Arminee Kazanjian

Professor

Relevant Degree Programs

 

Graduate Student Supervision

Doctoral Student Supervision (Jan 2008 - May 2019)
Assessing gaps and variations in depression care and the impact of physician incentives (2016)

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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Cancer and the family : distress and quality of life among Chinese-speaking patients and family caregivers (2016)

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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Promoting change through collaboration : reshaping the professional boundaries of family physicians through the Division of Family Practice (2012)

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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Gender and blindness : evaluating gender specific community interventions in Upper Egypt (2011)

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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Morbidity and mortality related to tuberculosis (tb) in British Columbia (BC), Canada (2010)

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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Master's Student Supervision (2010 - 2018)
Sexual health outcomes of a yoga therapy intervention for breast cancer survivors (2013)

Background: Breast cancer treatment has improved survival prognoses; as such, the late effects of breast cancer and its treatment have become an increasingly important field of inquiry. Although the prevalence of sexual health problems among breast cancer survivors (BCSs) varies, they are among the most distressing side effects associated with breast cancer and its treatment. However, effective interventions for sexual health issues within this population have yet to be established. Yoga therapy, a health promoting, non-invasive, and non-pharmaceutical intervention, holds promise as an effective and acceptable approach to sexual health problems after breast cancer and its treatment.Methods: Using a controlled pre-post design, changes in sexual health outcome scores were assessed for participants in a three-armed yoga therapy intervention (YTI) study (Anusara yoga, Iyengar yoga, or waitlisted control). Multiple linear regression analysis was guided by a modified version of a pre-established framework comprising sexual health predictors in BCSs, in order to assess the strength of the relationship between YTI participation and changes in sexual health outcome scores. A subset analysis of only partnered participants was carried out because of the established importance of partnered relationships to sexual health.Results: Participation in Anusara yoga was significantly associated with an increase of 14 (of 91) points (p-value
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Cervical cancer screening in immigrant populations in British Columbia : participation rates and sociodemographic characteristics of use (2011)

Background: The Pap screening practices of British Columbia's immigrant population and the specific barriers they face in accessing cervical cancer screening services are not well understood. This study attempts to gain a broad understanding of patterns in immigrant women's use of Pap screening programs, exploring rates of Pap screening participation, sociodemographic correlates of use and reported barriers to access for immigrant women in the BC relative to those of native-born Canadians in the province.Methods: Self-reported data on use of Pap screening services, immigration status and sociodemographic information were obtained from the Canadian Community Health Survey Cycle 3.1 for female respondents 18 to 69 years of age living in British Columbia. Lifetime and three-year Pap screening participation rates were calculated and multivariate logistic regression methods used to model the relationship between Pap screening participation and sociodemographic variables thought to be potential correlates of screening. Subgroup analyses of screening participation based on the racial or ethnic origin and country of birth of immigrant women were also conducted.Results: Immigrant women were found to participate in Pap screening, both over the lifetime and within the last three years, at rates significantly lower than those of non-immigrant women. Only 79% of immigrant women report having had a Pap test during their lifetime, compared to 93% of non-immigrant women. Those figures drop to 66% of immigrant women and 78% of non-immigrant women for Pap screens within the last three years. Many of the sociodemographic correlates of use are similar in the immigrant and non-immigrant populations, but often with different impacts on screening participation between the two groups. East Asian and South Asian immigrant women in particular report rates of screening participation below those of non-immigrant women, while participation rates among European immigrants are comparable to those of native-born Canadians.Conclusions: Subgroups of immigrant women in British Columbia are currently under-served by existing Pap screening programs in the province. Culturally-appropriate programs and policies are required to improve screening participation in these groups, thereby helping to decrease the cervical cancer burden presently being borne by these populations.

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