perspective of people accessing the shelter. Interviews were conducted in the spring of 2018, approximately 1.5 years after the OPS was opened. The primary research questions for this study were: How has the implementation of an OPS contributed to responses to substance use and the uptake of harm reduction policy, philosophy, and practice within the shelter, from the perspective of people accessing the shelter? What were the impacts of implementing an overdose prevention site for people accessing the shelter? To answer these broader questions, my specific research questions were: 1. Has the implementation of an OPS influenced responses to substance use in a shelter setting? 2. Has the implementation of an OPS reduced the harms experienced by people accessing the shelter? 3. How have the policies and practices within the shelter and organization impacted the implementation of the OPS? 4. Has the implementation of an OPS influenced the broader uptake and implementation of harm reduction policy, philosophy, and practice within the shelter setting? Methods: This qualitative study utilized an Interpretive Description methodology and is aligned with a social constructivist paradigm. The applied, practice-based orientation of Interpretive Description balances hermeneutic interpretive tradition with descriptive approaches. Participants were recruited by a third party using purposive sampling. Twenty-one participants were interviewed, and all participants had lived experience of substance use (legal or illegal substances) and were accessing services at the emergency shelter at the time of data collection. Accessing the OPS was not a criterion for participation; as such, experience accessing the OPS varied across participants providing deep insights into the implementation and impacts of the OPS in a shelter setting. Qualitative interviews were audio recorded and transcribed verbatim. Data were organized using NVivo software and analyzed using Interpretive Description. Rhodes’ Risk Environment Framework was used to guide the interpretation of findings. Findings: The OPS provided important micro-level pockets of safety for PWUD within the broader organizational context of the shelter as part of the meso-level risk environment. There were many positive impacts of OPS implementation including saving lives, providing novel inhalation services, preventing harms and complications, reducing criminalization, reducing stigma, improving relationships with staff, improving quality of care, and facilitating connections to care. Primary implementation issues include hours of operation, physical space, and privacy. Informal policy and substance use rules, a constantly changing policy environment, inconsistency in the application of rules, consequences of inconsistent application of rules, and a desire for consistency in the application of rules were all aspects of the broader policy context of the shelter that impacted the implementation of the OPS. Several aspects of the broader shelter influenced and were influenced by the implementation of an OPS. These included an organizational culture in transition, staffing within a transitional culture, the criminalization of substance use, and stigma. Lastly, the meso-level economic context of the shelter identified opportunities to further support implementation, including a need for increased resources, and the intersections of economics and safety. Conclusions: The OPS had positive impacts for those accessing it; however, these impacts were largely limited to the OPS itself. While the OPS shifted the micro risk environment for individuals accessing the OPS, the meso environment remained a risk environment in several ways. The novel inhalation service provided important spaces for safety; however, some lingering risks remained. Peer witnessing and eOPS are important adjuncts to OPS services for people who are unable or unwilling to access traditional OPS. Implementing OPS into an organization that serves diverse populations with different substance use goals and needs presents unique challenges. Organizational and funder policies, aligned with principles of harm reduction, are important for the robust implementation of OPS services and the uptake of harm reduction policy, philosophy, and practice. Peers were critical to the success of the OPS, but the inclusion of peers must go beyond service delivery to also include service planning and design. Adequate resourcing is important for the successful implementation of services, and without adequate resources, risk environments can remain. Robust implementation planning is an essential component of successful service implementation and organizational culture change.
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    Everyone Deserves a Sanctuary: Alienation as a Barrier to the Health and Healing of Older Women Who Experienced Homelessness
    (2023-10-05) Fraser, Kendall; Cloutier, Denise; Benoit, Cecilia
    Experiences of homelessness can result in social exclusion through stigmatization, discrimination, and displacement. Stress from lack of community integration for people who have been homeless can result in poorer health outcomes, including: higher rates of mental illness and chronic physical health conditions, substance dependence, loneliness, and suicide. This may be particularly true for older women who experience multiple intersections of marginalization. However, there is a lack of research that addresses how to facilitate a sense of belonging for and promote the health and healing of older women who have been homeless, and it is unclear what environmental conditions would help these women to transition out of homelessness and into a place of home that is stable, secure, and safe. This thesis stems from a larger community-based qualitative study that explores the experiences of older women who have been homeless and service providers in the homeless-serving sector, with the goal of building priority recommendations for system improvements. My research aims to address two research questions: 1) how have older women been marginalized and rendered invisible within homeless environments; and 2) how do homelessness experiences and environments shape older women’s behaviour? The theoretical frameworks of intersectionality and alienation guided this thesis, focusing on and developing insights into older women’s experiences of stigma and social exclusion and the impacts this marginalization has on their health. My findings derived from a secondary analysis of 11 out of 20 existing qualitative interviews with older women who have been homeless in Victoria, British Columbia, which revealed that older women were marginalized in homeless environments through a lack of safety and autonomy that contributed to high levels of alienation. Alienation prevented the development of a sense of home and belonging after homelessness that in turn impacted older women’s health and wellbeing. The recommendations from this analysis suggest that greater consideration to the concept of therapeutic landscapes for older women after homelessness would offer more opportunity for them to develop a sense of home and belonging. Overall, this project aims to fill a current gap in the literature on the social exclusion and subsequent health outcomes of older women who have experienced homelessness in Canada.
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    Exploring the Social Determinants of Health Associated with Sexually Transmitted Infections in Older Women
    (2023-09-28) Monks, Jordan; Lachowsky, Nathan; Stajduhar, Kelli
    Sexually Transmitted Infections (STIs) are on the rise among older women in British Columbia (BC); yet, sexual health research has paid little attention to this population. Similarly, STI prevention, testing, and treatment strategies often concentrate on youth or young adults. This community-based participatory research study examined how and to what extent social determinants influence STI prevention, testing, and treatment among older women (60+) in BC. This includes stigma around older adult sexuality, which is more prevalent in older women and creates barriers to safer sex practices and access to appropriate sexual health services. A mixed- method design, using cross-sectional surveys and interviews with older women across BC, contributed to understanding the sexual health needs of this population. The key themes that influence older women’s STI prevention, testing, and treatment experiences include: 1) knowledge and beliefs, 2) stigma and shame, 3) social determinants of health such as education, access to care without discrimination, and relationships with trust. This research not only contributes to the knowledge base around older women’s social determinants of health in relation to STI-related behaviours, but also provides data to inform recommendations regarding the development of equitable policies, programs, and services that promote the sexual health of older women in BC.
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    Navigating Conservative Drug Policy in Ontario's Safe Consumption Sites: A Critical Investigation of Harm Reduction Policy and Practice
    (2023-02-09) Arlt, Stephanie; Urbanoski, Karen; Mitchell, Lisa Meryn
    As harm reduction is increasingly integrated into social and health services and programs, it is essential to recognize the tension between healthcare provided by mainstream institutions and the values of harm reduction. Based on ten interviews with frontline staff who work at safe consumption sites in Ontario, Canada, I explore the challenges of providing harm reduction services under the 2018 Progressive Conservative Government’s Consumption Treatment Service (CTS) reform. My study interrogates the sociopolitical assumptions about drugs and drug use within the CTS policy and examines practices of micro-policy implementation by frontline staff. I characterize` harm reduction as an ontological expression rooted in the lived experience of drug use that places value on relationships and depathologizing drug use. I ask how frontline staff respond to the CTS policy if it changes their understanding and practice of harm reduction and how the policy is accommodated, refused, and disrupted? To answer these guiding questions, I turn my attention to investigating Policy Navigation Practices (PNP) which I define as the creative discretion staff use to balance policy implementation in their encounters with guests. I apply critical medical anthropology theory and methodology to analyze public health policy and services for people who use drugs. This research illuminates the gulf between the lived experience of drug use and the Ontario provincial government’s response to the overdose crisis. I prioritize how networks of care emerge in relation to and are embedded into, sociopolitical contexts that force these practices of care into existence. I situate Safe Consumption Sites (SCS) under the CTS policy as a microcosm of two conflicting worldviews about substance use, ideas of health, and forms of care. The findings advance our understanding of policy implementation practices in SCS and harm reduction as a form of care.
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    White Settler Racial Caucusing: Exploring How and to What Extent Racial Caucusing Motivates White Settlers to Address Indigenous-specific Racism
    (2023-01-03) Devereaux, Fiona; Hancock, Rob; Harding, Laurie
    This mixed-method study involving white settler staff in the Faculty of Human and Social Development at the University of Victoria explored how and to what extent racial caucusing motivates white settlers to address Indigenous-specific racism within post-secondary institutions. Educational institutions have long-standing colonial practices that perpetuate racism while denying and disrespecting Indigenous human rights. This research responded to legislation and documentation calling for settler societies to be held accountable and to take actions on Indigenous-specific racism. White settlers can play a critical role in disrupting Indigenous-specific racism. Through a six-session intervention to address Indigenous-specific racism, this study showed that white settler caucusing transforms white settler racial identity and supports changes in colonial thoughts and behaviours. Three themes emerged: critical reflexivity, relational accountability, and responsibility. Outcomes included racial caucusing curriculum was new and limited time had been spent exploring settler colonialism and whiteness previously. Participants shared they had increased understanding that the burden of responsibility to address Indigenous-specific racism should be on white settlers’ shoulders and that Indigenous-specific racism is created by systems and structures of whiteness that privilege white settlers and erase and silence Indigenous peoples. As a result of this intervention, participants developed a deeper connection to their identity as a white settler in that who they are has provided them with social, political, and economic meaning and benefits. This research has the potential to provide a possible pathway for targeted, focused, and accountable learning for white settlers as a part of their scaffolded Indigenous anti-racism learning journey.
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    An intersectional exploration of alternative menstrual management strategies amongst menstruators in a Canadian context
    (2022-12-22) Majewski, Courtney; Clark, Nancy; Cacchioni, Thea
    In this thesis I work to understand what factors influence low-income menstruators' decisions to use alternative menstrual management strategies in the Canadian context. In order to provide a critical review of the factors associated with period poverty, I conduct an exploratory and critical analysis of how intersecting aspects of identity and social location influence diverse low-income menstruators’ decision to use alternative menstrual management strategies. A short survey and semi-structured interviews were conducted with menstruators who use alternative menstrual management strategies. Through the thematic reflexive analysis, the qualitative data suggests that menstruation is a multifaceted experience, that is dependent on a number of diverse, personal, and variable factors. The findings indicate that menstrual management decisions by low-income menstruators are motivated by a number of factors including improved practical management of menstrual bleeding, the mitigation of menstrual management related stress and pain, as well as stigma and de-stigmatization. Contextual factors that support low-income menstruators manage their menstruation include receiving period-positive and comprehensive menstrual education, having access to supportive relationships, and having access to the financial and emotional resources.
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    Elders Living with Dementia: Nuu-Chah-Nulth First Nations Family Perspectives on Elder Healthcare
    (2022-09-21) Aro, Cheryl Lavern; Brown, Leslie; Morgan, Jenny
    In Canada, the literature regarding First Nations people’s experiences with dementia is sparse, as is the literature relating to the health and wellness of Indigenous dementia caregivers. Colonization has imposed physical, psychological and structural disadvantages on Indigenous communities that impact the family’s ability to provide informal dementia care. The First Nations senior population is growing rapidly and there is a pressing need to gather knowledge about the unique needs of First Nations informal dementia caregivers. This doctoral research seeks to contribute to the growing body of literature on this vitally important topic. This thesis reports the findings from my PhD research study, which was conducted in collaboration with the Nuu-Chah-Nulth Tribal Council, and with generous support from the Nuu-Chah-Nulth community. Using an Indigenous storytelling research method, the study explored the following questions: What are the experiences of Nuu-Chah-Nulth First Nations dementia caregivers? What support services do caregivers access and what services do they perceive are lacking? Nine Nuu-Chah-Nulth caregivers shared their experiences providing support and care to a family member with memory loss, and their perspectives on memory care resources. Interviews were conducted in various locations within the Nuu-Chah-Nulth territories to gather the caregiver’s knowledge. The author’s story as an informal dementia caregiver is also interwoven throughout the dissertation. The Nuu-Chah-Nulth caregivers narratives revealed diverse and complex experiences with the following central themes and sub-themes: trauma over the life-cycle (residential school, family violence, grief and loss); pressures of care-giving (managing the symptoms of dementia, health and family dynamics); and finally, participants’ perceptions of community resources. The findings from this research reveal that Nuu-Chah-Nulth dementia caregivers and the family members they supported were still healing from the various traumas that were inflicted on their mind, body and spirit through residential school experiences. Most of the caregivers reported that they prefer to care for their family member at home but community supports are limited.  
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    "Crisis" in the Four Pillars: A Mixed Methods Discourse Analysis of Human Security and Overdose in BC
    (2022-09-07) Fraser, James; Urbanoski, Karen; Greaves, Will
    The crisis of overdose deaths in British Columbia (BC) continues into its seventh year. This thesis applies a human security lens to a mixed methods computer-assisted discourse analysis on a corpus of public-facing documents from drug enforcement organizations in BC, and one from community-run harm reduction organizations in BC. Analysis uses a “What is the Problem Represented to Be”? (WPR) approach to analyze conflicting conceptual logics and answer the question “What human security problems are constructed in Harm Reduction and Enforcement discourses surrounding the crisis of overdose deaths in British Columbia?” Conclusion: Both corpora construct different problematizations. Whereas enforcement discourses emphasize criminality and proximal substance use harms, harm reduction discourses look at enforcement as a structural threat to people who use drugs.
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    Utility of electronic decision-support tools for patients with head and neck cancer
    (2022-04-29) Stringer, Eleah; Kushniruk, Andre W.; Lum, Julian J.
    Background: Patients with head and neck cancer (HNC) carry a clinically significant symptom burden, alterations in function (e.g. impaired ability to chew, swallow, and talk), and decrease in quality of life. Furthermore, treatment impacts social activities and interactions as patients report reduced sexuality and high rates of depression. Patients may suffer undue anxiety because they find treatment incomprehensible, which is partially a function of limited, understandable information. This can be particularly challenging for patients with limited health literacy. Furthermore, a globalized world consisting of cultural differences increases the need to enhance transparent communication of risk. Research on risk literacy and medical decision-making validates that across different cultures, people often have severe obstacles in grasping a host of prerequisite concepts for understanding health-related risk information such as numbers, graphs, and basic medical facts. Patients’ perceptions of having obtained adequate information prior and during treatment are predictive of positive outcomes. Providing patient-centered decision-support, utilizing visual images, may increase understanding of treatment options and associated risks to improve satisfaction with their decision and consultation, while reducing decisional conflict. A scoping review was conducted on electronic, decision aids (DAs) for oncology patients that returned 4217 articles, but only 167 for HNC, with 12 meeting the inclusion criteria. Three themes were identified: (1) both patients and physicians valued the DA; (2) DAs should be visually supported by images; and (3) use of a DA lessened decisional conflict and anxiety while improving knowledge, satisfaction and shared decision-making. This informed the design of a prototype DA. Semi-structured interviews were conducted with 12 survivors of HNC who completed treatment at BC Cancer- Victoria on their experiences, feedback on the utility of a DA, and insights into design features. Thematic analysis resulted in 12 themes that were organized into 3 categories. The first category, “the patient experience,” included three themes: “patients have high, through varying information needs”; “an emotional experience”; and “stories of coping, strength and resiliency.” The second category, “electronic DAs and decision support,” also included three themes: “familiarity with decision aids”; “support of concept: usefulness and of visual aids”; and “versatility of the prototype.” The last category, “evaluation of prototype”, contained six themes: “reaction to prototype”; “favourited features”; “complexity”; “preference for customizability”; “suggestions for improvement”; and “presentation device.” Key Message: The use of DAs have been shown to better inform and increase patients’ knowledge, accuracy of risk perception, and congruency between informed values and care choices allowing them to take part in active decision-making, compared to usual care. Survivors of HNC were in unanimous support of using visual images to help explain treatment and assist in decision making on treatment options. Furthermore, they contributed invaluable feedback on the prototype design, demonstrating the value of a co-design methodologies.
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    COVID-19 and pregnant and parenting women who use drugs: exploring the impact of stigmatization on help-seeking behaviour
    (2022-04-28) Nichol, Emily; Urbanoski, Karen; Pauly, Bernie
    Stigma surrounding substance use has been documented as a roadblock to recovery, posing a greater barrier to care for some populations more than others. In particular, pregnant and parenting women are an often overlooked and understudied demographic who could benefit considerably from targeted resources. Though, due to stigma surrounding substance use and motherhood, this demographic is routinely subject to judgement and discrimination resulting in delayed treatment entry. In the midst of the COVID-19 pandemic, issues of access have been compounded by a reduction in services despite heightened mental health struggles caused by prolonged periods of isolation and abrupt changes in lifestyle and environment. The purpose of this study is to understand how stigmatization affects help-seeking behaviour and to explore the impact of COVID-19 on women’s mental health and treatment experiences. Semi-structured telephone interviews were conducted from October 2020-February 2021, with current and past clients of integrated treatment programs in Ontario (n=24). Using an interpretive description approach, data was constructed to identify how stigma is internalized, anticipated, and embodied in the context of help-seeking behaviour, as well as to determine the extent to which the pandemic has interfered with maternal wellbeing. The following themes emerged: (1) stigma and help-seeking (2) COVID-19 and maternal wellness (3) stigma at the structural level: barriers to care and (4) mitigating stigma to enhance help-seeking: facilitating recovery through relationships. This research contributes evidence to a growing body of literature emphasizing the importance of relationships in the recovery process for combatting the effects of stigma and promoting early treatment entry and lends insight into the ways in which pregnant and parenting women with problematic substance use have navigated recovery during COVID-19.
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    The experience of ostomy surgery in young women with inflammatory bowel disease
    (2022-02-11) Clark, Ashley; Smith, André; Sheets, Debra J.
    Background: Inflammatory Bowel Disease (IBD) is a chronic, relapsing, autoimmune disease, affecting one in every 150 Canadians. Failure to induce remission of IBD with pharmacotherapy can necessitate surgical interventions, such as the creation of an ostomy. Ostomy surgery can help manage severe IBD and thus improve quality of life; however, individuals living with IBD report the possibility of ostomy surgery as a top concern, which can lead them to refuse or delay this decision until the disease becomes life threatening. Research Objective: The aim of this study is to understand what factors influence the decision to have ostomy surgery in young women with IBD, how the perception of the surgery compares to the reality of living with an ostomy, and the role healthcare professionals play in this decision. Methods: Nine participants who (1) identify as female, (2) are between the ages of 19 and 30, and (3) are currently living with an ostomy to treat IBD were recruited for this study. Additionally, seven healthcare professionals who work with IBD patients were recruited. Participants were invited for an individual, semi-structured interview. Findings: Young adult women living with an ostomy to treat their IBD reflected on their initial fears and concerns about undergoing surgery. Due to the severity of their illness, the majority of participants had requested surgery after having some time to adjust to the idea. This request, however, was often met with resistance or obstacles in the healthcare system. Healthcare professionals share mixed perceptions of ostomy surgery, with some viewing it as a last resort and others perceiving it as a treatment option. Once surgery had been performed, young adult women describe some challenges adjusting to life with an ostomy; but the majority report experiencing an overall improvement in quality of life. Conclusion: Understanding the perceptions that influence how young women perceive ostomies prior to versus after surgery will help identify the factors that influence the decision-making process for ostomy surgery, such as gender, age and stigma. Challenging current beliefs and assumptions may allow more supportive conversations between healthcare professionals and patients and provide insight on the actual lived experience of young women living with an ostomy.
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    A feminist post structural analysis of trauma informed care policies in BC
    (2021-09-17) Seeley, Terri-Lee; Strega, Susan; Worthington, Catherine
    My study examines trauma informed practice (TIP) policies in BC, Canada. My chosen methodology, what is the problem represented to be (WPR) (Bacchi 2009), makes politics visible in policies. I am interested in the effects of trauma policies on women who experience male violence. How does discourse produce certain effects and constitute specific subjects within these texts? I extend a politicized analysis of TIP policies, specifically, an in-depth feminist post structural analysis. I advance an understanding of the effects of policy, particularly for women who have experienced male violence and who receive services under the TIP guidelines. I note the absence of an intersectional analysis and the lack of attention paid to power relations, specifically associated with the provision of care within the health care system, the construction of the traumatized female subject and the absence of a social justice lens in TIP policies. My study addresses the meanings, and resulting practices arising from the TIP policy and its impacts on women's lived experiences. My feminist post structural analysis provides a critique of TIP policies glaringly absent from the literature. I examine available literature, which evaluates TIP. My analysis deepens the understanding of the policy's inherent assumptions by revealing the problem of trauma, as represented in TIP policies. I explore the emergence of the dominant concept of trauma in the completion of a genealogy of trauma. I uncover the commonly accepted trauma ethos, a set of principles and beliefs about violence against women that has set the path for a trauma discourse in BC's guidelines, policies, and programs. I explore my interest in iv the ontology of trauma, the nature of trauma itself and the way of being when trauma has occurred. While exploring this interest through a genealogy of trauma, I identify five historical figures; the traumatized female figure, the assaulted woman figure, the wounded veteran figure, the colonized Indigenous woman figure and the emancipated woman figure. My study explores how women are obscured and invisible in policies intended to address violence against women. I demonstrate that this invisibility results in gender-neutral policies-if there is no gender-based violence- we, therefore, do not have to think of gender-based treatment. The patriarchal erasure of women from trauma policies continually repositions what the problem is represented to be. These policies constitute women as the less valued subjects, fundamentally damaged and flawed. Trauma policies shape women as people who can damage staff; assuming they are a source of trauma infection; they can infect staff with their trauma resulting in vicarious traumatization of staff. Trauma policies characterize the traumatized female subject as fundamentally different from the staff or the professional expert. Only certain kinds of women can be traumatized, the mentally ill and substance-using women. My study exposes the presupposition embedded in policies that only certain women are violated, and other women are unlike them. This trauma discourse is grounded in racism, colonialism and sexism, built on stereotypical patriarchal representations of women, resulting in the stigmatization of women who experience male violence.
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    “Day by day: coming of age is a process that takes time”: supporting culturally appropriate coming of age resources for urban Indigenous youth in care on Vancouver Island
    (2021-07-16) Mellor, Andrea Faith Pauline; Cloutier-Fisher, Denise S.; Kobayashi, Karen M.
    The Truth and Reconciliation Commission’s first call to action is to reduce the number of Indigenous children and youth in care, including keeping young people in culturally appropriate environments. While we work towards this goal, culturally appropriate resources are needed to support children and youth as evidence shows that when Indigenous youth have access to cultural teachings, they have improved physical, mental, emotional, and spiritual health outcomes. Our project focused on the protective qualities of Indigenous coming of age teachings. Together with our community partner Surrounded by Cedar Child and Family Services, we worked to develop resources that inform and advocate for a culturally-centered coming of age for urban Indigenous youth living in foster care in Victoria, British Columbia on Lekwungen Territory. This dissertation begins with a literature review to provide the social and historical context surrounding urban Indigenous youth-in-care’s access to coming of age teachings. This is followed by a description of the Indigenous research paradigm that guided our work, what it meant for us to do this project in a good way, and the methods that we used to develop three visual storytelling knowledge sharing tools. Three manuscripts are presented, two published and one submitted, that reflect a strength-based vision of coming of age shared by knowledge holders who participated in our community events. The first manuscript retells the events of the knowledge holder’s dinner, where community members shared their perspectives on four questions related to community engagement and youth support. An analysis of the event’s transcripts revealed key themes including the responsibility of creating safe-spaces for youth, that coming of age is a community effort, and the importance of youth self-determining their journey. A graphic recording and short story are used to illustrate and narrate the relationship between key themes and related signifiers. This manuscript highlights the willingness of the community to collectively support youth in their journeys to adulthood. The second manuscript focuses on our two youth workshops that had the objective of understanding what rites of passage youth in SCCFS’s care engage with and how they learn what cultural teachings were most important to them. The findings suggest that when youth experience environments of belonging, and know they are ‘part of something bigger’, qualities like self-determination, self-awareness, and empowerment are strengthened. The third manuscript focuses on how we translated our project findings into different storytelling modalities using an Indigenist arts-based methodological approach. The project findings provided the inspiration and content for a fictional story called Becoming Wolf, which was adapted into a graphic novel, and a watercolour infographic. These knowledge sharing media present our project findings in accessible and meaningful ways that maintain the context and essences of our learnings. This research illustrates how Indigenous coming of age is an experience of interdependent teachings, events, and milestones, that contribute to the wellness of the body, mind, heart, and spirit of youth and the Indigenous community more broadly. Through our efforts, we hope to create a shared awareness about the cultural supports available to urban Indigenous youth that can contribute to lifelong wellness.
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    Including people who use drugs in the development and delivery of harm reduction programs, services, and drug policy: a scoping review of the literature
    (2021-05-03) Wojcik, Sarah Anne; Pauly, Bernie; Roth, Eric Abella
    Background: People who use drugs (PWUD) are disproportionately burdened by rates of HIV and Hepatitis C, more likely to experience stigma, social exclusion, and as a result, have poorer health outcomes. To mitigate these inequities in health, people with lived experience of drug use are, and should be, included in decisions that affect them. There is evidence that including PWUD in the development and delivery of harm reduction programs, services, and drug policy ensures such initiatives addresses their needs most effectively. As such, the purpose of this thesis is to present the findings of a scoping review of the peer-reviewed literature examining the involvement of people who use drugs (PWUD) in the development and delivery of harm reduction programs, services, and drug policy. Methods: Scoping reviews represent an increasingly popular method used to review the literature of a particular topic. It is a process of summarizing, or ‘mapping’, a range of evidence in order to convey the breadth and depth of a particular field. This scoping review implemented a search strategy focused on three categories: search terms that describe ‘peer engagement’, search terms that describe ‘substance use’ and finally search terms that describe ‘harm reduction programs/services/policy’. Searches of five academic electronic databases were conducted. Peer-reviewed literature published between 2010 and 2020 that discussed the involvement of PWUD in the development and/or delivery of harm reduction programs, services, or drug policy was included in the scoping review. Results: The search strategy produced a total of 1902 references. After duplicates were removed, thirty-two references met the inclusion criteria and were included for analysis. This scoping review identified five characteristics from each study: 1) type of study, 2) location of study, 3) year of publication, 4) type of engagement/participation, and 5) peer roles. Conclusion: One critical finding of this scoping review is the highest level of participation among PWUD was achieved when drug-user organizations were involved.
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    Needs, preferences and decision-making regarding long-term residential care: South Asian older adults' and family caregivers' perspectives
    (2021-04-20) Jamal, Sherin; Stajduhar, Kelli I.; Kobayashi, Karen M.
    The aging Canadian population is becoming increasingly ethno-culturally diverse primarily due to immigration. This, together with research indicating increased likelihood of long-term residential care (LTRC) use at older ages and challenges in providing these services, prompt important questions about whether LTRC services are prepared to provide culturally responsive and competent care to immigrant and ethno-cultural minority older adults (EMOA). This ethnographic study, informed by a critical theoretical perspective, explored these questions from the perspectives of South Asian older adults (SAOAs) and their family caregivers (FCGs). In-depth interviews with 18 SAOAs in LTRC, assisted living and those at home, their FCGs, and seven key informants from LTRC and the South Asian (SA) community (n=43) were undertaken. These interviews, in addition to 220 hours of participant observation in two LTRC facilities, provided information regarding the needs, preferences, experiences and situation of SAOAs in LTRC as well as how SA families make decisions regarding the use of such services. A select review of provincial policy, residential care regulation, health authority and facility documents, exposed taken-for-granted assumptions in how care and services are provided and the sociopolitical context of LTRC provision. Study findings suggest that LTRC services are challenged to meet the needs of immigrant and EMOA and reflect unequal and inequitable care, illuminated by the differential impact of macro-policies and resource-constrained LTRC environments on SAOAs and their families and on the ability of existing LTRC services to provide person-centred care. This inequity in service provision has implications for immigrant and EMOA and their family members in light of findings that the decision to move to LTRC is essentially a (non) decision influenced by a range of social structural factors that interact to necessitate the move to LTRC. Study findings revealed the salience of socio-economic status and economic resources in particular, in the (non) decision for LTRC placement. The findings from this study along with demographic shifts in the aging Canadian population call for LTRC service providers and policy makers to actively prepare for increasing ethno-culturally diverse resident populations and point to the need for equity informed approaches to the care of older adults.
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    Motivation and behavioural regulations of children and youth related to physical activity intensity during the COVID-19 pandemic
    (2021-04-08) Comeau, Elizabeth; Rhodes, Ryan E.; Vaghri, Ziba
    Background. Physical activity (PA) in children and youth is a necessary behaviour for health across the lifespan. Play and leisure time PA has also been declared as a right for children under the United Nations Convention on the Rights of the Child. Canadian levels of inactivity are highly concerning, with only 25% of children and youth aged 10-17 meeting national guidelines for PA behaviours in Canada. In 2020, COVID-19 pandemic regulations have additionally reduced the engagement of children and youth with leisure time PA. Rationale. Understanding key theoretical models of motivations and behavioural regulations for PA is necessary to developing appropriate interventions and strategies for targeting inactivity and ultimately changing PA behaviour for a healthier life. There is a gap in the literature regarding motivation for leisure time PA of children and adolescents, based on self-determination theory (SDT), and potential age and gender moderation or mediation. Objective. The purpose of this study was to investigate motivations for PA of children and youth, and any interactions between age and gender, utilizing Organismic Integration theory (OIT), a sub-theory of SDT. Design. The study was a cross-sectional design. Participants. Participants were children and youth aged 11-14 years, living in Canada at the time of questionnaire completion. The questionnaire was distributed from April 2020 to August 2020, and COVID-19 pandemic restrictions were in place during this period. Methods. Motivations and regulations were assessed online using the Behavioural Regulations in Exercise Questionnaire version 3 (BREQ-3) and PA was assessed using the Godin Leisure Time Exercise Questionnaire (LTEQ). Results. Higher levels of PA intensity were correlated with more autonomous forms of regulations and motivation, whereas lower levels of PA intensity were not significantly correlated with more controlled forms of motivation. No BREQ-3 variables predicted PA intensity after controlling for age and gender, therefore mediation analysis was not completed. Gender moderated the relationship between integrated regulation and PA, explaining 7-8% of the variance. Males had significant prediction from integrated regulation (ß= 5.80, p<.01), whereas females did not (ß= 1.34, p=.210). Sub-analyses revealed no BREQ-3 variables significantly predicted different levels of strenuous or moderate PA, yet greater scores of the relative autonomy index (RAI), a general measure of autonomous motivation, predicted higher levels of PA intensity. Conclusion. The study supported some facets of SDT theory. Autonomous forms of motivation correlated with higher levels of PA behaviour, and a generalized measure of autonomous motivation predicted PA intensity levels. However, controlled forms of motivation did not predict lower levels of PA intensity, which is not consistent with theory but somewhat consistent with empirical findings. Gender was the key predictor of PA outcomes, indicating other variables beyond motivation and regulations should be further explored regarding children and youth’s motivations for leisure time PA, in the context of the COVID-19 pandemic.
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    The impact of cannabis on the use of alcohol and tobacco: findings from observational studies of Canadian medical cannabis patients
    (2021-04-06) Lucas, Philippe; Milloy, Michael-John; Boyd, Susan C.
    Background A growing body of research suggests the therapeutic use of cannabis may affect the use of other substances, including reducing the use of alcohol, tobacco and prescription drugs such as opioid analgesics. However, most of the evidence stems from small, cross-sectional surveys or population-level studies, both of which have significant limitations, including the inability to conclusively determine causality for behavioural changes. Furthermore, very little detail has been gathered on the factors that potentially impact substitution, including patient characteristics and patterns of cannabis use (e.g., X, Y, Z). Additionally, despite consistent calls by physicians, academics, patients and policy-makers around the globe citing the need for high quality studies to identify the risks and benefits of cannabis in both medical and non-medical applications, there are many pre-existing and ongoing challenges to conducting such research. These include shifting regulatory policies that may be impacting access to cannabis for both medical and non-medical use, and that could ultimately be affecting patient retention in prospective medical cannabis studies. In the interest of learning more about how the use of cannabis effects the use of alcohol, tobacco and other substances, and to better understand factors that may be impacting retention in prospective cannabis research, I designed and conducted two studies: 1. The Canadian Cannabis Patient Survey 2019 (CCPS 2019) was a national cross-sectional survey of 2102 Canadian medical cannabis patients that examined demographics, patient patterns of cannabis use, and self-reported changes in the use of alcohol, tobacco, prescription drugs and illicit substances following medical cannabis initiation. 2. The Tilray Observational Patient Survey (TOPS) was a prospective, multi-site, observational study examining the impact of medical cannabis products on quality of life and the use of prescription drugs of 1145 patients over a 6 month period, which provided an opportunity to conduct a survival analysis and other analyses to assess variables potentially impacting retention in longitudinal cannabis studies. Methods This dissertation includes three analyses of the data resulting from these studies in the form of one published and two submitted manuscripts. The first paper provides an overview of research to date examining the impact of cannabis and cannabinoids on alcohol use, followed by an analysis of the 973 CCPS 2019 participants who either previously or currently use alcohol. The questionnaire gathered a detailed inventory of alcohol use prior and post medical cannabis initiation using two separate but related measures: drinking days per month, and standard drinks per week. The analyses used descriptive statistics as well as univariate and multivariate regression analyses to explore patient characteristics and other variables potentially associated with changes in alcohol use post medical cannabis, including assessing the impact of “intent” to use medical cannabis to reduce alcohol use, as well as participation in other substance use treatment modalities. Findings suggest that medical cannabis initiation is associated with significant reductions in alcohol use, and that younger age (<55 years of age), specific intent to use medical cannabis to reduce alcohol use, and greater patterns of alcohol use prior to medical cannabis initiation were associated with greater odds of reducing alcohol. The second paper follows a similar methodology and format as the first paper, but with a focus on tobacco/nicotine (T/N) use. In this case, 650 survey participants reported past or current T/N use, and the analysis focused on assessing patient characteristics and other variables associated with changes in T/N uses per day, with the primary outcome of interest being no use in the 30 days prior to the survey, which was considered to be complete cessation of T/N use. The findings suggest that odds of T/N cessation were greater amongst those who were age 55 or older or that reported >25 T/N uses per day prior to initiating medical cannabis use, and that specific intent to use medical cannabis in T/N reduction/cessation efforts resulted in significantly greater odds of reducing T/N use, while involvement with traditional T/N cessation treatments (pharmacological or psychobehavioral) was negatively associated with T/N cessation. The third paper addresses the challenge of retaining patients in prospective observational medical cannabis studies at a time when there are major policy changes disrupting the legal supply while also increasing access options for adults who use cannabis. The Tilray Observational Patient Study (TOPS) was one of the largest national prospective medical cannabis studies ever conducted, taking place at 21 medical clinics in five provinces. The study was designed to assess the impact of medical cannabis on quality of life and prescription drug use over a six month period. However, initial data analysis on 1145 patients enrolled at/before Oct 15, 2018 that had completed at least one post baseline visit highlighted a significant rate of patients that were lost to follow up (LTFU). This high drop out rate, coupled with a compensation scheme that provided credits to help cover the cost of medical cannabis led to concerns of potential retention bias limited the conclusions that could be drawn from this data. However, the study and resulting data provided a unique opportunity to examine baseline patient characteristics that may have been protective of LTFU, so a survival analysis was conducted on this cohort. Additionally, since the study took place during the official launch of the legalization of adult non-medical use of cannabis in Canada on Oct. 17th, 2018, the potential impact of this significant increase in legal access options on the odds of study retention was the subject of additional analyses. The survival analysis found that baseline use of antidepressants or antiseizure medications, citing no preference for either THC or CBD, and inhalation as a primary method of use were associated with increased probability of survival/retention in the study at six months. Additionally, while the legalization of non-medical adult cannabis use in October 2018 resulted in more than three times the odds of participants being LTFU at six months, being under 55 years old, having a preference for THC, or citing inhalation as a primary method of use was partially protective of LTFU following legalization. Discussion The studies in this dissertation presented an opportunity to gather subjective and objective data on naturalistic patterns of medical cannabis use from large, heterogeneous cohorts of patients, and to explore associated impacts on the use of alcohol, tobacco and other substances. The results of these studies provide a more comprehensive understanding of the public health risks and benefits associated with the medical use of cannabis, and could subsequently inform policy decisions affecting access to cannabis vis-à-vis other drugs, private and public payer considerations related to cost-coverage for medical cannabis, and potentially lead to the development of novel alcohol and tobacco cessation strategies. Additionally, the survival analysis conducted on TOPS participants highlights some of the challenges of conducting medical cannabis research at a time when patients have a multitude of cannabis access options, including legal adult dispensaries and a still robust illicit market. Future longitudinal medical cannabis studies should consider the potential impact of policy changes effecting cannabis access on study retention/survival, and may want to focus on patient populations with characteristics associated with lower odds of LTFU.
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    The psychosocial well-being of caregivers participating in an intergenerational community-based dementia choir
    (2021-01-04) Cervantes Navarrete, Matilde; Sheets, Debra J.; MacDonald, Stuart Warren Swain
    Compared to other kinds of caregivers, caregivers of persons living with dementia (PwD) are at higher risk of experiencing social isolation, emotional distress, and depressive symptoms which can adversely affect their psychosocial well-being. This study uses longitudinal data and multilevel modeling to explore trajectories of change over the course of a choir intervention in affect, social engagement, and caregiver distress. A multilevel coupled model of change was employed to examine two time-varying associations within-person and between-persons: (1) the association between social activities and affect, and (2) the association between caregiver distress and affect. The social activities coupling model (between-persons) found that increasing engagement in social activities was significantly associated with an increase in positive affect. The caregiver distress coupling model (within-person) found that higher levels of caregiver distress were significantly associated with decreases in positive affect. The caregiver distress coupling model (between-persons) found that higher levels of caregiver distress were significantly associated with increases in negative affect. The choir intervention may have a positive impact on caregiver psychosocial well-being but there are many factors to consider (i.e., dementia trajectory) that influence psychosocial well-being. This study advances our understanding of the impact of an arts-based intervention (i.e., community-based choir) as a source of support for caregivers of PwD. Findings can inform efforts to develop community art-based programs to support family caregivers.