Public Health Sciences (School of)

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This is the collection for the University of Waterloo's School of Public Health Sciences. The School was known as the Department of Public Health and Health Systems until January 2021.

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A psychometric evaluation and application of a measure of food literacy among young adults
(University of Waterloo, 2024-11-11) Holmes, Martin
Background: Food literacy is an emerging study area encompassing the knowledge, skills, and attitudes required to navigate dynamic food systems. Food literacy has been suggested as a potential leverage point for improving diet quality and health outcomes. The emerging adult population, facing unique dietary and life transitions, is highlighted as an important group in public health research. Following calls for standard and well-evaluated measures of food literacy, a collaborative working group of public health nutrition practitioners in Ontario, Canada, led the development of a comprehensive food literacy measure, the FLit50, for use with young adults. To support the broad use of the measure in public health practice, assessment of the construct validity of the FLit50 and the development of a shortened version were desired by the public health nutrition practitioners. Objectives: The objectives of this dissertation were to: (1) evaluate the construct validity of the FLit50 measure among post-secondary students (Chapter 5); (2) analyze the characteristics of the FLit50 items to facilitate the development and evaluation of a shortened measure (Chapter 6); and (3) explore the demographic, income adequacy, studentship, and health correlates of food literacy among post-secondary students (Chapter 7). This work was undertaken in collaboration with the public health nutrition practitioners. Methods and results: The first study (Chapter 5) drew upon data from 457 post-secondary students in Ontario, Canada, to evaluate the measure's construct validity by assessing whether it could differentiate between groups hypothesized to have differences in food literacy. The FLit50 showed adequate construct validity, evidenced by higher median food literacy scores among students in food and nutrition programs (KW χ2) = 108, p < 0.001), women (KW χ2= 49.2, p < 0.001), those with adequate health literacy (KW χ2 = 20.6, p < 0.001), those with higher general health (KW χ2 = 49.5, p < 0.001), those with higher mental health (KW χ2 = 17.4, p < 0.001), and those experiencing food security in the past 12 months (KW χ2 = 21.9, p < 0.001), as hypothesized. No differences were observed by age (KW χ2 = 5.24, p = 0.63) or perceived income adequacy (KW χ2 = 4.21, p = 0.38). Differences in group means were observed as hypothesized for scores on items reflecting the underlying domains of food and nutrition knowledge and self-efficacy and confidence, but not food skills or ecological factors. The second study (Chapter 6) involved the application of the 2-parameter Item Response Theory, using data from postsecondary students (n=457) along with data collected from young adults across Canada during the initial development of the measure (n=351). Item difficulty (mean= -1.72 SD from the sample’s average food literacy ability level, range: -3.64 to 3.05 SD) and item discrimination (mean= 1.78, range: 0.33 to 8.43) characteristics were estimated for items on the FLit50. The parameters informed discussions with the public health nutrition practitioner partners to select sixteen items for inclusion in the shortened measure, the FLit16. The correlation coefficient between scores on the FLit50 and the FLit16 was estimated, and whether the FLit16 could differentiate among groups hypothesized to have different levels of food literacy, as per study 1, was examined. Scores from the two versions of the measure were strongly and positively correlated (Rho = 0.87, p < 0.01) and the short measure was able to differentiate among groups, consistent with the full measure. The third study (Chapter 7) drew upon data from the sample of postsecondary students to explore associations between demographic, income, studentship, and health characteristics, identified a priori based on the emerging food literacy literature, and food literacy scores using multiple linear regression analysis. Data from 413 students were included in these analyses after accounting for missing data on the characteristics of interest. Food literacy was assessed using the FLit50 measure, with a mean score of 42 of 49 points. Adjusting for other characteristics, food literacy was higher among women compared to men (β = 2.509, p < 0.001) and those who reported positive or neutral general health (β = 1.743, p < 0.001). Food literacy was lower among individuals identifying as East/Southeast Asian (β = -2.036, p < 0.001), South Asian (β = -2.409, p < 0.001), and other racial/ethnic identities (β = -1.568, p = 0.005) compared to those identifying as White. Food literacy was also lower among those who lived on-campus (β = -1.457, p = 0.073) and those experiencing food insecurity (β = -1.274, p = 0.004). Food literacy scores did not differ by age, income adequacy, domestic or international studentship, whether students attended college or university, household composition, or self-reported mental health status. The regression analysis yielded an R2 of 0.403, indicating that 40% of the variance in food literacy scores was explained by this model, with an overall significance of F(15, 396 DF) = 17.79, p < 0.001. Conclusions: This dissertation continues the work of the collaboration of public health nutritionists by furthering two of its main aims: establishing the construct validity of the FLit50 and developing a shortened measure that demonstrates construct validity. The availability of two well-evaluated measures presents opportunities to better understand and monitor food literacy in emerging adults and assess associations with factors such as diet quality.
Acceptability of the interRAI Check-Up Self-Report Comprehensive Geriatric Assessment (CGA) Tool: Evaluating Check-Up Acceptability in Assessing Care Needs of Older Adults with Human Immunodeficiency Virus (HIV) in Kampala District of Uganda
(University of Waterloo, 2022-09-02) Kroetsch, Brittany
Background: The Ugandan healthcare system is ill-equipped to manage the emerging medical and social needs of its aging population. With the high burden of human immunodeficiency virus (HIV), food insecurity, and the erosion of support systems, older adults are limited in their ability to maintain physical and emotional health and well-being. High levels of impairment in activities of daily living, cognition, and frailty associated with HIV coupled with increased multimorbidity for aging Ugandans calls for the revision of healthcare policies and evidence-informed practice. Objectives: This thesis aimed to estimate the association between HIV status and (i) activities of daily living, (ii) cognitive function, (iii) health stability, and (iv) clinical frailty in older persons living in Kampala, Uganda using the interRAI Check-Up self-report assessment instrument. Additionally, this thesis aimed to (v) evaluate assessment acceptability to inform healthcare system planning and care practices. Methods: A mixed methods design was employed. In Phase One, HIV-positive and negative older adults aged ≥60 years were assessed using the interRAI Check-Up self-report in the Nakawa division of Kampala. Patient characteristics were summarized with descriptive statistics, and a logistic regression analysis was used to identify differences in activities of daily living, cognitive function, health stability, and frailty of older persons in the study. In Phase Two, key informant interviews with service providers at the Reach Out Mbuya Community Health Initiative were held to characterize the acceptability of the Check-Up in the Ugandan setting and to explore perceptions of its use. Results: In Phase One, 130 Check-Up assessments were obtained for older persons in the community. HIV status was found to not be statistically significantly associated with the outcomes of interest and age was found to be positively associated with outcome scores for activities of daily living, cognitive performance, and frailty. However, age was not found to be associated with health stability. In Phase Two, 12 interviews were held with service providers at the Reach Out Mbuya Community Health Initiative. The Check-Up was found to be acceptable for use in the Ugandan setting, with minor gaps identified for coverage of economic stability, food security, living arrangement, and the physical environment. Further, challenges with languages offered, the technology required, and length of time to complete was discussed. Discussion: Findings of age-related associations for activities of daily living, cognitive performance, and frailty were conclusive with expectations for the trajectory of health throughout the aging process. Similarities across HIV-positive and negative participants are attributed to participant age, low study sample size, viral suppression, and healthcare service utilization. For Check-Up use in the Ugandan setting, several recommendations are made to address identified gaps including question modifications, further translations, provision of additional tablets, and granted permissions to RAIsoft. Next, capacity training for Check-Up use by service providers is introduced, including the need for sensitization of gender differences and appropriate structuring of assessors in the field. Lastly, a theoretical framework assessment revealed barriers in the ability of the Theoretical Framework of Acceptability to identify key gender and socio-cultural differences in intervention recipients and deliverers. Implications: This thesis provided important information for describing the needs of aging Ugandans and insight into how a standardized instrument can help to support the development of a geriatric-friendly healthcare system across the nation. This was an important step in establishing an interRAI community of practice in East Africa.
Acceptance and Usage of Smart Wearable Devices in Canadian Older Adults
(University of Waterloo, 2017-05-09) Puri, Arjun
Background: As the Canadian older adult population grows rapidly, emerging solutions and technologies that have the potential to enable aging-in-place are garnering more attention from developers, public policy makers and international organizations. One category of emerging technologies is smart wearable devices; however, their acceptance is low. In addition, information about Canadian older adults’ attitudes toward smart wearable devices is scarce and requires additional exploration. Objective: To explore Canadian older adults’ attitudes toward and acceptance of two smart wearable devices, the Microsoft Band and the Xiaomi Mi Band. Methods: A mixed methods design was used to capture descriptive statistics and to explore participant’s attitudes and experiences. Twenty older adults aged 55 or older were recruited from the cities of Kitchener-Waterloo, Cambridge, and Guelph, Ontario. Participants were invited to use two different smart wearable devices, the Microsoft Band and the Xiaomi Mi Band, for 21 days each. Questionnaires were used to capture descriptive statistics, acceptance and explore attitudes towards smart wearable devices. Subsequently, semi-structured interviews were conducted with a purposively selected sample of four participants (three females and one male) and a content analysis was performed. Results: Older adults in the study ranged in age from 55-84 (mean = 64). Gender distribution was reasonably balanced and the sample had high levels of education. Older adults were willing to accept smart wearable devices and believed continuous health monitoring could be helpful. Older adults in the sample also had high levels of technology experience and smart wearable devices awareness. Older adults believed a smart wearable device should cost between $0-$200. The Mi Band gained higher levels of acceptance (80% accepted) compared to the Microsoft Band (45% accepted). Most older adults used each smart wearable device for the entire 21-day testing period. Quantitative analysis revealed smart wearable device acceptance was associated with facilitating conditions, perceived risks and equipment characteristics. Content analysis resulted in the formation of four main themes regarding older adult’s attitudes toward and acceptance of smart wearable devices: 1) smartphones as facilitators of smart wearable devices, 2) privacy concerns, 3) subjective norm and facilitating conditions, and 4) smart wearable device equipment characteristics. Conclusion: This exploratory study contributes to addressing the scarcity of research that explores Canadian older adults’ attitudes toward and acceptance of smart wearable devices. Findings from this study suggest that older adults are willing to accept smart wearable devices and find them useful. However, lack of knowledge and experience in operating smartphones, reduced facilitating conditions, and unfavorable equipment characteristics (regarding comfort, aesthetics, and battery life) may deter the usage and acceptance of wearable devices. Privacy concerns of using smart wearables were not impactful on acceptance for older adults in the sample. These findings add to emerging research that investigates acceptance and factors that may influence acceptance of smart wearable devices among older adults.
Accessing Indigenous Foods in Urban Northwestern Ontario: Women’s Stories of Indigenous Food Sovereignty and Resistance to Policy
(University of Waterloo, 2021-04-28) Phillipps, Breanna
Indigenous populations living in urban northern Ontario have been repeatedly ignored in research regarding Indigenous Peoples food insecurity and food systems, despite the large proportion of Indigenous Peoples living in the region and the unique challenges of the urban northern food environment. The purpose of this thesis is to explore and better understand how Indigenous Peoples in the urban northwestern Ontario service hubs of Sioux Lookout and Thunder Bay access Indigenous foods and the relationship of Indigenous food to their food security and Indigenous food sovereignty. The methodology of this project is based upon on the principles of community-based participatory research, intersectional feminist theory, and the USAI Framework (utility, self-voicing, access, and inter-relationality). Data were collected in open-ended interviews with stakeholders from three groups across the two cities (1) Indigenous female community members (n=6), (2) non-Indigenous staff of Indigenous-serving organizations (n=6), and (3) policymakers (i.e. those related to wild food policy or its implementation)(n=6). Two analyses were conducted. First, a thematic analysis of interview data from Indigenous community members and non-Indigenous staff of Indigenous-serving organizations characterized the impact of place and urbanicity on accessing Indigenous foods in both urban northwestern Ontario cities. Second, an Intersectionality-Based Policy Analysis framework was applied to analyze interview data from the entire sample which illuminated how the provincial and federal policy contexts have historically and continue to impact Indigenous women and their communities’ experiences of accessing wild foods in urban northwestern Ontario. Both place and urbanicity are central to how Indigenous populations in these towns harvest, share, and consume their Indigenous foods. On the community and individual levels, Indigenous Peoples in these towns are often in situations of food insecurity due to financial, geography, and policy barriers. Participants highlighted the abundance of ways that Indigenous food sovereignty is being expressed. Building food networks and sharing practices amongst friends, family, and broader communities (both inside and outside the city) was central to promoting access to Indigenous food for Indigenous Peoples in this study. Indigenous women pointed to colonial policies which make it impossible for most people to harvest in a self-determined way; thus, resistance is necessary. We found that stakeholder groups defined the policy problem differently and brought different values to their place in the systems which impede or facilitate access to wild foods. There was an acknowledgment of the conflict of Western food safety and natural resource management principles with Indigenous rights and Indigenous food sovereignty in theory and application. Implementation of food and natural resource policy is often unclear due to the tensions of government jurisdiction and the erasure of Indigenous Peoples’ experiences within Canadian cities. This thesis reiterates that Indigenous-led and culturally safe collaborations between the Indigenous community and other organizations are critical to improving Indigenous food sovereignty in these urban settings. Illuminating the non-Indigenous actors’ understandings of Indigenous Peoples' food security and sovereignty in urban settings is key as they hold power in colonial institutions. There is a continued need for Indigenous distinctions-based and intersectional approaches in all policy at all levels – from the federal to the institutional.
Accuracy of Parental Reporting of Preschoolers’ Dietary Intake Using an Online Self-Administered 24-h Recall
(MDPI, 2018-07-29) Wallace, Angela; Kirkpatrick, Sharon I.; Darlington, Gerarda; Haines, Jess
Parents are typically relied upon to report young children’s dietary intake. However, there has been limited research assessing the accuracy of such reports captured using novel dietary assessment tools. The purpose of the current study was to assess the validity of the web-based Automated Self-Administered 24-h Dietary Assessment Tool (ASA24-Canada) for capturing dietary intake among children aged two-five years (n = 40), using parental proxy reporting. The study was conducted in a daycare setting, allowing for standardization of foods and drinks offered and direct observation of intake. Parental-reported intake was compared to true intake for lunch and dinner, as well as an afternoon snack, on a single day. Each eating occasion, including plate waste, was unobtrusively documented. Parents were not present for lunch or the afternoon snack, but joined their children at the daycare centre for the dinner meal. The following day, parents reported their children’s intake from the previous 24-h period using ASA24-Canada. For the eating occasions assessed, parents reported exact or close matches for 79.2% (82.3% for lunch, 81.2% for the snack, and 77.4% for dinner) of the foods and beverages truly consumed by children. Estimates of intake for energy and macronutrients examined (carbohydrates, fat, and protein) based on parental reports were higher than those based on true (observed) intake. Our findings suggest that parents are able to report what their preschool children eat and drink relatively accurately. However, the accuracy of portion size estimates is low. Strategies to enhance portion size reporting are needed to improve parental proxy reporting.
Activated Motivation: An Opportunity for HCI Research?
(University of Waterloo, 2022-02-24) Wallace, James
Self-Determination Theory [7, 13, 14] is a decades-old, widely-validated macro-theory that describes human motivation. Generally, it defines motivation on a spectrum ranging from amotivation, or a lack of motivation, to extrinsic motivation driven by external factors like rewards, to intrinsic motivation associated with one’s internal enjoyment or interest. Moreover, the theory establishes the benefits of more internal forms of motivation: individuals acting with internal forms of motivation will tend to feel more open and curious, be more persistent, and are more likely to succeed at difficult tasks [8, 13, 14]. Indeed, these concepts have been widely validated, and have been shown to provide a practical framework for technology design [9]. However, researchers have also argued that current engagement with the theory is shallow [11, 12], particularly some of the concepts described in Self-Determination Theory’s ‘micro-theories’ [9].
Addressing Health Care Needs For Frail Seniors In Canada: The Role of InterRAI Instruments
(Canadian Geriatrics Society, 2013-12-30) Heckman, George A.; Gray, Leonard C.; Hirdes, John P.
Fiscal pressure on the Canadian health care system results from rising numbers of frail seniors with multiple concurrent medical co-morbidities and geriatric syndromes. Improving outcomes in such seniors is contingent on a comprehensive geriatric assessment (CGA) to identify strengths and deficits and to facilitate the development of a comprehensive care plan. InterRAI instruments are standardized, reliable, and validated suites of tools to conduct CGAs; they offer several benefits, including helping clinicians identify important health issues among patients, develop appropriate care plans, and monitor patient progess. These instruments also provide several benefits beyond the bedside, including quality indicators to assess care quality, and case-mix classification algorithms to facilitate funding of health services. Finally, interRAI instruments, which are implemented in several health care settings across Canada and abroad, provide a standardized and common language that is compatible with electronic medical records and will facilitate greater integration of the health care system.
Adolescent Maternal Nutrition and Health in Uganda: Voices from the Community
(University of Waterloo, 2018-01-23) Nabugoomu, Josephine
INTRODUCTION: Over one quarter of adolescent girls in rural Uganda and more than one fifth of them in the Busoga region of Eastern Uganda experience pregnancy and childbirth. These young mothers have disproportionately high rates of poverty, food insecurity, social isolation and poor health, and lack adequate access to health care and employment. Improvement of adolescent maternal/child nutrition and health may be compromised by a number of barriers faced by young mothers. Challenges met by stakeholders who could support adolescent maternal/child health may also complicate issues. Community-level action is a key strategy to reverse the cycle of oppression for these girls and their offspring. There is scanty literature about studies that have focused on needs and barriers of teenage mothers, opportunities available in the community, challenges faced by service providers, and stakeholder recommendations and avenues of capacity building in rural Eastern Uganda with a goal of understanding influences on adolescent maternal/child nutrition and health. Moreover, the application of the social cognitive theory and ideas borrowed from the social ecological framework to this issue helps to emphasize the individual and environmental (social/economic/physical/nutrition/health service) factors that interact to influence the behaviors of young mothers. Since an aim of the research is ultimately to guide community-level intervention, it was important to understand context from the perspectives of a range of stakeholders of adolescent maternal/child nutrition and health relevant to the geographic setting of rural Jinja district. This study could help to inform further research and may help in forming feasible and acceptable community-based interventions towards enhancing adolescent maternal/child nutrition and health. OBJECTIVES AND METHODS: This qualitative research examined, from the perspectives of a range of community-level stakeholders, the needs, barriers, opportunities, challenges, recommendations and areas of capacity building for improved adolescent maternal/child nutrition and health. The research was conducted in the rural Budondo sub-county of Jinja district, Uganda. Based on constructs of the social cognitive theory (SCT), in depth individual interviews were conducted among 101 purposively sampled respondents recruited from parishes surrounding 6 public health centers of the study area. The study participants included: pregnant adolescent mothers (n=11); lactating young mothers with infants of 0-6 months (n=8); lactating mothers of infant 7-12 months (n=6); mothers of young mothers (n=6) and grandmothers of young mothers (n=5). Other interviewees were: midwives (n=7); traditional birth attendants (n=3); village health team members (n=5); doctors (n=4); teachers (n=5); head teachers (n=11); agriculture officers (n=3); religious leaders (n=3); village political leaders (n=6); staff members of non-governmental organizations in the study area (n=5); and sub-county and district area administrators (n=13). Interview recordings were transcribed word for word and then translated into English. Codes were created from the transcribed interviews based on the constructs of the SCT model (individual factors; environmental factors [including social, economic, physical, nutritional and health service environments] and, as relevant, behavioral factors) and a priori themes of the study objectives. Using Atlas-ti 7.5.4 phrases in each transcript were linked to the created codes which were networked towards the main theme of adolescent maternal/child nutrition and health. RESULTS: Needs reported by the study include schooling and home-based employment at the individual level; belonging and encouragement at the social level; jobs and money to purchase basic needs at the economic level; and shelter, beddings and clothing at the physical level. Other needs included: food for young mothers and their infants at the nutrition level; and medical supplies, health home visits and training in good newborn care practices at the health service level. Barriers identified were: young mothers’ lack of knowledge in income generation and food preparation skills and confidence to handle new responsibilities or stay in school at the individual level; harsh treatment and stigmatization by family members and medical staff at the social level: and, at the economic level: young mothers’ lack of experience in income generation, lack of academic job qualifications and/or capital/fees for self-employment, heavy responsibilities of motherhood, lack of markets, and government programs such as the National Agricultural Advisory Services (NAADS) which support adults and men with agricultural items, like seeds for planting or animals for rearing, but not girls. At the physical level, barriers included long distances and slippery roads to the health centers or training programs, failure to inherit land by girls (unlike boy children), and restriction from sharing houses with their parents as, culturally, young mothers are taken to become in-laws belonging to the families of the boys/men they had sex with. At the nutrition level: infants did not benefit from exclusive breastfeeding (EBF) due to a range of maternal factors including, in some cases, negative attitudes towards breastfeeding, insufficient breastmilk, return to school, or breastfeeding problems; and at health service level barriers included: late reporting of medical personnel, long waiting lines, absence of medicines, failure to receive delivery materials, absence of tailored medical attention, and poor health communications. Opportunities identified at the individual level were the positive attitudes of some young mothers towards: taking-up health advice and practices, laboring for a pay and keeping their pregnancies to term. At the social level, some parents and community members were kind and caring, and provided emotional support. At the economic level: some family and community support in transferring income generation skills to young mothers was identified. Similarly, at the physical level: provision of land and shelter by family and community members was sometimes reported. At the nutrition level: provision of food by families, and training and support in maternal/child feeding were assets. At the health service level, medical care and availability of health-related staff were reported for some health centers. These cases could be held up as examples. Challenges raised by stakeholders that could block the identified opportunities included: at the individual (stakeholder) level: demotivation due to serving with a low/no pay and negative attitudes of community members, and inadequate training in adolescent maternal care; at the social level: lack of an organization supporting young mothers; and at economic level: uncertainty regarding how to use available resources to better serve young mothers and how to enhance the quality of agriculture and handcrafted products to be competitive for desired market prices. At the physical level, challenges included use of the available land by families to better their own lives rather than their daughter’s, finding ways to provide for more proximal services, e.g., equipping village health team members (VHTs) with protective materials for their work. At the nutrition level, challenges included determining how to improve the skills in food preparation for mothers when faced with a lack of food and trained facilitators, and at health service level, meeting medical needs with poor access to medical supplies, poor working conditions and understaffing. Recommendations given by stakeholders included: individual level: sensitization of family and community members to support young mothers, and motivation of community members with pay; social level: community collective responsibility and policing for better health services, special schooling for young mothers, supervision of medical staff, presidential directive to fathers of babies who fail to assume financial responsibility, and use of suggestion boxes at health centers. At the economic level: employment creation, improved facilitation in agriculture, payment of service providers, putting up vocational institutes, and prioritizing the health sector within the national budget were recommended. At the physical level: building medical staff houses and operating theatres, provision of medical equipment, and supporting local health-related personnel with protective gear and delivery materials, were suggested. Further recommendations included, at the nutrition level, use of tailored nutrition education videos and expanding food preparation facilities, while at the health service level: adequate, timely and informed supply of medicines and medical supplies, employing more medical staff, having a designated space or health center for young mothers, and use of tailored health education videos. Capacity building avenues that were suggested included: at the individual level: training health personnel to meet the needs of young mothers, training young mothers and VHTs in income generation skills and use of adult VHTS by future organizations that could support young mothers; at the social level: training teachers and community workers to counsel parents; and at the economic level: teacher training to, in turn, train youth on handcraft skills while VHTs could train and monitor projects of young mothers. Other areas of capacity building included: at the physical level: training of local health-related personnel on use of anthropometry equipment to support better monitoring of maternal and child growth; at the nutrition level: training community workers in nutrition and food preparation to better support their training of mothers, and at the health service level: training of community workers, like VHTs, in the unique maternal/child health needs of adolescents and monitoring, and licensing traditional birth attendants (whose could be revised by the World Health Organization). DISCUSSION: The study revealed perceptions of diverse stakeholders that call for improved well-being of adolescent mothers and their infants at the individual and environment level in rural Uganda. By understanding the needs, barriers and supports of young mothers, challenges of service providers and suggested solutions, it may be possible to consider opportunities to shift behavior or overcome obstacles. Lessons from strategies used by a number of organizations in the study area or other districts in rural Uganda could be taken up for improved adolescent maternal/child nutrition and health. At the individual level, counselling, sensitization, and peer groups could be used to encourage, support and strengthen positive attitudes and practices of young mothers. For example, since young mothers were involved in family agriculture and home-based employment, personal projects in the same could be possible, while, staying in school could also be possible for mothers who were interested in schooling. At the social level, information sharing, counselling and sensitizing families, local community members, district administrators, civil society organizations and policy makers, could shift collective support for young mothers at home, schools, and health centers, as demonstrated elsewhere [Leerlooijer et al., 2014]. At the economic level, partnering with non-governmental organizations and government programs in the area could help in providing skill training, and grants, in the form of money or resources, to support income generation by young mothers. The said programs could also support train-the trainer opportunities for educators and other community workers. Use of agriculture for income generation is an ideal opportunity in the region as young mothers are involved in agriculture, since, on the gender level, women and girls are the major agriculture labor force in Africa. At the physical level, lessons learned from other studies could help to improve the well-being of young mothers through avenues such as family joint land ownership or and lobbying for infrastructure improvement and support to service providers such as medical staff, VHTs, and TBAs. At the nutritional level, production of food through crop growing and bird/animal rearing, in addition to adolescent maternal child nutrition education is important as suggested by several studies [Nabugoomu et al., 2015a; Nabugoomu et al., 2015b; Nabugoomu & Hanning, 2015; Shefner-Rogers 2014, Berti et al’, 2010]. Nutrition education by VHTs who are the community-based workers could also be explored as an opportunity suggested by other studies [Stanback et al., 2007; Tylleskär et al., 2011; Kirkwood et al., 2013; Penfold et al., 2014; Flax et al., 2014]. This opportunity would be possible as some of the VHTs were willing to use their homes for training of young mothers in practical food preparation skills. At the health service level, district and national authorities could be lobbied, so as to aid in the training of medical staff in adolescent friendly services, and taking and recording of measurements of young mothers and translating these measurements in a manner that can be understood by the young mothers. Lobbying to facilitate home visits by health-related personnel could also be helpful. Training of VHTs and TBAs in maternal/child health education and health monitoring by organizations such as World Vision [Ononge et al., 2016] could also help since VHTs and TBAs were trusted by community members. For example, these service providers could be used as agents of change for gender and cultural biases. This study involved a large, diverse sample of participants and hence captured a broad range of views. Conducting interviews in homes or places of work helped to make use of observations and extra information from non-participants for triangulation of information. In addition, observations at health centers were triangulated with views of stakeholders. CONCLUSION: Using the SCT, this study identified a range of needs and barriers faced by adolescent mothers in rural Uganda making them vulnerable to poor maternal/child health. Participants also identified opportunities that could support young mothers, challenges of service providers, and gave feasible steps to addressing the needs, barriers and challenges by building on available opportunities to enhance health and well-being. This research underpins the importance of research at the community level and the inclusion of knowledge users and decision makers in the process. Findings of this study may help to direct future community-based interventions for improvement of adolescent maternal/child nutrition and health.
Adult Hippocampal Neurogenesis, Cognitive Flexibility, and Depression
(University of Waterloo, 2016-02-23) Lui, Erika
Depression is a serious and complex mental health disorder that is becoming increasingly prevalent, and is among the leading causes of global disease burden. Although depression is thought to be primarily an affective disorder, there is growing evidence that it is associated with memory deficits. Adult hippocampal neurogenesis has been implicated in depression and may also contribute to cognitive flexibility. Therefore, the present study used an animal model of depression involving chronic corticosterone (CORT) injections to assess learning and memory, and changes in adult hippocampal neurogenesis. In Experiment I, rats were randomized to receive either CORT (40 mg/kg) or vehicle injections for 21 days. On the second day of treatment, all rats received injections of BrdU to label newborn neurons. Six days before the end of the CORT treatment, rats were subjected to behavioural testing in the Morris water maze (MWM). Neurogenesis was also assessed using immunofluorescence staining. Although CORT-treated rats performed on par with vehicle-treated rats during spatial learning of the MWM, cognitive flexibility of the CORT-treated rats was significantly impaired during the first day of reversal training. The probe test revealed enhanced memory retention of the platform location for the CORT-treated rats. Experiment II was similar to Experiment I in all respects, except that injections were stopped 3 days before behavioural assessment. In Experiment II, CORT-treated rats performed better in the spatial learning phase of the MWM, while reversal learning and memory retention in the probe test were no different than control animals. In both Experiment I and II, no difference in the number of newborn neurons between the two groups was observed. These findings suggest that cognitive flexibility is impaired in a CORT-induced animal model of depression, the effect is reversible and seems to be independent of suppressed hippocampal neurogenesis.
Advancing methods to capture and analyze dietary patterns
(University of Waterloo, 2024-08-12) Hutchinson, Joy
Background: Suboptimal diet quality is linked to poor health outcomes and is associated with many sociodemographic characteristics, including several that are indicators of inequities. Assessments of dietary intake have shifted over time from investigations of single foods and nutrients towards dietary patterns. This change has led to developments in methods to capture and analyze dietary patterns, from short tools that quickly assess the overall diet to novel analytic methods. These methodological advances present opportunities to better understand dietary patterns in Canada and globally. Research objectives: The objectives of this research were to (1) develop a brief dietary screener to assess alignment of dietary intakes with the 2019 Canada’s Food Guide healthy food choices recommendations; (2) develop a scoring system for the screener and assess the construct validity of the screener; (3) identify novel methods used to characterize dietary patterns through a scoping review of the literature; and (4) explore the capacity of probabilistic graphical models to expand our understanding of the joint relationships between multidimensional dietary patterns and intersecting sociodemographic characteristics. Methods and results: The first study in this dissertation (Chapter 4) discusses the process to develop the Canadian Food Intake Screener. This was achieved by mapping the dietary guidance in the 2019 Canada’s Food Guide and reviewing existing tools to develop a draft screener, which was reviewed by Health Canada and external collaborators (n=15). The screener was revised iteratively based on feedback from cognitive testing conducted among adults aged 18-65 years in English (n=17) and French (n=16) and from face and content validity testing conducted with experts (n=16). The screener was well understood overall and testing informed refinement to finalize the Canadian Food Intake Screener, which includes 16 questions to rapidly assess alignment of adults’ intake with the 2019 Canada’s Food Guide healthy food choices recommendations. The second study in the dissertation (Chapter 5) was conducted to develop a scoring system for the screener and evaluate the screener’s construct validity among adults aged 18 to 65 years. Analysis of variance (ANOVA) was used to compare screener scores among subgroups with known differences in diet quality. The correlation between scores on the screener and the Healthy Eating Food Index-2019 (HEFI-2019), which also assesses alignment of intake with the 2019 Canada’s Food Guide healthy food choices recommendations, was assessed. Adults aged 18-65 years (n=154) completed the screener, answered a range of questions about their health and sociodemographic characteristics, and completed up to two 24-hour dietary recalls. The mean screener score was 35 points (SD = 4.7; maximum 65), ranging from 25 (1st percentile) to 45 (99th percentile). Meaningful differences in screener scores were observed in hypothesized directions by gender identity (p = 0.06), perceived income adequacy (p = 0.07), education (p = 0.02), and smoking status (p = 0.003). The correlation between screener and HEFI-2019 scores was 0.53 (SE = 0.12). The screener demonstrated moderate construct validity, indicating that it is appropriate for use for rapid assessment of alignment of adults’ intake with the healthy food choices recommendations when comprehensive dietary assessment is not possible. In Chapter 6, novel methods used to characterize dietary patterns in peer-reviewed literature were summarized using a scoping review. The databases MEDLINE, CINAHL, and Scopus were searched using keywords such as such as machine learning, latent class analysis, and least absolute shrinkage and selection operator (LASSO) to identify novel methods used to describe dietary patterns. Of 5274 records identified, 24 met the inclusion criteria. Twelve of 24 articles were published since 2020. A range of methods was applied to identify dietary patterns, with nine studies using approaches that have applications in machine learning to characterize dietary patterns, and the remaining 15 using other novel methods such as latent class analysis, LASSO, or treelet transform. Future work to guide the application, interpretation, and comparability of these methods is necessary to enable synthesis of the literature to inform policies and programs. The final study (Chapter 7) in this dissertation examined the ability of probabilistic graphical models to explore the joint relationships between dietary patterns and sociodemographic characteristics. While prior research has established relationships between dietary patterns and sociodemographic characteristics, it has rarely considered the multidimensional relationships between dietary components or possible intersecting relationships among sociodemographic characteristics. Mixed graphical models, a network method, enable explorations of these complex joint relationships, which have largely been unexplored in the Canadian context. We conducted a secondary analysis of first 24-hour dietary recalls collected from adults aged 18 years and above who participated in the 2015 Canadian Community Health Survey Nutrition (n=14 097). Mixed graphical models were used to identify joint relationships between amounts consumed in grams of thirty log-transformed food groups and age, sex, education, income, household food security status, geographic region, employment status, and smoking status. Sociodemographic characteristics formed a network, with several pairwise relationships. Several dietary components also formed networks, often patterning by food group. Age and sex were the sociodemographic characteristics most strongly connected to dietary components. This research applied mixed graphical models to provide deeper insights into the internal structures of the dietary patterns of adults in Canada, and how sociodemographic characteristics are jointly related with dietary patterns. Probabilistic graphical models offer promise to complement existing methods to characterize dietary patterns, such as indices. Conclusions: This dissertation makes contributions to dietary patterns research with respect to both collecting data reflective of overall dietary patterns and analytic methods to capture their complexity. The advances from these studies can be applied to inform targeted research and policies promoting public health nutrition in Canada and beyond.
Advancing the evidence to improve the nutrition of populations: a refreshed vision and scope for Nutrition Journal
(Springer, 2017-07) Kirkpatrick, Sharon I.; Collins, Clare E.
This editorial introduces a revised and refreshed scope for Nutrition Journal, one of BioMed Central’s open access journals. Diet is among the leading risk factors for morbidity and mortality globally [1]. This signals the need for high-quality policy-relevant nutrition research to advance the evidence base on strategies to promote and support healthy eating, as well as effective dissemination of that research.
Adverse events among Ontario home care clients associated with emergency room visit or hospitalization: a retrospective cohort study
(BioMed Central, 2013-06-22) Doran, Diane M.; Hirdes, John P.; Blais, Régis; Baker, G. Ross; Poss, Jeffrey W.; Li, Xiaoqiang; Dill, Donna; Gruneir, Andrea; Heckman, George A.; Lacroix, Hélène; Mitchell, Lori; O'Beirne, Maeve; White, Nancy; Droppo, Lisa; Foebel, Andrea Dawn; Qian, Gan; Nahm, Sang-Myong; Yim, Odilia; McIsaac, Corrine; Jantzi, Micaela
Background: Home care (HC) is a critical component of the ongoing restructuring of healthcare in Canada. It impacts three dimensions of healthcare delivery: primary healthcare, chronic disease management, and aging at home strategies. The purpose of our study is to investigate a significant safety dimension of HC, the occurrence of adverse events and their related outcomes. The study reports on the incidence of HC adverse events, the magnitude of the events, the types of events that occur, and the consequences experienced by HC clients in the province of Ontario. Methods: A retrospective cohort design was used, utilizing comprehensive secondary databases available for Ontario HC clients from the years 2008 and 2009. The data were derived from the Canadian Home Care Reporting System, the Hospital Discharge Abstract Database, the National Ambulatory Care Reporting System, the Ontario Mental Health Reporting System, and the Continuing Care Reporting System. Descriptive analysis was used to identify the type and frequency of the adverse events recorded and the consequences of the events. Logistic regression analysis was used to examine the association between the events and their consequences. Results: The study found that the incident rate for adverse events for the HC clients included in the cohort was 13%. The most frequent adverse events identified in the databases were injurious falls, injuries from other than a fall, and medication-related incidents. With respect to outcomes, we determined that an injurious fall was associated with a significant increase in the odds of a client requiring long-term-care facility admission and of client death. We further determined that three types of events, delirium, sepsis, and medication-related incidents were associated directly with an increase in the odds of client death. Conclusions: Our study concludes that 13% of clients in homecare experience an adverse event annually. We also determined that an injurious fall was the most frequent of the adverse events and was associated with increased admission to long-term care or death. We recommend the use of tools that are presently available in Canada, such as the Resident Assessment Instrument and its Clinical Assessment Protocols, for assessing and mitigating the risk of an adverse event occurring.
Adverse Events Associated with Hospitalization or Detected through the RAI-HC Assessment among Canadian Home Care Clients
(Longwoods Publishing, 2013-08-19) Doran, Diane M.; Hirdes, John P.; Blais, Régis; Baker, G. Ross; Poss, Jeffrey W.; Li, Xiaoqiang; Dill, Donna; Gruneir, Andrea; Heckman, George A.; Lacroix, Hélène; Mitchell, Lori; O’Beirne, Maeve; Foebel, Andrea Dawn; White, Nancy; Qian, Gan; Nahm, Sang-Myong; Yim, Odilia; Droppo, Lisa; McIsaac, Corrine
Background: The occurrence of adverse events (AEs) in care settings is a patient safety concern that has significant consequences across healthcare systems. Patient safety problems have been well documented in acute care settings; however, similar data for clients in home care (HC) settings in Canada are limited. The purpose of this Canadian study was to investigate AEs in HC, specifically those associated with hospitalization or detected through the Resident Assessment Instrument for Home Care (RAI-HC). Method: A retrospective cohort design was used. The cohort consisted of HC clients from the provinces of Nova Scotia, Ontario, British Columbia and the Winnipeg Regional Health Authority. Results: The overall incidence rate of AEs associated with hospitalization ranged from 6% to 9%. The incidence rate of AEs determined from the RAI-HC was 4%. Injurious falls, injuries from other than fall and medication-related events were the most frequent AEs associated with hospitalization, whereas new caregiver distress was the most frequent AE identified through the RAI-HC. Conclusion: The incidence of AEs from all sources of data ranged from 4% to 9%. More resources are needed to target strategies for addressing safety risks in HC in a broader context. Tools such as the RAI-HC and its Clinical Assessment Protocols, already available in Canada, could be very useful in the assessment and management of HC clients who are at safety risk.
Aging-related technologies: A multiple case study of innovation processes
(University of Waterloo, 2017-09-21) Koch, Melissa
Introduction: As part of a Canadian research network focused on aging and technology – Aging Gracefully across Environments using technology to support Wellness, Engagement, and Long Life (AGE-WELL) – this thesis explored how technologies currently being developed to support older adults and their caregivers fare through the processes of innovation. This included an exploration of the factors that might facilitate or constrain these new technologies from their initial development to implementation, as well as any policy, regulatory and/or health system issues that may be relevant. Methods: A multiple case study was conducted of four AGE-WELL technology projects. For each, data were collected through: interviews with project members and key stakeholders (n=20); surveys (n=4); ethnographic observations at each project site (n=4); and document reviews. Data were analyzed using directed coding, guided by the ADOPT (Accelerating Diffusion of Proven Technologies for Older Adults) framework (Wang et al., 2010). The results were compared across sites using a cross-case analysis. Results: Challenges related to the initial stages of the work included obtaining ethics clearance, recruitment of study participants, and getting small-scale studies completed. Challenges were also experienced in creating business models – including uncertainties around who might benefit from or pay for the technologies. Facilitators included collaboration among stakeholders (e.g. clinicians, industry, end-users) and support from the AGE-WELL network to form partnerships. Conclusions: Technologies have the potential to help older adults maintain their independence, health and quality of life. Understanding the factors that facilitate or constrain the development and implementation of these types of technologies can help promote their diffusion and adoption.
Alcohol and Select Medications as Fall Risk Factors in Community Dwelling Older Adults in Canada
(University of Waterloo, 2018-05-04) Laberge, Sarah
Abstract Introduction: Falls are the leading cause of accidental injury in community dwelling older adults, often resulting in emergency room visits, hospitalization and early admission to long-term care. Studies have identified many risk factors for falls including increasing age, diagnosis of a chronic disease, poor vision, fear of falling, hazards in the home, alcohol and prescription medications. While studies have examined many risk factors associated with falls, there is limited information on whether prescription medications and alcohol are risk factors in community dwelling older adults. Purposes: The primary thesis objectives were to: i) conduct a literature review to synthesize the literature on whether alcohol and psychotropic, anti-depressant and anti-hypertensive medications are risk factors for falls in community dwelling older adults; ii) examine what health and social factors are associated with high-risk alcohol use in community-dwelling older adults in Canada,; and iii) examine whether alcohol and select medications are predictive of falls in community dwelling older adults. Methods: The first aspect of this thesis was to conduct a literature review on select medications (psychotropics, benzodiazepines or anti-psychotics, anti-depressants, and anti-hypertensives) and alcohol, both singly and in combination, on fall risk in community dwelling older adults using the following search terms: drug or medication, aged or elderly or older adult or senior, accidental falls or falls or falling, and alcohol or alcohol drinking. These search terms were entered into four databases (PubMed, EMBASE, CINAHL and SCOPUS). A total of 1,146 articles were retrieved and screened for inclusion. Studies were included if 1) was a primary study; 2) included community dwelling persons aged 60 years and older; 3) included alcohol use as an independent variable; 4) included medications of interest; 5) falls were the primary outcome variable; and 6) published in English. We excluded studies if they were: 1) review articles, conference proceedings, books, editorial, case studies or commentary; 2) if articles relied on qualitative data (interviews, focus groups); 3) if they were not in English; and 4) included institutionalized persons (e.g. living in LTC or hospital). Chapters 3 and 4 used data from the Canadian Injury Prevention Survey. The survey was distributed online to local, provincial and national organizations across Canada that cater to older adults (2016-2017) and collected information on demographics, perception of physical and mental health, fall history, alcohol use, use of psychotropic, anti-depressant and anti-hypertensive medication use, smoking status, diagnosis of a chronic disease, physical activity, usual sleep quantity, likelihood of daytime sleepiness, and executive duties. While data was collected on community dwelling individuals 45 years and older, only data of those 65 years and older was examined in the present thesis (n=2,281). Chapter 3 examined alcohol use in community dwelling older adults (n=2,279). Participants reported the number of drinks they consumed per week and the number of days per week they consumed alcohol. The purpose of this chapter was to: 1) examine alcohol use in community dwelling older adults in Canada using current alcohol consumption guidelines; 2) develop and test new alcohol consumption guidelines to determine if they better differentiate drinking habits on health outcomes; and 3) determine risk factors of high-risk drinking. Low risk drinking was defined as 1-2 drinks per week for both males and females. Moderate drinking was defined as 3-9 drinks per week for males and 3-6 drinks for females. High risk drinking limits were defined as 10 drinks per week for males and 7 drinks per week for females. Using logistic regression, we examined demographic and health factors to predict low and high-risk drinking. Multinomial regression was used to examine predictors of low, moderate and high-risk drinking. Chapter 4 examined the use of alcohol and select medications as risk factors for falls, both as independent predictors of falls, and together with alcohol (n=2,281). Participants reported prescription medication, alcohol use on a weekly basis and fall history. Medications examined included psychotropic (anxiolytics, anti-psychotics, hypnotics/sedatives), anti-depressants (selective serotonin reuptake inhibitors (SSRI), serotonin antagonist reuptake inhibitors (SARI), serotonin-norepinephrine reuptake inhibitors (SNRI), tricyclic anti-depressants, or other) and cardiovascular agents (diuretics, beta-blockers, angiotensin converting enzyme inhibitors, angiotensin II receptor antagonist, calcium channel blockers) on fall risk. Correlations were performed to determine health factors correlated with falls. Logistic regression determined medications predictive of falls. Results: The literature review (Chapter 2) found 29 observational studies that met the inclusion criteria after screening. Sample sizes ranged from 307 to 321,422. Twenty-six studies examined the effects of benzodiazepines, hypnotics/sedatives or anti-psychotic use on falls, and twenty found benzodiazepines, hypnotics/sedatives or anti-psychotics were predictive of falls. Thirteen studies examined anti-depressant use and falls; 10 studies found that anti-depressants are predictive of falls. Twelve studies examined anti-hypertensives as a risk factor for falls and four found anti-hypertensives were predictive of falls. Fifteen studies examined alcohol use and five found alcohol was a predictor of falls. Findings from Chapter 3 show that 70% of participants reported drinking at least once per week. Using the current Canadian alcohol consumption guidelines, 6.2% of older males and 10.1% of older females were classified as high-risk drinkers. Moderate drinking was reported by 32.8% of males and 23.3% of females. When comparing current alcohol consumption guidelines to the new additional category (moderate drinking), there were no significant difference on health outcomes. Findings from Chapter 4 show that 33.4% of older adults had a fall in the previous two years. In fallers, 5.3% reported psychotropic use, 10.4% reported anti-depressant use, and 51.6% reported anti-hypertensive use. Anti-hypertensive medication and alcohol use was not associated with falls. As a group, psychotropic drug use was predictive of falls after controlling for potential confounding factors (p<0.05). Anti-depressant sub-classes SSRIs, SARIs and SNRIs were predictive of falls on their own and when controlling for sex (p<0.05). Conclusions The literature review found benzodiazepines, hypnotics/sedatives, anti-psychotic and anti-depressants are predictive of falls in community dwelling older adults. Anti-hypertensive medication and alcohol use were not predictive of falls. Compared to females, males were more likely to be moderate drinkers, however, overall adding a moderate drinking category did not help differentiate health and social factors associated with alcohol consumption. Psychotropic drug use overall, as well as individual anti-depressant drug classes (i.e. SSRI, SNRI and SARI) were all predictive of falls after controlling for sex. Anti-hypertensives and alcohol were not predictors of falls in community dwelling older adults based on the survey data. Findings of the literature review and survey data confirm psychotropic and anti-depressant use increase fall risk in community dwelling older adults. Clinicians should exercise caution when prescribing psychotropic and anti-depressant medications to older adults.
Alcohol use among Older Adults in Inpatient Psychiatry in Ontario: Individual and Community Factors Related to Problematic Use
(University of Waterloo, 2018-10-18) Indome, Eunice Ofeibea
Background: Alcohol use among older adults is usually not identifiable and could be mistaken for other medical or psychiatric conditions. As sometimes an underlying cause, problematic alcohol use (PAU) continues to impact older adults with mental health issues who are admitted to inpatient psychiatry care. About 60% of older adults with undiagnosed alcohol related problems are found to have depression, repeated falls, delirium, heart failure, or chest infections when admitted to acute care (2). The associations between PAU and poor health outcomes is concerning as it could exacerbate the health conditions of older adults. Current predictions indicate an increase in the older adult population in Canada. Therefore, using the Andersen behavioural model of health care use, this study sought to investigate the prevalence of PAU among older adults, the characteristics of older adults who use alcohol, and the types of community support systems available. Methods: Two data sources were used for this study. First, data from the Ontario Mental Health Reporting System (OMHRS) with inpatient information on mental and physical health, social support and service use, based on the Resident Assessment Instrument-Mental Health (RAI-MH) was used to conduct a multiple logistic regression analysis. OMHRS sample data included all older adults discharged from an inpatient mental health hospital between January 1, 2011, and December 31, 2016. Second, data from ConnexOntario was used to conduct a geographic analysis of psychiatric admission rates in relation to health service locations and PAU in the Waterloo-Wellington region of Ontario. Results: Study results from the OMHRS data indicated that of the total number of older adults admitted to inpatient psychiatric care (n = 21,577), about 10% (n = 2,107) had PAU. Older adult men were twice as likely to have PAU compared to women. Older adults had an increased the odds of having PAU if they were educated (1.4), employed (1.5), or living in their own residence (1.3). However, living with someone (0.8) and being 65 years or older (0.6) decreased the odds of an older adult having PAU. Contextual results for the Waterloo-Wellington region of Ontario showed that the clustering of psychiatry admissions for older adults were higher in areas with a cluster of services such as Guelph and Cambridge. However, in areas such as rural Wellington, there were high psychiatry admission rates for older adults but fewer mental health and addictions services. The study findings indicate that more seniors programs were needed to support older adults with mental health and addiction problems. In addition, older adults with PAU were likely to face the challenge of traveling further to utilize current available mental health and addictions support services in other cities. Conclusion: This study identified the prevalence and characteristics of PAU among older adults admitted to psychiatric inpatient treatment; and highlighted some of the individual and contextual factors that are associated with the increased odds of PAU among this population. On an individual level, understanding the associated mental health and addictions service needs of older adults could contribute to providing better support before, during, and after psychiatry admissions. Contextually, factors such as the availability and accessibility of these mental health support services for older adults need to be further investigated to identify its role in service utilization.
Antecedents and Consequences Associated with Health Literacy or Health Numeracy in Adult Immigrants and Refugees: A Systematic Review of Empirical Evidence
(University of Waterloo, 2018-09-19) Zhu, Meng
Background: Health literacy and health numeracy refer to skills that are fundamental and essential to fulfill health activities. Limited health literacy and numeracy levels have been associated with various poor health outcomes, such as increased emergency department or hospital visits, difficulty in interpreting health messages, inability to take medications properly, and increased mortality in older people. Immigrants and refugees tend to have inadequate health literacy skills, compared to the native-born population, indicating that they may be more susceptible to suffer the negative impacts of low health literacy. Currently, many empirical studies have investigated the antecedents (factors which could influence or predict health literacy or health numeracy, such as demographics) and consequences (outcomes that result from different health literacy or numeracy levels, such as mortality) of health literacy or health numeracy in adult immigrants and refugees. However, efforts that summarize the relevant empirical evidence do not exist. Objectives: The thesis research aimed to bring together individual empirical studies dispersed in the literature and synthesize both quantitative and qualitative evidence in regards to antecedents and consequences of health literacy or health numeracy in adult immigrants and refugees by applying the systematic review approach. My purpose was not to quantitatively synthesize the results on a specific antecedent or consequence in a specific immigrant or refugee population, but to narratively summarize the relevant evidence to provide information on what antecedents and consequences of health literacy or health numeracy have been investigated in the adult immigrants and refugees, to identify potential research gaps, and to offer insights for future research and practice. Methods: The reporting of the systematic review mainly followed the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA) checklist. Index terms and free terms relating to health literacy, health numeracy, immigrants and refugees were searched in eight databases, including PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, SCOPUS, the ProQuest Dissertations & Theses database, the Conference Proceedings Citation Index-Science (CPCI-S), and the Conference Proceedings Citation Index-Social Science & Humanities (CPCI-SSH). Studies that met the eligibility criteria were included. The reviewers assessed the risk of bias of each individual study and narratively synthesized the extracted evidence by thematic identification. The thematic identification mainly followed the framework approach, in which a working thematic framework was established. The working thematic framework consisted of themes and subthemes pre-existing in Sorensen’s comprehensive conceptual model for health literacy and numeracy. Antecedents and consequences from the included studies were coded with these themes and charted into a matrix, the row of which represented an included study, and the column of which denoted to the themes. Additionally, we also carried out inductive thematic identification for the antecedents and consequences that did not fit the pre-existing themes. Results: In total, 77 included studies, published between 2004 and 2018, were included. Forty-nine of them were quantitative research, out of which 47 applied the cross-sectional study design and two adopted the cohort study design. The rest 28 included studies were qualitative, all of which conducted thematic analysis with information collected by interviews or focus groups. Sixty-seven studies focused on only health literacy; 1 on health numeracy only; and 9 involved both. In terms of the research sample, 63 included studies involved immigrants, 13 investigated refugees, and one involved both. Twenty-four and 58 included studies explored antecedents and consequences, respectively. The antecedents were coded with the following themes (subthemes): personal antecedents (personal characteristics and personal competence), societal and environmental antecedents, and personal belief, experience, and behaviour. The consequences were coded with themes including health service use or behaviour, health outcome, health cost, health experience and perception, and health knowledge and understanding. Conclusion: The systematic review was the first study to examine the current state of the research activities on antecedents and consequences of health literacy or health numeracy in the population of adult immigrants and refugees. Our major findings suggest the following recommendations: 1) Future research needs to direct more focus on other health literacy dimensions, such as interactive critical health literacy, rather than the functional dimension of health literacy (i.e., reading and writing skills) in adult immigrants and refugees. 2) More empirical research is needed on antecedents and consequences of health numeracy in adult immigrants and refugees. 3) Inductively identified themes such as “personal belief, experience, and behavior” for antecedents and “personal experience and perception” and “knowledge and understanding” for consequences should be added for the further development of the current framework for health literacy and health numeracy in the context of immigrant and refugee health. 4) More research is required on the associations between health cost and health literacy or numeracy in adult immigrants and refugees. 5) Future quantitative studies need to apply more advanced study designs (e.g., cohort studies) and improve the sampling methods to increase their research validity. 6) Immigrant- and refugee-specific antecedents (e.g., primary language, acculturation, duration of residence in the destination country) and consequences (e.g., health needs) should draw more attention in future empirical research.
Application of interRAI Assessments in Disaster Management: Identifying Vulnerable Persons in the Community
(University of Waterloo, 2016-09-02) Van Solm, Alexandra
Background: Several studies have shown the increased vulnerability and disproportionate mortality rate among frail community dwelling older adults as a result of disasters. Parallel to an escalating number of disasters, Canada is faced with an aging demographic and a policy shift emphasizing aging at home. This results in a greater vulnerability of this group of high needs community dwelling individuals to the effects of events that lead to interruption of home health care services and/or displacement. Despite the growing vulnerability it has proven to be difficult to identify those most vulnerable older adults and their characteristics. This makes it challenging for emergency managers, first responders and health care providers to develop targeted preparedness, response and recovery strategies aimed at the most vulnerable older adults living at home. Relatively recent developments in electronic health records provide an unprecedented opportunity to use comprehensive assessment information collected as part of routine clinical practice in the home care sector to identify vulnerable community dwelling older adults. In Ontario, the Resident Assessment Instrument for Home Care (RAI-HC) is the mandated primary assessment tool for long-stay home care clients. Objective: The three specific objectives of this dissertation are to examine: 1. The application of the New Zealand Priority Algorithm used during the Christchurch earthquake to the Ontario Home Care Client database. 2. Determinants of Emergency Response Level (ERL) designation within CCACs. 3. The person-level factors that contribute to increased vulnerability of home care clients to power interruptions through examining the health effects of the power outage that occurred as a result of the December 2013 Ice Storm including emergency department (ED) visits, hospitalization and service utilization. Conceptual Framework: The person-environment fit model is used as the conceptual framework for this dissertation. This model views individual vulnerability as a product of the interaction between individual competence, adaptive behavior and the strength of the environmental stress (the emergency or disaster). Where the demands of an emergency or disaster exceed the ability of the older adult to cope, a person- environment misfit may lead to negative health outcomes. Methodology: All research questions were addressed using RAI-HC datasets in combination with other datasets. Chapter three used the RAI-HC database by selecting unique home care clients with assessments closest to December 31st 2014 (N=275,797). For chapter four Emergency Response Level (ERL) codes were provided by the Hamilton Niagara Haldimand Brant (HNHB) and Toronto Central (TC) Community Care Access Centre (CCAC) and matched with a RAI-HC assessment in both CCACs (N=70,292 and N=8,996 respectively). In addition, linkages were made with data regarding death, hospitalization and long term care (LTC) admission. Lastly, chapter five uses information on Toronto Hydro power outages and an estimation of outage areas based on outage mapping in addition to the HC database. The exposure group (N=10,748) was compared to two comparison groups. Group one included clients with HC assessments in the same period and receiving services during the same week but were unaffected by the hydro outage (N=12,072). The second comparison group was comprised of clients residing in the same area as the hydro outage one year prior to the storm (N=10,886). Service utilization was collected from the Client Health Related Information System (CHRIS). Statistical analyses were done using SAS version 9.4 and methods used include frequency tabulation, bivariate logistic regression, multivariate logistic regression as well as Kaplan-Meier survival plotting and Cox proportional hazards ratios calculations. Results: When comparing four decision support algorithms (University of Waterloo, Canterbury, Vulnerable Persons at Risk (VPR) and VPR Plus) to identify high priority clients, the VPR and VPR Plus were most predictive of mortality, LTC admission and hospitalization. The high priority groups were significantly more impaired than lower priority clients with both the VPR and VPR Plus. They had higher levels of health instability, experienced more falls, required more assistance with Activities of Daily Living (ADL), were more cognitively impaired and had higher levels of depression ratings. When comparing the chosen algorithms, the VPR and VPR Plus, with ERL levels assigned by care coordinators the analysis showed considerable overlap in predictive variables. The ERL was highly predictive of mortality and LTC admission, but less predictive of hospitalization. C-stats of logistic regression modeling with ERL and VPR/VPR Plus in predicting mortality showed that the VPR and VPR Plus models were a better or equal fit as models with the ERL. Finally, when examining the characteristics of clients that were affected by the 2013 power outage with the two comparison groups, a significant difference was found for the non-exposed group in the year of the outage in relation to numbers of nursing and personal support worker (PSW) visits, hospital admission and emergency department (ED) visits as well as mortality, LTC admission and hospitalization rates. The analysis showed that clients in the non-affected areas in the year of the outage were more likely to decline in Depression Rating Scale (DRS), Changes in Health, End-Stage Disease, Signs and Symptoms Scale (CHESS) and Instrumental Activities of Daily Living (IADL). This is consistent with the higher rates of LTC admission and hospitalization within six months after the outage for non-exposed clients as well as higher frequency of nursing and PSW visits during and 30 days after the outage. In contrast to the expectation that exposed clients would do worse during and after the outage, the analysis showed that exposed clients showed in fact less health decline than non-exposed clients. However, when looking at those clients that would have been considered high and medium risk clients based on the VPR and VPR Plus, the analysis showed that those clients in areas with hydro outages were more likely to die and to be admitted to long term care (LTC) than the high and medium risk clients living in unaffected areas. Conclusions: The analyses in this dissertation have shown the usefulness of information collected as routine clinical practice using interRAI assessment tools. The current system of designating Emergency Response Levels (ERL) by care coordinators is highly dependent on consistent updating of the ERLs in the system whenever a new home care assessment is completed. The analyses showed that this is not consistently done, and may render the ERL code obsolete overtime. The VPR and VPR Plus have been shown to be valid and reliable alternatives to ERL codes and they are kept up to date as new assessments are completed on home care clients. Incorporating these decision support algorithms into the RAI-HC assessment system software enables an automatic and up to date vulnerability assessment of clients. This can make it possible for emergency managers, first responders and health care providers to use a comprehensive priority system before, during and after emergency, ultimately preventing unnecessary death or health deterioration.
Applying a Systems Thinking Approach to Health Care for Women & Children in the Flood Plains of Western Zambia
(University of Waterloo, 2022-09-16) Njungu, Mwimanenwa
At least half of the world’s population are reportedly unable to obtain essential health services with significant gaps being noted in sub–Saharan Africa and Southern Asia. Access to health services incorporates physical accessibility, acceptability and affordability and is influenced by multiple factors. Environmental factors such as flooding and changing weather patterns due to global climate change, contribute to limited geographical access to health services particularly for rural communities. Like many low- and middle-income countries, Zambia, a predominantly rural country in southern Africa has some poor health indicators such as high infant and under-five mortality rates, demonstrating that some communities are lacking access to essential health services. The aim of this research was to apply a systems’ thinking framework to the investigation of contextual factors influencing access to maternal and child health (MCH) services in Zambia’s Western Province where there is increasing variability in seasonal floods, with a view to improving mitigation strategies. The main objectives of this study were: 1) To identify the effects of flooding on access to maternal and child health services in flood prone areas of Western Province, Zambia. 2) To explore the perceptions of environmental change among residents of the Zambezi flood plains in Western Province and how these changes influence health outcomes. 3) To understand the interaction of contextual factors on public health interventions for maternal health from a systems perspective and identify potential leverage points for improvement. A qualitative study design was used for this research based on interviews, focus group discussions observations and some document reviews. Data collection for this research was undertaken over several field visits between June 2019 and February 2021. The findings of the research indicate that there were four main effects of flooding on access to care. These were disruption of the health service delivery system, disruption of routes of access and transportation challenges, negative economic effects and negative effects on water and sanitation. Environmental changes most reported by residents in the flood plains were changes in timing of the different seasons and rainfall patterns and increasing intensity of both droughts and floods with devastating consequences on the livelihoods. Consequently, residents’ resort to use of traditional remedies and self-medication to treat illness. Home deliveries are common for remote communities with many complications reportedly being experienced. Contextual factors that are influencing the effectiveness and outcomes of maternal health interventions included political and developmental factors, socio-cultural factors, and environmental factors. The findings illustrate the effects of floods on access to essential health services in the flood plains of Western Province. They also describe the perceptions of residents on environmental changes observed and the resulting health outcomes experienced. The interaction of different systems in influencing access to health services and public health interventions is presented demonstrating that long term solutions require a multipronged strategy involving multiple departments and the participation of local communities. The study makes several significant contributions. It builds on existing knowledge on the potential of a systems approach to strengthening design of interventions for health system challenges. By applying a systems framework and using some systems tools it makes theoretical and methodological contributions. It also adds to the body of knowledge on the effects of flooding on health systems in LMICs such as Zambia. These findings are significant for the global community to be aware of the wide-reaching effects of ongoing climate change among communities that contribute minimally to such change.
Applying systematic review search methods to the grey literature: a case study examining guidelines for school-based breakfast programs in Canada
(BioMedCentral, 2015-10-15) Godin, Katelyn Marina; Stapleton, Jackie; Kirkpatrick, Sharon I.; Hanning, Rhona; Leatherdale, Scott T.
Grey literature is an important source of information for large-scale review syntheses. However, there are many characteristics of grey literature that make it difficult to search systematically. Further, there is no ‘gold standard’ for rigorous systematic grey literature search methods and few resources on how to conduct this type of search. This paper describes systematic review search methods that were developed and applied to complete a case study systematic review of grey literature that examined guidelines for school-based breakfast programs in Canada. Methods: A grey literature search plan was developed to incorporate four different searching strategies: (1) grey literature databases, (2) customized Google search engines, (3) targeted websites, and (4) consultation with contact experts. These complementary strategies were used to minimize the risk of omitting relevant sources. Since abstracts are often unavailable in grey literature documents, items’ abstracts, executive summaries, or table of contents (whichever was available) were screened. Screening of publications’ full-text followed. Data were extracted on the organization, year published, who they were developed by, intended audience, goal/objectives of document, sources of evidence/resources cited, meals mentioned in the guidelines, and recommendations for program delivery. Results: The search strategies for identifying and screening publications for inclusion in the case study review was found to be manageable, comprehensive, and intuitive when applied in practice. The four search strategies of the grey literature search plan yielded 302 potentially relevant items for screening. Following the screening process, 15 publications that met all eligibility criteria remained and were included in the case study systematic review. The high-level findings of the case study systematic review are briefly described. Conclusions: This article demonstrated a feasible and seemingly robust method for applying systematic search strategies to identify web-based resources in the grey literature. The search strategy we developed and tested is amenable to adaptation to identify other types of grey literature from other disciplines and answering a wide range of research questions. This method should be further adapted and tested in future research syntheses.

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