Doctor of Philosophy in Population and Public Health (PhD)
Human health and its connection with nature and ecosystems health
This dissertation aims to inform more equitable and effective practice in the emerging field of global health. To address this overriding question of how principles of equity and effectiveness can best be implemented, I critically analyze discursive and practical challenges facing Northern researchers as they approach health problems in the global South, and explore solutions to these challenges. This exploration employs a case study on the articulation of a specific problem in a specific, nominally ‘Southern’, setting: pesticide-related health effects in Ecuador's banana-producing El Oro province. I employ three methodological approaches, in three substantive chapters. Chapter 2 uses discourse analysis to understand how Latin American research sites are framed in peer-reviewed pesticide epidemiology articles. These articles often employ geographic representations of Latin America as inexplicably underdeveloped to demonstrate the need for pesticide research and health sector interventions, typically exhibiting ‘mainstream’ (Northern) public health institutional dynamics. I also show how some epidemiologists are pursuing more politically engaged approaches, in an uneasy negotiation with epidemiology's disciplinary norms. Chapter 3 reports on ethnographic pesticide risk perception work in El Oro, drawing on theories from anthropology and human geography. I document how pesticide risk perception narratives reflect El Oro's position in unstable global commodity chains. Scalar elements of these narratives combine individual and structural explanations for health problems in complex ways. In Chapter 4, I describe a political ecology of health explanation of pesticide exposure in El Oro. I employ a modified meta-narrative methodology, complemented by ethnographic fieldwork, to synthesize literature relevant to the pathways – biological, political economic, environmental and cultural – leading to pesticide-related impacts in El Oro. This analysis complements Chapters 2 and 3 in making the case for empowerment-based participatory approaches to pesticide exposure problems (and, by extension, to global health more generally), with special attention to international linkages, environmental complexity and political economy. The introduction, conclusion and 'linking' material between chapters serve to enhance the coherence of the dissertation by providing additional material not appropriate for inclusion in the three chapters, including elements of reflexivity.
This dissertation considers the implications of applying of global health perspective to guide the development of culturally appropriate mental health services in Canada. Recognizing that forces of globalization can both affect determinants of health that vulnerable populations face and the kind of mental health services that are available, I focus on the situation of immigrants in the Greater Toronto Area, a population that has been prioritized for increased access to equity-driven health services, drawing on my personal and professional positionality with the issues examined. This study specifically examines Latin American immigrants, a group that has been identified as a high-growth population at-risk for mental health difficulties. An extensive and comprehensive review of social determinants of health as it relates to the mental health of Latin American immigrants in Canada is conducted, and the availability and effectiveness of patient-centred care for Latin American populations is also reviewed, with particular attention to the standard delivery versus the cultural adaptation of cognitive behavioural therapy – currently regarded as the ‘gold standard’ in psychotherapeutic treatment. Clinical, service delivery, and social policy issues that may arise in providing culturally appropriate, patient-centred care are exemplified in the findings of a secondary qualitative analysis of focus groups that were conducted for a feasibility study for a culturally adapted cognitive behavioural therapy (CA-CBT) for Latin American immigrants in Canada. A key contribution of this work is the synthesis of the foregoing evidence to conclude that the provision of culturally adapted mental health services is necessary but not sufficient to promote the health equity of Latin American immigrant population in Canada. Recommendations for policy, future research, and changes to the philosophy of psychiatric practice are discussed, and the findings are related to debates on the concept of “global mental health” that are currently underway.
This dissertation explores how knowledge management approaches and socio-political systems affect the accessibility to and application of evidence to improve the health of socially and politically disempowered groups of people. As, dengue provides a particularly vivid example of a human health issue intricately linked to biological, environmental, social and political systems, this study is embedded in a participatory dengue prevention and control program in Machala, Ecuador, that is committed to capacity-building and scaling-up. Guided by a transformative emancipatory approach with a focus on equitable participation, a multi-method approach was pursued including ethnographically-framed stakeholder analyses, social network mapping and analysis, illustrative vignettes and participatory indicator development. Six major stakeholder groups were identified in Machala: community, local government, government functionary, government administrator, researcher and private sector. Varying degrees of collaboration and interaction with one another as well as with the problematic of dengue are shaped by the dynamics of differing health priorities, paternalism/equitable participation, quemeimportismo/social resentment, nepotism/centrism/social justice, marginalization/self-determination and Buen Vivir. Power dynamics and knowledge valuation schemes dictate definitions of success and shape evaluation tools and processes tend to marginalize experiential and tacit knowledge, perpetuating narrow conceptions of health, benefit and dengue transmission risk. Overall, opinions regarding evaluation criteria did not significantly differ by stakeholder group, which suggests that social and cultural dynamics, as well as history and narrative of place, may be far more important factors in determining both stakeholder priorities and the character of intersectoral spaces than previously thought. A participatory evaluation tool is developed to assess both impact and process-related performance of proposed dengue prevention and control strategies. A knowledge translation model is developed with a strong emphasis on equitable participation and health equity. This study observes that there is deep need for change in underlying institutional power structures and research-to-policy processes, without which new evaluation tools will likely not “make sense” or result in improved policy, programs and community well-being. These findings and their implications challenge current macro, mid and local-level knowledge management strategies. This study indicates that opportunity for change exists through participatory evaluation processes situated at the interface of equitable knowledge translation and social determination.
Statement of the Problem This study has taken advantage of a “natural experiment,” the holding of International Cancer Control Congresses (ICCC) to conduct research that assesses the value of such undertakings, and examines ways for effectively pursuing positive change in improving policy and practice related to cancer control. Given the importance of this global challenge, this study investigates the question: Do International Cancer Control Congresses influence reported changes in participant behaviors and activities that enhance the development or implementation of population-based cancer control programs and increased collaborations? Methods of Investigation The population of interest included all the congress registered participants for two International Cancer Control Congresses—362 individuals at the 3rd ICCC for the first pod of surveys; and 310 participants at ICCC4 for the second pod of surveys. The primary data collection instrument was self-report surveys, surveyed in two pods. Each pod included an on-site survey followed by a follow-up survey a few months later on the same census sample of participants. Research instruments for data collection included surveys, interviews, conference documentation, observations as well as secondary data from WHO publications and appropriate web based publications like country plans and others. The study was organized as a mixed methods research using a triangulation design that allowed a mix of both quantitative and qualitative data in a single study.Conclusions The study indicates that most respondents gained professionally in improved understanding of global population based cancer control programs and new insights into cancer control. Through sharing best practices and insights gained at the congress in their jurisdictions, many indicated that the Congress has helped them in their cancer control work, including increased awareness for establishing collaborations and for setting up surveillance systems; also highlighting for them the importance of expediting national cancer/integrated non-communicable disease plans. Increasing their networks, participants continue experiencing a rise in interest and involvement in cancer control. The Latin American Region research reveals that it takes time before initiatives emerge and can be attributed to ICCC. In revealing which finds are inconclusive, this study offers opportunities for cohort longitudinal investigations.
No abstract available.
This work aims to better understand the capacity of small farmers, their organizations and other social players in the Ecuadorian indigenous communities of Quilloac and San Rafael to reduce pesticide-related environmental health risks. I used a multi-method approach that included Pierre Bourdieu’s field theory along with a 187-household survey, ethnographic methods, and participative approaches in 2007-2008. This study analyzed community capacity-building as social relationships co-determined by human agency and social structure in local and global contexts. By mapping community stakeholders’ differential access to cultural, social and economic capital, this study reveals connections between the degree of access to resources and health vulnerabilities.Four key findings emerged. First, in a context in which workers were forced to diversify their income through strategies such as emigration and urban employment, families had reduced time for their crops and increased reliance on pesticides. Members of households with fewer people applied pesticides more times. Elders from poor households were left to care for crops and experienced more problems with pesticide handling and symptoms. Children experienced increases in accidental pesticide poisoning cases that coincided with a period of high farmer migration to find work. Second, despite numerous well-intended efforts by community leaders, farmers with the highest participation in agriculture had less contact with community organizations. Third, structural factors such as inequitable land distribution, unfavorable market policies, and limited state support for small farmers represent critical barriers for harnessing the capacity of small farmer organizations. Fourth, community leaders tended to adopt peasantry-focused strategies that were likely to further marginalize some vulnerable families who combined non-agricultural activities with their farming, which was characterized by consumption crops with low workforce and high pesticide use. My findings provide theoretical and practical contributions for understanding the causes of environmental health inequities. Results from this research informed the development of several community-based initiatives (workshops, a radio show). My approach described important contextual barriers that need to be addressed by national and international stakeholders in order to harness the capacity of local organizations. It also identified specific social mechanisms that could increase health inequities despite great efforts by community organizations.
Background: Ecuador shows high and increasing rates of diet-related non-communicable diseases, attributed in part to a nutrition transition toward more animal-based and processed foods. In 2008, Ecuador introduced the right to food sovereignty to its constitution in an effort to improve diets and protect local agricultural production. However, this has not yet translated to evidence of improved nutrition at the community level. Objective: This thesis examines whether the promotion of food sovereignty has contributed to improving access to healthy diets for marginalized populations in Ecuador; if so, it asks how and to what extent, and if not, it explores the barriers to achieving change and opportunities for improvement. This project thus seeks to provide suggestions of entry points for policies and programs to improve access to and consumption of healthy foods.Methods: Complementary qualitative methods were used to examine geographic access, food prices, nutritional knowledge and dietary preferences, and priorities for food policy improvement in three low-income neighbourhoods in the city of Machala, El Oro. Results: Access to affordable healthy foods is still an issue as perceived by the study neighbourhoods. Poor nutritional knowledge, high relative cost of fruits and vegetables, and inequitable geographic access to affordable healthy foods were the main barriers to healthy eating. Price was the primary factor influencing food purchasing and consumption behaviours. Knowledge of the concept of food sovereignty and its inclusion in the constitution was nonexistent, as was the awareness of any new policies or programs implemented to improve access to healthy foods since 2008.Conclusions: As there are no food sovereignty policies in place so far that address price, the affordability of healthy foods could be addressed either by improving the linkages between producers and consumers to reduce intermediaries, or by adopting fiscal policies that subsidize healthy foods and tax unhealthy foods to help make healthy options more affordable and viable. These policy initiatives fall within the potential scope of a commitment to food sovereignty, but greater focus is needed as the government advances in the development of specific policies and programs in order to have an impact on population health.