Patricia Spittal


Relevant Thesis-Based Degree Programs


Graduate Student Supervision

Doctoral Student Supervision

Dissertations completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest dissertations.

The phone is my lifeline: impact of the Cedar Project WelTel mHealth program for HIV treatment and prevention among young Indigenous people who have used drugs (2020)

Indigenous scholars have called for responses to substance use and HIV among young Indigenous people that acknowledge ongoing colonization, structural violence, and the impacts of intergenerational traumas, while building on cultural strengths and resilience. This mixed method dissertation took place within The Cedar Project cohort involving young Indigenous people who have used drugs in Vancouver and Prince George, British Columbia (BC). The purpose was to examine experiences of engagement with the HIV cascade of care, and evaluate The Cedar Project WelTel mHealth program for HIV-related health and wellness, among young Indigenous people who have used drugs living in British Columbia, using both qualitative and quantitative approaches. Findings support understanding of how a wholistic perspective of health and wellbeing, as well as experiences of ongoing colonial violence including child apprehension, inform engagement with the HIV cascade of care among Indigenous peoples. Results add to mounting evidence that state-based apprehensions of Indigenous children are a negative determinant of health for Indigenous families. Findings further illustrated how mobile phones can be a tool to support family (re)connections, relationships with health and social services, and self-determination within young Indigenous people who have used drugs’ health and wellness journeys. Moreover, this dissertation demonstrates that a supportive two-way texting mHealth initiative integrated into existing wraparound care from trusted case managers is acceptable and valued by young Indigenous people who have used drugs. Study findings provide evidence that the Cedar Project WelTel mHealth program may be an effective approach to support engagement in HIV care for young Indigenous people who have used drugs, and should be considered for application in other program settings as well. Four overarching recommendations for policy makers and health providers were developed in collaboration with Cedar mentors, committee members, and investigators: (1) uphold a wholistic perspective to walk with young Indigenous people who have used drugs on their health and wellness journeys; (2) urgently address ongoing apprehensions of Indigenous children; (3) offer the Cedar Project WelTel mHealth model for HIV health and wellness; and (4) explore integrating mHealth with healing modalities for substance use and other aspects of wholistic health and wellness.

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The intersection of conflict, substance use, trauma, and HIV: exploring their complex interplay among conflict affected populations in a rapidly changing northern Uganda (2018)

Background: Epidemiologists have long noted a paucity of research addressing the role of substance use in conflict and post-conflict settings especially as it interacts with mental health and HIV vulnerability in affected populations. Such is the case in northern Uganda where after two decades of conflict the region is rapidly changing, and where community leaders are expressing concerns as to perceived rapid increases in substance use and its impact on the population and growing HIV epidemic.Methods: This multidisciplinary research explored the intersection of mental health, substance use, and HIV in the context of conflict. This project was conducted in partnership with the “Cango Lyec Project” a five-year cohort project exploring HIV risk among Acholi people aged 14-49 in the Gulu, Nwoya, and Amuru districts of northern Uganda. The quantitative analyses began with a confirmatory factor analysis of the structure and underlying validity of the AUDIT alcohol scale. Next, multivariable regressions explored factors associated with hazardous drinking in the population. Qualitative analyses used an interpretive and interpretive description (ID) thematic approach to analyze 30 in-depth interviews and explored within the context of the quantitative analyses.Results: Quantitative findings indicated strong validity for the AUDIT scale. Overall, rates of drinking were much lower than the rest of Uganda, and women were significantly less likely than men to consume alcohol or have hazardous use behaviors. After adjustment neither post traumatic stress disorder (PTSD), depression, nor HIV were significantly associated with problematic drinking though there were significant associations with many sexual behaviors, and abduction was protective against problematic drinking among men. Qualitative findings highlighted participants’ views that substance use remained a large and growing problem in the region that was closely tied to HIV. Use was highly stigmatized especially as it pertained to perceptions that it constituted a rejection of Acholi traditions.Conclusion: This research highlights the need to integrate rigorous and population-level epidemiological evidence within community perspectives and understandings of risk. While at times the results appeared to contrast, underlying both were clear areas for intervention that acknowledge the profound trauma inflicted by the conflict and areas to support community- driven change.

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The Cedar Project: understanding the sexual vulnerabilities of Indigenous young people who use drugs in British Columbia, Canada (2017)

Background: For Indigenous communities in Canada, the legacies of colonization have severely compromised sexual wellbeing. Indigenous leaders are growing increasingly concerned for the sexual health of their young people, particularly those who use drugs to cope with adversity. However, there is a critical gap in evidence pertaining to the complex and multifaceted relationships between intergenerational trauma, self-medication, and sexual wellbeing.Methods: Data was gathered from the Cedar Project: an ongoing prospective cohort study of Indigenous young people who use drugs and live in British Columbia. A multidisciplinary approach was used to investigate historical and lifetime factors that impact sexual health. Epidemiological analyses were used to determine the prevalence and correlates of Herpes Simplex Virus-2 (HSV-2) and syphilis positivity among 250 participants. An interpretive thematic approach was used to qualitatively analyze in-depth interviews with 28 participants.Results: The seroprevalence of HSV-2 among women and men was 79% and 36%, respectively. For women, HSV-2 positivity was associated with being taken away from biological parents, involvement in survival sex work, and injecting drugs. For men, having ever been in prison was significantly associated with HSV-2 positivity. Young men who stated that culture played an important role during their developmental years were less likely to test positive for HSV-2. A history of syphilis infection was observed among 21 participants, 95% of which occurred among women living in Vancouver. Results from the qualitative study highlighted how sexual health continues to be negatively impacted by intergenerational trauma stemming from the residential school and child welfare systems. Participants’ narratives demonstrated the protective effect of family and cultural connectedness on sexual wellbeing. Participants offered detailed recommendations on how to improve sexual health outcomes through culturally-safe and trauma-informed sexual health resources that are integrated with mental health and drug recovery programs aimed at supporting struggling families.Conclusion: To support the sexual wellbeing of Indigenous young people who use drugs, the underlying causes of ongoing trauma and social marginalization must be urgently addressed. These findings call for the backing of Indigenous-led healing strategies that focus on young people’s inherent strengths, and use Indigenous wellness frameworks to promote collective healing.

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Sociocultural determinants of HIV vulnerabilities among ethnic and religious minority men who have sex with men in North China (2016)

BACKGROUND: In China, 29% of new HIV cases are among men who have sex with men (MSM). Sociocultural factors may be influencing the HIV vulnerabilities of certain ethnic and religious minority MSM, but little such research exists in China. This dissertation seeks to understand how ethnicity and religion are shaping HIV vulnerabilities and testing among MSM in China.METHODS: Data were collected in three phases in Beijing and Tianjin, China from January 2013 – April 2014. Participants were self-identified MSM over 18 years old. In phase one, in-depth qualitative interviews were conducted with MSM of various ethnic and religious affiliations (n=41). Interview transcripts were analysed using an interpretive thematic approach. In phase two, findings from phase one informed the design of a structured questionnaire, which was pilot tested in two feedback sessions (n=8). In phase three, the structured questionnaire was used in a clinic-based cross-sectional survey (n=400). Statistical tests were conducted to assess if HIV infection, vulnerability, and testing were correlated with: ethnic and religious affiliation, acculturation, religiosity, and ethnic and religious discrimination. Inter-ethnic and inter-religious sexual partnerships were also assessed. Homonegativity was also assessed as a possible mediating variable between: (a) ethnicity and religion and (b) HIV-related outcomes. RESULTS: Ethnic and religious affiliations profoundly influenced individuals’ social reference groups. Religious social norms, codes of sexual morality, and beliefs in supernatural interventions appear to be inhibiting same-sex sexual behaviours among religious MSM, especially Muslims. Buddhists and ethnic minorities of South China had higher odds of various HIV vulnerabilities. Religiosity appears to have both positive and deleterious influences on HIV vulnerability. Sexual minority religious organisations can provide unique social support. Buddhists, Muslims, and ethnic Hui were more likely to report sex with their own religious and ethnic peers. Homonegativity did not account for any associations between ethnicity and religion and HIV-related outcomes.CONCLUSION: This dissertation is the first study to explicitly explore the intersectionality of ethnicity, religion, sexuality, and HIV vulnerability in China. Findings highlight the ethnic and religious diversity among MSM in China and its salience for HIV prevention. Public health models of conceptualizing ethnocultural difference in China should be re-examined.

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The Cedar Project: Understanding the association between childhood maltreatment and psychological distress, resilience, and HIV and HCV vulnerability among young Indigenous people who use drugs in three Canadian cities (2015)

Background: Indigenous leaders are deeply concerned about the adverse impacts of intergenerational and lifetime trauma on their young people, particularly those who use drugs and are vulnerable to HIV and HCV infection. However, few researchers have investigated the complex intersections of trauma, mental health, resilience, and HIV and HCV vulnerability among young Indigenous men and women in Canada. Methods: This multidisciplinary research was based on information gathered by the Cedar Project, a cohort of young Indigenous people (aged 14-30) who use drugs in Vancouver, Prince George, and Chase, British Columbia. The qualitative analyses used an interpretive thematic approach to analyze in-depth interviews. The quantitative analyses first evaluated the construct validity of psychometric questionnaires that measured childhood maltreatment, psychological distress, and resilience. Next, those questionnaires were integrated with longitudinal Cedar Project data to assess associations between childhood maltreatment with HIV and HCV vulnerability, psychological distress, and resilience. Results: The qualitative research highlighted participants’ ongoing struggles with unaddressed childhood maltreatment and the association between emotional pain and HIV and HCV vulnerability. However, participants were actively resisting the negative effects of trauma maintaining hope for a better life. In quantitative analyses, each of the psychometric questionnaires had acceptable fit for the data. In total, 91.7% of the participants had experienced at least one form of childhood abuse/neglect. Longitudinal vulnerabilities associated with specific types of childhood trauma and cumulative trauma experiences included significant drug and sex-related HIV and HCV risks, in addition to HCV infection. Childhood maltreatment, sex work involvement, sexual assault, heavy alcohol use, and injection drug use increased psychological distress, while living by traditional culture decreased psychological distress. Resilience was increased by having grown up in a traditional family environment, and by having access to and being able to speak traditional languages.Conclusion: This research supports the development of comprehensive, Indigenous-directed healing strategies for HIV/HCV prevention that are tailored for young Indigenous people who use drugs. These strategies must address concurrent trauma and mental health, support connections to Indigenous cultural identity, and facilitate understanding of the impacts of the residential school system and intergenerational trauma on family relationships.

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Lost in Transition: Determining HIV Prevalence and Relagated Vulnerabilities Among Young People Surviving Abduction and Displacement in Post-Conflict Northern Uganda (2012)

Background: Little is known about HIV infection and the related vulnerabilities of young people living in resource-scarce, post-emergency transit camps that are now home to thousands of IDPs following two decades of war in northern Uganda. This population in transition provided a unique opportunity to assess the influence of conflict on HIV infection among young people in post-conflict settings. Methods: In 2010, a cross-sectional demographic and behavioural survey was conducted with a purposively selected sample of 384 transit camp residents aged 15 to 29, in two of Gulu District’s sub-counties. Biological specimens were collected for HIV rapid testing in-field and confirmatory laboratory testing. Multivariable logistic regression identified independent predictors for HIV infection among the sample and stratified by gender. Additionally, a bivariate analysis was conducted comparing HIV risk profiles of former abductees to non-abductees.Results: Of the 384 participants sampled, 192 (50%) were female and 107 (27.9%) were abductees. HIV prevalence was alarmingly high, at 12.8% overall; 15.6% among females; 9.9% among males, and; 12.1% among abductees. Sample sub-groups revealed no significant differences in proportions positive. The strongest predictor of HIV infection among young people was non-consensual sexual debut (Adjusted Odds Ratio [AOR]: 9.88, 95% Confidence Interval [CI]: 1.70, 18.06). Among females, having practiced dry sex was the strongest predictor (AOR: 7.62, 95%CI: 1.56, 16.95), and among males, non-consensual sexual debut was the strongest predictor (AOR: 3.24, 95%CI: 1.37, 7.67). Finally, in bivariate analysis comparing abductees to non-abductees, limited differences in risk profiles were demonstrated.Conclusions: This study sought to fill a lacuna in epidemiological evidence and provide the Ugandan government and NGOs with the data necessary to inform timely and appropriate responses to HIV among young people in post-conflict transition. Study findings serve to recommend a gradual cessation of post-emergency aid and the design of interventions based on well-identified needs rather than circumstantial categorization. Additionally, development of population-specific responses sensitive to local contexts and sufficient to address the underlying causes of complex risk factors influencing the spread of HIV will reach beyond traditional prevention programming in a manner more effectively beneficial to young people in post-conflict settings.

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Master's Student Supervision

Theses completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest theses.

The Cedar Project : exploring resiliency and housing among young Indigenous peoples who use drugs during COVID-19 in two Canadian cities (2023)

Background: Indigenous peoples have been resistant and resilient against the historical and ongoing colonial processes. Yet, young Indigenous peoples who use drugs are currently facing another challenge to their resilience in the form of the quadruple crises: overdose, racism, housing, and COVID-19. There is a lack of information on how aspects of the lives of young urban Indigenous peoples who use drugs have been impacted by COVID-19. The decampments on the downtown eastside of Vancouver, and punitive by-law policies of Prince George associated with COVID-19 responses have also necessitated an investigation of housing transience during the pandemic. Objective: This thesis evaluates how young Indigenous peoples who use drugs in two Canadian cities were impacted by COVID-19, with a focus on resilience and strengths. Specifically, it examines how resilience was supported during COVID-19, and how recent policy decisions have impacted the housing landscape.Methods: The Cedar Project is a prospective cohort study that involves young Indigenous peoples who use drugs in Vancouver and Prince George, BC. Baseline and nested COVID-19 cohort data from the Cedar Project were used in analyses. The nested COVID-19 study was conducted from February 2021-August 2022; and resilience was captured by the Connor-Davidson Resilience Scale (CD-RISC). Multivariable linear regression was conducted to investigate factors associated with resilience stratified by gender. Multivariable logistic regression was used to model housing transience in Prince George. Results: Among women, cultural and emotional connection and knowing “who you are” were significantly associated with higher resilience. For men privacy in housing was found to be associated with higher resilience. Ever having been incarcerated and ever having participated in sex work greatly increased the odds of having experienced housing transience during COVID-19, while high CD-RISC scores were protective – reducing the odds of experiencing housing transience. Conclusions: Our findings support the call for housing to be grounded in Indigenous culture and knowledges while further supporting what Indigenous peoples have known all along, culture, community, and Nation is where strength and resilience is found.

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Evaluation of the Kidney Check project using an applied two-eyed seeing approach (2021)

Indigenous people in Canada experience rates of chronic kidney disease (CKD) higher than those of non-Indigenous Canadians as a direct result of colonization. Early detection and prevention through screening is a critical public health strategy in optimizing patient outcomes and reducing burden to the health care system. As such, a screen, triage and treat initiative called Kidney Check is currently offering point of care kidney health screening in sixteen First Nations in British Columbia (BC). One of the important aims of the Kidney Check project in its current iteration is to assess the value, acceptance, and sustainability of the project, with the aim of making a case for expansion and continuity. This thesis describes a culturally safe and respectful framework to understand these parameters from the perspective of Kidney Check team members responsible for organization and implementation of the program in community. A two-eyed seeing evaluation approach combining principles from Indigenous evaluation frameworks with qualitative approaches to evaluation was used to ensure a respectful, relational, and academically rigorous evaluation. Specifically, a narrative approach was taken to honor the tradition of oral knowledge sharing and to ensure that the evaluation priorities were set by community members themselves. Ten members of the Kidney Check screening team told their stories through conversational interviews. Interviews were transcribed verbatim and then thematically analyzed in collaboration with an Indigenous Knowledge Holder to maintain an Indigenous perspective throughout. Themes relating to value are described within the framework of the 4R’s; Respect, Relevance, Reciprocity and Responsibility. Themes around sustainability include levers and barriers. Levers to sustainability are intimately connected to the value of Kidney Check. Subthemes around barriers to sustainability include cost, staffing and logistics. The Indigenous metaphor of cedar bark weaving is described as an appropriate visual representation of how the themes illuminated by participants are interconnected and woven together, creating a wholistic evaluation. The results of this evaluation have important implications for both the field of public health as it relates to Indigenous communities and health policy in BC.

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Cango Lyec (Healing the Elephant): exploring impacts of the Lord's Resistance Army insurgency on mental health of conflict-affected populations in Northern Uganda (2020)

Background: From 1986 to 2006, Northern Uganda experienced an atrocious civil war between the Lord’s Resistance Army and the Ugandan government which left in its wake mass casualties, child abductions, sexual violence, and socio-economic breakdown. The local Acholi people continue to be impacted by trauma sequelae of the war and a variety of daily stressors including poverty, hunger, and an ongoing HIV epidemic. To date, there is a dearth of gender-differentiated research in this post-conflict context examining mental health and associated vulnerability factors.Objectives: This thesis explores two mental health outcomes, PTSD and depression, among conflict-affected people in Northern Uganda five years after the cessation of hostilities. A socio-ecological framework is adopted to investigate risk factors at individual, relationship, and community levels. Special attention is paid to the plight of women and formerly abducted children.Methods: This research is embedded within a longitudinal cohort project, Cango Lyec (Healing the Elephant), which evaluates HIV and associated risks in post-conflict Northern Uganda. Baseline categorical variables were compared between males and females using Fisher’s exact test. Bivariate and multivariate logistic regression was used to model correlates of positive screening for PTSD and depression. All analyses were stratified by gender, and subgroup analyses for former abductees were conducted.Results: We found the overall prevalence of probable PTSD and depression was 11.7% and 15.2% respectively. Among former abductees, the prevalence was 23.2% for probable PTSD and 26.6% for probable depression. Females were significantly more likely to have poor mental health than their male counterparts. Factors found to be associated with poor mental health included environmental stressors, war-related trauma, abduction and experiences in the bush, sexual violence, intimate partner violence, sexually transmitted infections, and HIV.Conclusions: Cango Lyec participants displayed lower rates of PTSD and depressive symptoms compared to previous studies. Reviving the local agrarian economy, ensuring food and housing security, providing trauma-informed care, eliminating sexual violence and gender-biased social institutions, as well as increasing educational and employment opportunities for former abductees remain important tasks to facilitate post-conflict rehabilitation in Northern Uganda.

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From prison to plate: how connections between men in federal custody and Indigenous families impacts food security, food sovereignty and wellbeing (2017)

For many Aboriginal communities in Canada, the legacies of historic and ongoing colonialism and the impacts of marginalization, dispossession and racism have produced barriers to meaningful and nutritious foods and foodways. This has resulted in high rates of diet-related diseases among Aboriginal populations. The same factors that impact Aboriginal food security also create barriers to employment and housing, and inequitable treatment within the criminal justice system. Founded in 2012, a prison garden based at a minimum security correctional institution in Mission, British Columbia (BC), attempts to address these correlates of crime and poor health by engaging men in federal custody in meaningful activity; specifically, the growing and subsequent donation of organic produce. The fruits and vegetables grown in the garden are donated to a variety of local organizations and Aboriginal communities, including the Tŝilhqot’in Nation of central interior BC. This ethnographic research, founded in critical social justice theories and the principles of food sovereignty, set out to understand the impacts of the garden on both the participating men and the recipient Tŝilhqot’in communities. Qualitative interviews were conducted with 10 participating men in custody, 10 Tŝilhqot’in recipients, and 5 program stakeholders. Iterative thematic analysis revealed multi-layered impacts for the participating men, starting with access to food and increasing over time to include gardening as a means to figuratively escape the correctional environment, to work productively, to give back, and as a means to begin imagining meaningful futures outside of prison. The distribution of vegetables within the Tŝilhqot’in highlighted a passive coalescence with histories of culinary imperialism, truncating impacts to two layers: access to food and connections with the men in prison. Drawing on the insights of both the men and Tŝilhqot’in community members and the theoretical principles of food sovereignty, decolonizing methodologies and food as social justice, potential ways to acknowledge the legacies of colonialism, increase connection between the prison and the communities, and increase impacts are discussed.

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Finding safe space: historical trauma, housing status and HIV vilnerability amoung young aboriginal people who use illicit drugs (2013)

Background: Dispossession and dislocation of Aboriginal people in Canada through the reserve, residential school and child welfare systems have contributed to the gross overrepresentation of HIV/AIDS infection, substance use, and housing instability in Aboriginal communities. Ensuring young Aboriginal people who use illicit drugs have access to safe spaces, including places to live, is a fundamental part of dismantling structural injustices that lead to their elevated vulnerability to HIV infection.Objective: This thesis investigates access to safe spaces among young Aboriginal men and women who use illicit drugs in Vancouver and Prince George, British Columbia, Canada within the context of historical and intergenerational trauma. It examines how accessibility of safe spaces, and housing in particular, affects young Aboriginal people’s vulnerability to HIV infection.Methods: Baseline categorical variables were compared based on participants’ housing status using Pearson’s Chi-squared test and Fisher’s exact tests when expected cell values were five or less. Continuous variables were analyzed using a Student t test and all p values are two sided. Longitudinal analyses utilized data collected every six-months between November 2005 and January 2010. Generalized linear mixed models fitted with a Gauss-Hermite approximation were used to find odds ratio (ORs) for associations between trauma, housing status, and sex- and drug-related HIV vulnerabilities over time. Results: We found an independent association between historical trauma and housing status: childhood sexual abuse was independently associated with 2.76 greater odds of living in an unstable type of housing over the study period. We uncovered important associations between sub-optimal housing status and drug- and sex-related HIV vulnerability, including sex work, sexual assault, use of injection drugs, high frequency opiate and cocaine injection, and public injection. Conclusions: Our findings reveal that both material and spatial dimensions of housing are closely linked to HIV vulnerability among young Aboriginal people. Further, the links between housing status and historical trauma indicate that addressing the legacy of historical trauma is a crucial component of tackling the underlying causes of housing instability among young Aboriginal people who use illicit drugs.

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