Arminee Kazanjian

More than half of Canadians share their homes with a pet (i.e. companion animal). Outside of the home, researchers and practitioners have increasingly embraced pets for their health-enhancing potential. Still our understanding of the relationship between cancer patients and their pets remains inadequate and incomplete. The purpose of this phenomenological study was to explore the lived experience of the human-companion animal relationship for people with cancer. I sought to examine how people engage in meaning-making through their intimate relationships with their pets. I recruited participants from cancer centres and community-based organizations that provide psychosocial support to cancer patients and their families. Using the method of photo-elicitation, I conducted in-depth interviews with nine women and five men. The participants varied with respect to age, the stage and type of cancer, and the type of pet in their care (e.g. dog, cat, and fish). After transcribing the interviews verbatim, I analyzed the transcripts using an iterative process of reading, reflecting upon, and writing out my interpretations. One such method involved seeking the assistance of researchers and health care professionals to analyze data extracts from the 14 original interviews. From the eight phenomenological themes that I generated, I identified three higher-level themes, known as super-ordinate themes, which correspond to the following meaning-making strategies: disengagement/acceptance, distraction, and support seeking. These super-ordinate themes are presented using anecdotes and quotations from participants, as well as, my own interpretive commentaries. I discuss the findings in light of theoretical constructs and empirical research. Highlighted in the discussion are implications of the study for research and practice in supportive cancer care, along with potential avenues for future investigation.

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Depression is increasingly becoming the leading cause of disability worldwide. While effective treatments like psychological or antidepressant therapies are available, concerns remain about under treatment and disparities in care as these can adversely affect mental health outcomes. Through a series of studies, this thesis estimated the magnitude of the gap and variations in depression care and the impact physician incentives had on treatment gaps. To perform all population-based analyses, this thesis used linked health administrative data from the Canadian province of British Columbia. An algorithm for identifying cohorts was developed to ensure that observation periods for detecting diagnosis and assessing use of mental health care were identical for all individuals. Administrative data were used to derive indicators that measure receipt of counseling/psychotherapy, receipt of antidepressants, adherence to antidepressant therapy, and physician continuity of care. Analytical approaches used in the study include calculating proportions to estimate treatment gaps, building generalized and mixed effects regression models to examine treatment variations and running interrupted time series analysis to investigate policy impacts.Results of the analyses suggest that four out of ten individuals with depression did not receive any depression care from the formal health system. Among the treated, only one in two received minimally adequate care, mostly through antidepressants. Minimally adequate treatment varied by sex, age, overall health status, place of residence, physician practice, and presence of specific comorbid physical conditions. Study results also indicate that physician incentives affected depression care patterns, although the overall impact was modest. Specifically, the downward trend in counseling/psychotherapy and the upward trend in antidepressant therapy initiation were disrupted. Likewise, the percentage of individuals who received minimally adequate counseling/psychotherapy increased gradually over time while the percentage of those who received minimally adequate antidepressant therapy decreased. Some gains were also achieved in measures of physician continuity of care.Overall, study results show that wide gaps in depression care persist despite recent efforts to improve mental health care. Expanding public coverage for psychological therapies and exploring reforms that require fundamental changes in mental health service delivery are needed to enhance treatment options and accessibility.

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Background: Cancer is a family disease affecting the patient and family members. To date, few studies have explored the psychological distress of family caregivers and its relation with patient quality of life (QOL), particularly among culturally diverse cancer populations. This study seeks to understand the associations between patient distress, family caregiver distress and patient QOL in a Chinese-speaking population in British Columbia, Canada. Methods: A cross-sectional survey of Chinese-speaking (study population) and Anglophone (comparison group) patients (N = 55) and their family caregivers (N = 40) was used to examine patient QOL and correlates. Multiple imputation of missing data for incomplete dyads resulted in data for 29 Chinese-speaking and 28 Anglophone dyads. Multiple linear regression and mediation analyses examined predictors of QOL, and its domains, and mediation effects of patient distress and family caregiver distress. Semi-structured interviews with a subset of the Chinese-speaking survey participants comprising ten patients and six family caregivers, including five patient-family caregiver dyads, were also conducted. Analysis of culturally-embedded experiences of patients and family caregivers regarding their distress and QOL was conducted, to provide further context and explanation for the findings from the quantitative analysis.Results: Patient distress emerged as the key factor in explaining patient QOL. The effects of patient age on patient emotional well-being were mediated by patient distress, such that lower distress in older patients explained better emotional functioning. A key theme that surfaced from the qualitative data analysis was the emotional regulation occurring in the family when coping with cancer. The negative impact of family caregiver distress on patient emotional well-being was acknowledged by both the patients and the family caregivers. Younger and older patient interviewees alike indicated anxiety and worries about the impact of their cancer diagnosis on their families. Conclusions: This study provides insights to Chinese-speaking patients’ and family caregivers’ illness experience and the interrelatedness of the dyads’ responses to cancer. In expanding our knowledge of cross-cultural cancer care, these findings highlight the important role of cultural background in shaping service needs and, in turn, service delivery to cancer patients and their families.

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A collaborative framework is increasingly being used to promote change in the way health services are being provided. Collaborations have been studied mostly from a team perspective in health services research (HSR); system and institutional levels of analysis are underutilized. Applying an (neo) institutional perspective, this dissertation explored the role of interorganizational collaborative relationships in promoting practice change in family physicians. Specifically changes in the professional boundaries of family physicians were examined. The dissertation is comprised of two parts. The first study was a systematic qualitative examination of the HSR literature on the concept of professional boundary for family physicians. Fifty articles were reviewed. Conceptual distinctions used by family physicians to describe their role and their work were synthesized to form a multi-faceted notion of professional boundaries of family physicians (i.e., task-related, object-related, and relational). The second study was a case study of a new organizational form, the Division of Family Practice, in a suburban community in British Columbia. The new organizational form employed a collaborative framework to promote system and professional practice change in primary care. Findings were generated from interview texts, organizational documents, and participant observations. The study investigated how professional boundaries of family physicians are being reshaped through family physician’s involvement in collaborative relationships under the Division of Family Practice. Conclusion: collaborations provide a physical as well as a social space for partners (family physicians, the health authority, the government, and the medical association) to share, challenge, and shape each other’s perspectives, values, interests, and goals. The case study demonstrated the Division of Family Practice was successful at disrupting the physician institution and reshaping professional boundaries for family physicians as 1) the profession of family practice is undergoing a process of deinstitutionalization: the professional boundaries of family physicians are not as clear and distinct as they once were and have become a weakened institutional element; 2)the Division was able to disturb and reformulate the reward and sanction mechanisms for family physicians; and 3) the Division has enabled core assumptions and beliefs about family practice to be broken down and redefined.

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The prevalence of low vision and blindness is commonly high in developing countries. The majority (70%) of blindness burden is avoidable. Socioeconomic status and other community development aspects are highly affected by this burden. Cataract and Trachomatous Trichiasis are the major causes of avoidable blindness. Females are more affected by these diseases and less likely to use eye care services than males. Recently, the concept of multi-component intervention models was introduced to the research arena. There is a need for an integrated model that tackles different axes of blindness focusing on women. The current study adopts an integrated gender sensitive interventional model where community health education is its major component in addition other components including; screening and referral of eligible cases, breaking down barriers to eye care utilization, and capacity building of local eye care providers. In this study, we attempted to evaluate the effectiveness of the proposed mode through a community interventional trial. The intervention was applied to two villages in rural Upper Egypt where two other villages served as control. The proposed model managed to increase community knowledge, enhance attitudes and practice along with reducing most of its specific barriers to eye care service utilization. As a result, service utilization at the local hospitals increased by 20.6 %. Cataract and Trachomatous Trichiasis surgical uptakes also increased by 36.9% and 41.4% respectively. The local provider’s efficacy improved by 8.9 % increase in post operative visual functioning score. Patient satisfaction improved by 16.6% among cataract patients and by 11.1% among trichiasis patients. Selection of local provider as the first choice increased by 31.1%. Consequently, the prevalence of cataract reduced by 16.3% (18.4% female specific), and trichiasis prevalence by 5.7 % (8.2% female specific). The overall prevalence of low vision and blindness decreased by 13.3 % (14.1% female specific) and 7.2% (9% female specific) respectively.Integrated community based interventions that tackle different aspects of the prevention of blindness are highly effective. Gender sensitive community health education should be the major component of such models. These models could be modified and tailored to address specific needs of target communities.

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BACKGROUND: The epidemiology of tuberculosis (TB) related recurrence and mortality is not well characterized for British Columbia (BC) or Canada. The objectives of this thesis were: 1) to estimate the incidence of recurrence of TB and identify predictors associated with TB recurrence; to investigate the relative contribution of exogenous re-infection as a mechanism of recurrence; to characterize mortality among TB patients and to identify potentially modifiable risk factors for patients whose deaths were attributable to TB. METHODS: This study was conducted using population-based data maintained by the centralized provincial TB service (TB Control Division at BC Center for Disease Control). All TB cases recorded with this Division from 1990 to 2006 were reviewed. TB patients who developed recurrence and who died during the observation period were identified. Cox regression was performed to identify risk factors associated with recurrence and mortality. RESULTS: During the study period (1990 to 2006), over 5400 TB patients were registered with the provincial TB control program. The incidence of recurrence was 370 per 100,000 person-years (pys). Several factors such as foreign-birth, incomplete treatment, poor-compliance to treatment, place of initial diagnosis, HIV and drug abuse were significantly associated with TB recurrence. The relative contribution of re-infection was 8% and the incidence of reinfection was 19 per 100,000 PYs. There was an excess mortality among TB patients compared to the general BC population. 1069 TB patients died during 1990 to 2006 (29 per 1000 PYs). The cumulative mortality at the first 6 and 12 months were 8% and 10% respectively. Increasing age, Aboriginal ethnicity, miliary TB, HIV/AIDS, alcoholism, substance abuse, etc was significantly associated with all-cause mortality in multivariable analyses. Among these deaths, 109 (109/5408=2%) deaths were primarily caused by TB and another 177 (177/5408=3.3%) deaths were partially contributed by TB (one of the causes of death). Miliary TB, far advanced PTB and Aboriginal ethnicity were the strongest predictors of mortality related to TB. CONCLUSIONS: This study identified several important risk factors in a population-based TB cohort. Effective interventions targeting these high-risk populations are urgently required in order to prevent recurrence and mortality related to TB.

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