Jean Shoveller


Relevant Degree Programs


Graduate Student Supervision

Doctoral Student Supervision (Jan 2008 - May 2019)
Social-emotional functioning in early childhood : investigating developmental patterns in childhood mental health and well-being (2018)

Early childhood is a critical developmental period when children form social and emotional sensitivities that will support or undermine their mental health throughout their lives. It is estimated that over half of lifetime mental health problems develop before the age of fourteen, and yet early identification and intervention efforts are often hindered by limited recognition of early mental health indicators and a general absence of population-level monitoring systems. This dissertation addresses these gaps, applying a novel approach (person-centered analysis) to identify latent profiles of social-emotional functioning within population cohorts of children entering Kindergarten in British Columbia from 2001 to 2012. Early childhood social-emotional functioning was measured using the teacher-rated Early Development Instrument (EDI) population health survey that includes measures of internalizing and externalizing behaviours (readiness to explore, aggression, hyperactivity) as well as social competence. Latent profile analysis was used to identify distinguishable profiles of early childhood social-emotional functioning at a population-level. Unique profiles of social-emotional functioning were identified consistently across the three analyses included in this dissertation, with over 55% of children demonstrating overall high social-emotional functioning, over 40% of children demonstrating relative vulnerabilities in internalizing and externalizing behaviours, and approximately 3% of children experiencing multiple comorbid vulnerabilities on nearly all measures. Chapter 2 identifies social gradients in the severity of early childhood social-emotional vulnerabilities, with boys and lower income children over-represented in lower functioning social-emotional profiles. Chapter 3 examines children’s likelihood of depression, anxiety, conduct disorder, attention deficit hyperactivity disorder, and multiple conditions, and finds that the profile group to which children belong in Kindergarten is predictive of their experience of mental health conditions up to ten years later. Chapter 4 demonstrates that children’s Kindergarten social-emotional profile group is also predictive of their self-reported well-being in middle childhood, with evidence that supportive relationships with adults and peers partially mediates these associations. These studies inform our understanding of patterns of early childhood social-emotional functioning by identifying social conditions and behaviour patterns predictive of children’s future mental health outcomes that can be targeted earlier in the life course to help mitigate mental health problems and promote well-being.

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Clearance, reinfection and re-clearance of hepatitis C (2017)

Purpose: Despite the availability of effective treatments for Hepatitis C virus (HCV) infection, public health experts face challenges to intervening effectively, in part due to gaps in understanding the natural history of HCV. To address these knowledge gaps, the current dissertation uses a large population-based cohort in British Columbia (BC), Canada, to examine spontaneous clearance, reinfection, and spontaneous clearance of reinfection (i.e., re-clearance) of HCV.Methods: This study draws data from the BC Hepatitis Testers Cohort that includes all individuals tested for HCV in BC (1990-2013), with linkages to data on their medical visits, hospitalizations, and prescription drugs. HCV-positive individuals with ≥1 valid HCV-PCR test on/after HCV diagnosis (n=46,783) were included, with varying eligibility criteria for each of the three primary analyses. Logistic regression and Cox proportional hazards regression models were used, as applicable.Results: The proportion of primary spontaneous clearance, reinfection, and re-clearance was 25.1% (11,737 of 46,783), 7.6% (452 of 5,915), and 33.9% (121 of 357), respectively. Chapter 2 shows that the likelihood of spontaneous clearance of primary HCV infection is lower in people with primary T-cell immunodeficiency (adjusted odds ratio [aOR]: 0.55, 95% CI: 0.32-0.94) and higher in females (aOR: 1.61, 95% CI: 1.54-1.68). Chapter 3 shows a higher reinfection risk in the spontaneous clearance group compared to sustained virological response group (adjusted Hazard Ratio [aHR]: 2.71, 95% CI: 2.0-3.68), those coinfected with HIV (aHR: 2.25, 95% CI: 1.78-2.85), and people who inject drugs [PWID] (aHR: 1.53, 95% CI: 1.21-1.92). Among PWID, opioid substitution therapy [OST] (aHR: 0.73, 95% CI: 0.54-0.98) and mental health counseling (aHR: 0.71, 95% CI: 0.54-0.92) were associated with a lower HCV reinfection risk. Chapter 4 shows that, among those who spontaneously cleared the primary infection, the likelihood of HCV re-clearance was 54% lower (aHR: 0.46, 95% CI: 0.24-0.86) if reinfected with a heterologous HCV genotype.Conclusions: People with compromised immunity may be prioritized for HCV treatment allocation. The positive impacts of scaled-up HCV treatment might be enhanced if accompanied by appropriate harm reduction programs to prevent reinfections among PWID with a view to achieving World Health Organization’s goal of HCV elimination.

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Sexual identity, minority stress, and the mental health of lesbian, gay, bisexual, and heterosexual Canadians (2017)

Background: Addressing mental health has emerged as a priority in Canada. The mental illness burden is thought to disproportionately affect some subgroups, including those self-identifying as lesbian, gay, and bisexual (LGB). Yet, to date, no reliable population estimates are available to characterize the prevalence of common mental health disorders amongst LGB Canadians. Objectives: (1) Investigate the prevalence and correlates of anxiety, mood, and anxiety-mood disorders, heavy drinking, and co-occurring anxiety or mood disorders and heavy drinking among Canadians self-identified as LGB. (2) Examine whether life stress mediates and sense of community belonging moderates the relationship between sexual identity and the study outcomes. (3) Assess the heterogeneity in the prevalence of the study outcomes by sexual identity at intersections with other social positions (i.e., sex, age, income, education, and racialized minority status).Methods: Pooled data from the 2007–2012 cycles of the Canadian Community Health Survey (N = 222,548) were used to obtain a multi-year sample of Canadians aged 18–59 years, who self-identified as LGB or heterosexual. Analyses included a series of logistic regression models, stratified binary mediation models, and models with multiple interaction terms. Bootstrapping was used to obtain standard errors and confidence intervals. Results: LGB-identified Canadians reported substantially greater odds of mental health disorders compared with heterosexual peers: the odds of anxiety, mood, anxiety-mood, and co-occurring disorders were double for gay/lesbian-identified respondents, and more than triple for bisexual-identified respondents. Perceived life stress partially mediated the effects of sexual identity on the outcomes, and the greatest odds were observed for bisexual respondents. Combinations of disadvantaged positions of reporting a gay/lesbian or bisexual identity (vs. heterosexual) with vulnerabilities related to income, age and sex were found to have multiplicative effects on the rates of mood and anxiety disorders. Discussion: The results provide the first national estimates for common mental health disorders reported by LGB-identified Canadians. They suggest that universal interventions (thought to be applicable to all sexual identities) may ameliorate some, but not substantially diminish all, observed mental health disparities. Informed by these results, future interventions tailored to meet the specific needs of LGB people, particularly bisexual-identified, may hold promise.

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Exposure to work place and war time violence among female sex workers living in conflict-affected northern Uganda (2015)

Background and objectives: Sex workers in sub-Saharan Africa are dually affected by HIV/STIs and violence. It is estimated that over one-third of commercial sex workers in sub-Saharan Africa are living with HIV; within Uganda, the site of the current study, 37.2% of female sex workers are reportedly living with HIV compared to 8.5% among the general Ugandan female population. There is limited information on the health and safety of sex workers living in environments affected by conflict despite the structural conditions that heighten risk of HIV infection and exposure to violence. This dissertation explores the prevalence and factors associated with exposure to violence among women currently involved in sex work in conflict-affected northern Uganda.Methods: This dissertation drew on data from a community-based cross-sectional study of HIV prevention, treatment, and care among 400 sex workers living in northern Uganda. Analyses investigated exposure to violence from commercial sources (e.g., clients) and non-commercial sources (e.g., conflict-related violence, including abduction). Descriptive statistics were used to display the individual-level, sex work environment, and conflict related characteristics of study participants. Bivariable and multivariable logistic regression methods were used to examine demographic, conflict-related, and sex work-related factors associated with exposure to violence.Results: 49.0% of sex workers had experienced sexual and physical violence in the previous six months, including physical assault, rape, and gang rape. Police harassment, inconsistent condom use, and managers/pimps that controlled sex workers’ negotiations were factors independently associated with increased odds of violence from clients. Exposure to historical conflict-related violence was common, as 32.3% of sex workers had been abducted into the Lord’s Resistance Army. From this sample, less than half reported accessing post-abduction reintegration programming.Conclusion: Sex workers in this study were exposed to extreme levels of commercial and non-commercial violence while concurrently facing substantial barriers to care. Rights-based policies, programming, and protective services for sex workers are needed to improve access to care and social services to reduce the burden of violence and improve health and well-being outcomes.

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Health-related information practices and the experiences of young parents (2015)

Background: Young parents are targeted by a variety of health information interventions, aiming to educate and monitor them in order to improve population health. However, we know little about the ways young parents use health information or experience health information interventions in their everyday lives.Objectives: The objectives of the dissertation are to use a series of article-style chapters to: (1) describe the health-related information practices of young parents (Chapter 3); (2) explore how knowledge and expertise are discursively constructed within young parents’ health information worlds (Chapter 4); and (3) examine the functioning and values of population health information interventions in the lives of young parents (Chapter 5). Methods: The analyses presented in this dissertation are based on data collected via ethnographic observation at two Young Parent Programs and individual interviews with 37 young mothers and 2 young fathers ages 15-24 in Greater Vancouver, British Columbia. Data was analyzed in accordance with constructivist grounded theory and situational analysis.Results: Young parents in Greater Vancouver were often sophisticated health information seekers. Information assessment was a major task, for which young parents employed various methods of triangulation. These practices took place in social worlds that discursively constructed the “teen mom” as paradoxically knowledgeable (in matters of sexuality and technology) and ignorant (in matters of parenting and health. Population health information interventions (communication and surveillance) were prominent in these social worlds, and carried ethical implications for social justice. Young parent acceptance varied depending on the positionality of those implementing interventions, as well as their intrusiveness and level of stigmatization of young parents. Conclusion: By investigating, documenting, and theorizing the ways young parents interact with health information in the contexts of their everyday lives, this study generated theory that can help inform information interventions aimed at supporting this public health priority population. Programs and materials for young parents should take into account the heterogeneity of their childcare experience and parenting knowledge, as well as cultural norms. Future research should further explore the intersection between individual information practices and health information interventions, and test the emergent theoretical propositions related to population health information interventions.

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Informingn Selective Screening Through More Robust Estimation of STI Risk (2015)

No abstract available.

Advancing population and public health ethics regarding HIV testing among young men (2014)

Background: Despite the epidemiological and clinical rationale supporting a shift from voluntary approaches to HIV testing (e.g., in which a patient seeks an HIV test) towards the expansion of more routine approaches (e.g., in which a clinician routinely offers patients testing), a set of rather polarized ethical debates has remained somewhat unresolved. And, within these discussions, considerations of young men’s experiences and health care needs have remained conspicuously absent. Objectives: This dissertation aims to: (1) Systematically investigate the status of ethical debate and discussions within the peer-reviewed literature in the realm of voluntary and routine HIV testing, with a particular emphasis on understanding the structural and agentic factors associated with testing experiences (e.g., HIV-related stigma); (2) Examine and identify the social processes associated with voluntary and routine testing that attenuate or exacerbate HIV-related stigma among young men; and (3) Describe how ‘public’ values (e.g., solidarity; reciprocity; health equity) may influence the ‘autonomous’ decisions and/or HIV testing practices of young men. Results: The findings highlight a set of social processes that can provide transformative opportunities for young men to reconceptualise expectations pertaining to HIV and HIV-related stigma within routine testing practices. These findings also distil the extent to which young men ‘take up’ relational values (e.g., solidarity; reciprocity), as well as individual reasons (e.g., obligations to the Self) in their HIV testing practices. Discussion: Empirical-normative approaches to advancing population and public health ethics regarding HIV testing may be most usefully pursued as an iterative project (rather than as a linear project), in which the normative informs the empirical questions to be asked and new empirical evidence constantly directs conceptualizations of what constitutes morally robust public health practices. This dissertation provides a set of methodological considerations regarding research techniques that may be useful in advancing future empirical-normative inquiry regarding HIV-related population health interventions.

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Investigating the role of structural determinants in shaping sex workers' reproductive health access and outcomes (2014)

Background and objectives: While sex workers are disproportionately impacted by reproductive health inequities, a significant knowledge gap regarding the contextual drivers of sex workers’ broader reproductive health access and outcomes remains. This dissertation therefore sought to disentangle the role of multiple, and intersecting structural factors on sex workers’ ability to exercise their reproductive rights. Specifically, this dissertation’s objectives were to: explore the structural correlates of sex workers’ pregnancy intentions; investigate the influences of community organization and venue-based features on indoor sex workers’ ability to negotiate and use contraceptives; and examine the structural correlates of accessing cervical screening. Methods: This dissertation drew on data collected from AESHA (An Evaluation of Sex Workers’ Health Access), an open prospective cohort of street- and off-street sex workers across Metro Vancouver, Canada. Bivariable and multivariable regression methods, using generalized estimating equations for longitudinal data, were employed to examine the associations between intersecting structural, community organization, venue-based, interpersonal and individual-level factors and various reproductive health access and outcomes. Spatial analysis using geographical information systems (GIS) were used to examine geographical correlates of reproductive health services access.Results: This dissertation found that sex workers exhibited pregnancy desires similar to that of the general population, with access to off-street venues, inconsistent condom use by clients and intimate partner violence among the important factors shaping these desires. The availability of supportive indoor work features and increased social cohesion increased sex workers’ ability to negotiate for and use condoms. Finally, this dissertation documented suboptimal cervical cancer screening access among HIV seropositive and sero-negative sex workers. While barriers to health care services in general reduced odds of cervical cancer screening, access to screening via outreach models increased odds of screening.Conclusion: Structural factors play a pivotal role in shaping access to reproductive health services and sex workers’ negotiation of their sexual and reproductive health. Given the Canadian government is in the process of revising its sex work legislation, this study offers critical insights into how structural interventions including safer workplace models, sex worker-led integrated HIV/sexual and reproductive health services within a decriminalized legal framework can promote positive sexual and reproductive health.

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Senses of place among young people entrenched in a "local" drug scene : an urban ethnography (2013)

In the public imagination, street youth are frequently defined through their relationships with place. Whether because they are viewed as innocent victims or violent criminals, young people who are homeless, destitute and visibly addicted to drugs are often understood to be out-of-place in the public spaces of city centers. This thesis is based on ethnographic fieldwork with a group of street-entrenched youth in Greater Vancouver conducted from January 2008 to January 2013. It included the creation of photography by youth exploring their sense of place in the city over time. Merging phenomenological perspectives on place-making with a focus on the processes of political economy and power that make some place worlds more enduring than others, I demonstrate that sense of place among youth who occupy the margins of urban space is far more complicated than conventional understandings imply. My findings reveal that, among youth, the “local” drug scene was produced in tension with a broader social spatial landscape of power, political economy and possibility, in which various remembered and imagined places were also implicated. In the context of this wider landscape-in-motion, involvement in Vancouver’s inner city drug scene could be articulated as both a sense of belonging and dislocation, “being in the center of something” and “getting lost in the city.” The drug scene could be a frontier of economic opportunity, in which anyone could attempt to stake a claim through activities like street-based drug dealing. And, it could be the site of a strictly enforced moral logic of violence and organized crime. The overarching objective of this thesis is to characterize these complex understandings, experiences and affects, and how they intersected with the regimes of living youth enacted on the streets. I conclude by highlighting that in order to meaningfully address youth’s initiation into and sustained involvement in “risky” forms of drug use and crime in settings like Vancouver, intervention at the level of policy is urgently needed in order to address social suffering across young people’s lives, and the wider geographies they implicate.

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The epidemiology of methamphetamine use among street youth and injection drug users (2011)

Background: Given the limited understanding of the epidemiology of methamphetamine (MA) use among street-involved youth and injection drug users (IDU), this thesis sought to: systematically characterise the evidence base demonstrating associations between MA use and adverse health outcomes among young people; examine the incidence and predictors of MA injection initiation among a cohort of IDU in Vancouver; describe the prevalence and correlates of MA use among sexual minority drug users; determine whether frequent MA injection predicts emergency department (ED) utilisation; and finally, explore the pathways through which MA use drives injection-related risk behaviour including syringe sharing.Methods: Street-involved youth and IDU participating in three open prospective cohort studies were asked to complete semi-annual interviewer-administered questionnaires, provide blood samples for HIV testing, and consent to hospital database linkages. A variety of longitudinal techniques were used to investigate the association between self-reported MA-related outcomes (e.g., initiation, frequent use) and individual, social, and structural determinants of interest.Results: A systematic review identified consistent associations between MA use and a number of health outcomes, including depression, suicidal ideation, and psychosis. Scientific evidence to suggest an association between MA use and a number of previously suggested harms (e.g., infectious disease transmission, dental problems) is equivocal. Some subpopulations, including sexual minority drug users, are more likely to use MA, which appears to exacerbate exposure to HIV-related risks and other vulnerabilities. Longitudinal analysis revealed that young people, non-injection stimulant users, homeless individuals, and those involved in the city’s open drug scene are most likely to initiate MA injection. The injection of MA, particularly frequently, was associated with a number of health and behavioural outcomes, including an increased hazard of ED utilisation and syringe sharing. Barriers to accessing harm reduction and HIV prevention services likely account for many of these relationships. Conclusions: Methamphetamine use is increasingly common among street youth and IDU in Vancouver. Its use and resultant harms appear to be driven by intersecting individual, social, and structural factors. Comprehensive interventions that are based upon sound scientific evidence and that address existing health and social inequities among marginalised populations are required.

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The structure of sex work : variability in the numbers and types of sex partners of female sex workers in southern India (2011)

Background and objectives: There is limited knowledge of sexual structure (i.e., the numbers, types and distributions of sex partners and patterns of sexual contact) and its relationship with HIV infection and prevention among female sex workers (FSWs). The objectives of this study were therefore: to examine the social and environmental factors associated with the numbers of clients of FSWs; to characterize heterogeneity in sexual structure and assess how sexual structure influences HIV prevalence; and to examine the impact of an HIV intervention on condom use by different partners (clients, intimate partners), as reported by FSWs. Methods: This study used data collected from FSWs and clients in Karnataka state, southern India as part of the Avahan AIDS Initiative, an ongoing large-scale HIV intervention. Bivariate and multivariable statistical techniques were used to examine the relationships between two outcomes (numbers of clients and condom use) and key social and environmental factors, including exposure to the Avahan intervention. A deterministic compartmental mathematical model was developed to understand how sexual structure influenced HIV prevalence on a population level. Results: Sexual structure displayed substantial geographic variation across districts in Karnataka. The most common predictors of higher rates of clients were a reliance on sex work as sole income, younger age, and being single or cohabiting as compared to married. The effect of the solicitation environment (e.g., brothels, public places, homes) varied by district. Intervention exposure was associated with increased condom use by FSWs’ clients, but not their intimate partners. Mathematical modelling identified sexual structure parameters with the largest influence on increasing (numbers of clients of FSWs; numbers of visits to FSWs by clients; frequency of sex acts with repeat clients) and decreasing (duration of the repeat FSW-client partnership; fraction of repeat clients) HIV prevalence within and across districts. Conclusions: Differences in the sexual structure of FSWs and their commercial clients have important implications for HIV transmission dynamics. In light of findings related to both differences in sexual structure across districts and the impact of an intervention on condom use by different partners of FSWs, HIV prevention planners need to tailor interventions to respond to local contexts.

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Injection settings and drug-related harm in Vancouver, Canada (2010)

Ecological approaches to addressing injection-related risk seek to reduce drug-related harm by identifying and removing environmental barriers to risk-reduction. While the settings where drugs are injected represent a key location for these efforts, further knowledge regarding the role of injection settings is required to understand and address context-specific barriers to risk-reduction. This thesis sought to employ the risk environment framework and use ethnographic methods to examine two key types of injection settings, public injection venues and a local supervised injection facility (SIF), in the Downtown Eastside (DTES) of Vancouver, Canada.Ethnographic fieldwork, including naturalistic observation of activity within drug use settings and 50 in-depth interviews with local injection drug users (IDUs), generated information regarding local public injection settings and the SIF. Generating detailed descriptions of the settings investigated, and the use of analytical approaches drawing on the risk environment framework, permitted identification of the influence of various ecological forces upon risk production/reduction in relation to these settings.In Vancouver, public injecting often occurs in spaces characterized by unsanitary conditions and a lack of adequate amenities for hygienic injecting, where the threat of street violence or arrest impedes individual ability to employ safer injecting practices. While the SIF fosters risk-reduction by addressing many of these contextual features which pose barriers to safer injecting, the perspectives of IDUs emphasise that they inject at the facility because it addresses multiple salient risk priorities, including health concerns as well as “everyday risks” associated with injecting. A contextualised understanding of the operation of Insite highlights how the interactions between macro-level forces (e.g., regulatory mechanisms), operational features of the facility, and the local drug using context shape utilisation of the SIF by local IDUs. This work highlights the importance of developing contextualized understandings of injection settings in order to identify barriers to risk-reduction, and inform the development of safer injecting environments. While initiatives fostering injection safety within existing injection settings must be pursued, these should be complemented by efforts to remove barriers to accessing SIFs.

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The recruitment and retention of community health workers in small cities, towns, and rural communities (2010)

This study focused on the recruitment and retention of community health workers (CHWs) who work outside of large urban centres in small cities, towns, and rural communities in Canada. The study had three objectives: (1) to describe what CHWs working in small cities, towns, and rural communities have to say about their jobs, their working conditions, and their roles within the health care system; (2) to investigate these CHWs’ experiences of, and motivations for, pursuing a career in the home support sector; and (3) to develop recommendations to inform the design of policies and programs for the recruitment and retention of CHWs in small cities, towns, and rural communities. The study employed a qualitative research design informed by a feminist approach to health services research aimed at fostering “bottom-up” policy development informed by the perspectives of marginalized health care workers. The research process was carried out in partnership with a regional health authority in British Columbia, Canada. Data collection took place in four Vancouver Island communities: Campbell River, Parksville, Port Alberni and Port Hardy. Semi-structured interviews were conducted with 32 participants across the four study communities. The majority of the participants (n = 17) were unionized CHWs. The other respondents included nurses, managers, team leaders, and a scheduler. All interviews were transcribed and thematically analyzed. Study findings were later reported back to and validated by the participants.The study found that CHWs in the study communities performed a wide range of duties that extend beyond standard definitions of home support, of particular relevance to smaller communities with limited access to other health and social services. The primary facilitator of CHW recruitment and retention was the opportunity to build positive relationships with clients. Wages were the primary barrier to CHW recruitment and retention, in particular the wage disparity between community- and facility-based workers. Other barriers included the costs associated with paying for one’s own mobile phone and using one’s own vehicle on the job, CHWs’ unpredictable schedules, and feeling isolated from other members of the health care team.

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Master's Student Supervision (2010 - 2018)
The impact of structural inequities and interpersonal violence on food security and HIV care among women living with and affected by HIV in a Canadian setting (2017)

BACKGROUND: Women living with HIV (WLWH) and sex workers (SWs) are priority populations for HIV prevention, diagnosis, treatment, and care. There is limited research into the impacts of structural (e.g., laws) and interpersonal violence (i.e., physical, sexual, verbal) on access to necessities (e.g., food, housing), HIV treatment, or the relationship between violence and HIV stigma. This thesis investigated the role of structural and interpersonal violence in an environment of HIV non-disclosure criminalization, in food insecurity among SWs living with and affected by HIV, and in antiretroviral (ART) adherence.METHODS: Data were drawn from two community-based prospective cohort studies, An Evaluation of Sex Workers’ Health Access (AESHA) and Sexual Health and HIV/AIDS: Women’s Longitudinal Needs Assessment (SHAWNA). Bivariate and multivariable logistic regression were used to examine the correlates of physical and/or verbal violence due to HIV disclosure without consent among WLWH in the SHAWNA cohort. Bivariate and multivariable logistic regression using generalized estimating equations (GEE) were used to model correlates of food insecurity among SWs in the AESHA cohort. Finally, a multivariable confounder model was created to assess the independent relationship between ART adherence and physical and/or sexual violence for WLWH in the SHAWNA cohort.RESULTS: Among 255 WLWH enrolled in SHAWNA between 2010-2016, bivariate and multivariable logistic regression showed that WLWH who were “outed” had elevated odds of experiencing physical and/or verbal violence (Objective 1). In AESHA, among 761 SWs living with or affected by HIV between 2010-2014, bivariate and multivariable logistic regression using GEE revealed increased odds of food insecurity for SWs who experienced physical and/or sexual violence (Objective 2). Among 250 WLWH enrolled in SHAWNA between 2014-2017, bivariate and multivariable logistic regression using GEE found decreased odds of optimal ART adherence among WLWH who experienced physical and/or sexual violence (Objective 3).CONCLUSIONS: Structural and interpersonal violence are important factors in the health needs and outcomes of SWs and WLWH. Universally applied trauma-informed care by primary healthcare providers is crucial. The decriminalization of sex work and HIV non-disclosure must be a priority. Given the high proportion of Indigenous women represented in this thesis, culturally relevant programming must be accessible.

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Access to health care among women sex workers in Vancouver, Canada : universal health coverage in a criminalized sex work environment (2016)

Background: Universal access to health care is a critical determinant of health. Despite the numerous health inequities faced by women sex workers, research on access to health services among this population remains limited, particularly on the role of social-structural factors. This thesis sought to investigate sex workers experiences along the continuum of health care access in a setting with universal health coverage.Methods: Data was dawn from “An Evaluation of Sex Workers’ Health Access”(AESHA), an open prospective cohort of women sex workers in Vancouver, Canada. Logistic regression analyses were employed to evaluate correlates of institutional barriers to care (using generalized estimating equations for longitudinal data), and to assess baseline engagement in the HCV continuum of care. Extended cox regression analyses, with a confounder model approach, were used to examine the independent effect of depot medroxyprogesterone on HSV-2 acquisition.Results: These analyses demonstrated inequities faced by sex workers all along the continuum of health care access, from trying to reach health services (Chapter 2), to utilizing these services (Chapter 3), to the impacts of inadequate and sub-optimal care on their health outcomes (Chapter 4). Among 723 participants, 70.4% reported institutional barriers to health care, only half (52.9%) of 552 HCV-seronegative participants having a recent HCV test, and less than 1% of the 302 women living with HCV receiving treatment. Further, high incidence rates of HSV-2 were documented, with depot medroxyprogesterone use independently associated with approximately 4-times increased risk. Importantly, barriers to care appeared to be exacerbated among most vulnerable women, including sexual/gender minorities, migrants, women of Aboriginal Ancestry, uninsured and those with previous experiences of violence.Conclusions: Findings from this research revealed systemic and persistent barriers to appropriate and quality care among sex workers, highlighting the crucial role played by structural factors in shaping their health care seeking patterns and outcomes. These results further underscore the need to explore new models of care, as well as broader institutional and legal changes to fulfill women sex workers health and human rights, and fully realize the aims of the Canadian universal health system.

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HIV/STI prevention, unmet health needs, and work stress among im/migrant sex workers in Metro Vancouver (2016)

Background: Im/migrant women often face barriers to conventional labour markets in destination countries, and are disproportionately represented in precarious employment arrangements, including sex work. Apart from sexual health, research examining broader health concerns of im/migrant sex workers (SWs) remains scarce. This thesis sought to investigate the relationship between im/migration experiences and (1) inconsistent condom use with clients, (2) unmet health needs, and (3) dimensions of work stress among SWs. Methods: This thesis utilized data from “An Evaluation of Sex Workers Health Access” (AESHA), a community-based prospective cohort of SWs in Metro Vancouver. Bivariate and multivariable logistic regression using generalized estimating equations (GEE) were used to model correlates of inconsistent condom use among im/migrant SWs only (Objective 1) and unmet health needs among all SWs (Objective 2). Multivariable confounder models using linear regression with GEE were developed to examine independent relationships between im/migration experience and dimensions of work stress (Objective 3). Results: In Objective 1, multivariable GEE analysis conducted among 182 im/migrant SWs enrolled in AESHA from January 2010 and February 2013 revealed that difficulty accessing condoms was the strongest predictor of inconsistent condom use (Objective 1). In Objective 2, among 742 im/migrant and Canadian-born SWs enrolled from January 2010 to February 2014, multivariable GEE analysis found that recent and long-term im/migration, police harassment and arrest, and lifetime abuse/trauma were associated with greater unmet health needs. In Objective 3, among 545 SWs enrolled from January 2010 to September 2014, multivariable confounder GEE modeling revealed that recent and long-term im/migrant SWs faced decreased work stress related to job demands compared to their Canadian-born counterparts, after adjustment for key confounders. Conclusions: Findings suggest that im/migration experience is a key driver of HIV/STI prevention, healthcare access, and work stress among SWs. Importantly, im/migration experiences intersect with other structural factors – working conditions, violence, policing, sex work criminalization– to shape the health and safety of im/migrant SWs. Culturally appropriate, low-barrier health and support services should be made accessible to im/migrant SWs. Sex work decriminalization along with supporting collectivization efforts within the workplace are also recommended to improve working conditions, health, and human rights for im/migrant SWs.

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Looking for emergency contraception online : analysis of internet search patterns and website content (2012)

Background: Emergency contraception (EC) effectively reduces the risk of pregnancy following unprotected or under-protected sexual intercourse. EC has recently become available without a prescription in Canada and the USA in order to improve its availability and use, especially by young women. At the same time, the Internet is increasingly relied on as a source for health information, and Internet use is now nearly universal in younger age groups. Nevertheless, how people use the web to look for information about EC, and the qualities of information they find, are not well understood. The objectives of this thesis were to: (1) investigate the change in Internet search patterns for EC-related search terms in Canada and the USA over time and through shifts in EC-related policy and (2) assess the qualities (e.g., credibility, readability) and source (e.g., financial affiliations) of web-based information available about EC. Methods: The impact of policy changes in Canada and the USA on Internet search volume was estimated using interrupted time series analysis for two search terms:“morning after pill” and “Plan B”. Quality ratings and readability scores were generated for the ten most frequently found websites in Canada and the USA. Results: Policy changes making EC available without a prescription in Canada and the USA appear to have had an impact on information-seeking patterns online for EC-related search terms. The university-based website and Wikipedia ( were found frequently in searches for EC-related search terms in both countries. The website sponsored by the makers of Plan B®,, was found most frequently in Canadian searches. All websites achieved fair to medium ratings in a systematic quality assessment, and 14 (83%) of websites had a reading grade level higher than the reading grade levels recommended for written health information. Discussion: Regulatory changes making EC available without a prescription appear to have affected the frequency with which people look online for information about EC. Public health agencies may want to improve the quality, readability and prominence of their web pages in online searches for EC-related search terms to ensure easy and convenient access to comprehensible, unbiased, and high quality web-based materials.

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Youth and online sexual health services : intersections of the social and the technical (2012)

Background: Sexually transmitted infections (STIs) remain a significant public health concern, especially among youth (ages 15-24), who account for an increasingly disproportionate rate of infection. Novel, web-based interventions are being developed to improve sexual health outcomes among youth (e.g., condom use; participation in testing). To date, much of the literature in this area employs a ‘read-only’ perspective (e.g., examining frequency of use; topics of interest). Some research also has begun to explore ways in which the nexus of the social and the technical aspects of web-based health interventions may affect experiences with online STI/HIV prevention (e.g., how youth identify salient, credible online resources). For many young people, accessing sexual health resources (e.g., STI/HIV testing; counseling) remains a stigmatized activity, and it is unlikely that this will be resolved solely through the web-based provision of these services (e.g., online enactments of gendered stereotypes; traditional ‘sex-as-risk’ discourses). The objectives of this thesis are to provide an in-depth analysis of young people’s (1) perspectives on how the use of reverse discourse in online sexual health resources affects their perceptions of these resources; and (2) descriptions of their experiences with accessing online sexual health resources and their perceptions of the ways in which gender stereotypes feature in those experiences; and will discuss designing (and conducting further research on) online sexual health resources for youth. Results: Youth’s experiences with online sexual health resources are heavily influenced by ‘real world’ youth culture (e.g., values; beliefs; practices). These analyses provide an in-depth examination of the ways in which reverse discourse within online sexual health resource contexts can negatively affect perceptions of these resources, as well as illustrate the ways in which gendered stereotypes regarding sexual health help-seeking practices extend to online practices. Discussion: Intersections of the social and technical aspects of Internet-based sexual health resources need to be addressed in order to generate more equitable opportunities for young people to engage with sexual health resources.

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Masculinity, heteronormativity and young men's sexual health in British Columbia, Canada (2011)

Background: Young men account for a substantial proportion of reported sexually transmitted infection (STI) and HIV cases in Canada. However, STI/HIV testing rates remain low among young men. While men’s health-related behaviour have been linked to masculine expectations that demand stoicism, independence and denial of illness, little is known about how dominant masculine and/or heteronormative expectations may affect men’s sexual health-related practices that can put them at both an elevated risk of acquiring an STI(s)/HIV and/or affect their ability to access STI/HIV testing services. The objectives of this thesis are to: (1) explore how heteronormative and heterosexist discourses function within clinical settings where young men access STI testing services to better understand the extent to which dominant masculine ideals are (re)produced or resisted in these clinical contexts; (2) identify the social and contextual conditions which facilitate or create barriers to effective sexual health communication amongst men, paying special attention to how idealised masculinities influence these interactions; (3) develop recommendations for sexual health services and future research to improve the sexual health of young men in BC. Results: The findings drawn from this research highlight how idealized masculinity influences young men’s sexual health, including their sexual health-seeking behaviour, sexual practices and the ways in which they talk about sexual health. Specifically revealed are instances in which dominant heternormative expectations ‘hurt’ all men in clinical encounters (e.g., by stereotyping gay men as ‘risky’, thereby alleviating STI/HIV concern for straight men by virtue of their sexual identity). Men’s conversations about sexual health focused primarily around their sexual encounters (e.g., using ironic/teasing humour to embody masculine identities that neither dismiss nor actively express concerns about sexual health), amid processes of ‘manning up’ to break with dominant masculinity (e.g., stoicism) to permit talk about sexual health with peers or sex partners. Discussion: By examining situations in which men (and clinicians) align with or socially reconfigure idealized notions of masculinity related to sexual health, theorists and interventions will better understand how more equitable gender relations can be produced, thereby improving the sexual health of men (and women).

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