Western University Scholarship@Western Electronic Thesis and Dissertation Repository 7-3-2019 1:00 PM Social Determinants of Health and Substance Use among Women Living with HIV in Canada: Inequalities and Impacts Mostafa Shokoohi The University of Western Ontario Supervisor Bauer, Greta R. The University of Western Ontario Graduate Program in Epidemiology and Biostatistics A thesis submitted in partial fulfillment of the equirr ements for the degree in Doctor of Philosophy © Mostafa Shokoohi 2019 Follow this and additional works at: https://ir.lib.uwo.ca/etd Part of the Epidemiology Commons, and the Women's Health Commons Recommended Citation Shokoohi, Mostafa, "Social Determinants of Health and Substance Use among Women Living with HIV in Canada: Inequalities and Impacts" (2019). Electronic Thesis and Dissertation Repository. 6287. https://ir.lib.uwo.ca/etd/6287 This Dissertation/Thesis is brought to you for free and open access by Scholarship@Western. It has been accepted for inclusion in Electronic Thesis and Dissertation Repository by an authorized administrator of Scholarship@Western. For more information, please contact [email protected]. Abstract The objective of this doctoral research was two-fold: 1) to estimate inequalities with regard to a) social determinants of health (SDoH) and health-related quality of life, and b) substance use between women living with HIV and the general population of women in Canada; and 2) to assess the impact of the SDoH clusters/classes on a) illicit drug use and b) heavy alcohol drinking among women living with HIV. For the first objective, prevalences of social determinants, self-rated health status, and substance use were estimated from 1,422 women with HIV aged 16+ in the 2013-2015 Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS, time-point 1), and then compared with their counterparts estimated in 46,831 general population women in the 2013-2014 Canadian Community Health Survey (CCHS), standardized to the age/ethnoracial group distribution of women with HIV. For the second objective, we used longitudinal data from the 2013-2017 CHIWOS at time-point 1 (N=1,422) and time-point 2 (N=1,252). Findings showed that compared to general population women, a higher proportion of women with HIV reported a) adversities regarding the social determinants (e.g., poverty, food insecurity, poor social support), poor/fair self-rated health status [manuscript 1], and b) greater cigarette smoking and illicit drug use, but similar to lower likelihood of binge drinking [manuscript 2]. Latent class analysis was used to determine the clustering of SDoH. We identified four distinct classes: no/least SDoH adversities, discrimination/stigma, economic hardship, and most SDoH adversities. Inverse-probability weighted regression models showed a substantial difference in a) illicit drug use [manuscript 3], and b) heavy alcohol drinking [manuscript 4] between no/least SDoH class and other SDoH classes. These findings underscore the need for novel approaches to address socio-structural ii adversities and substance use among women with HIV. We also discuss additional implications and future research directions. Keywords: Social determinants of health; Substance use; Disparities; Women; HIV; Canada iii Summary for lay audience People with HIV now live longer. This is due to advances in HIV care and treatment services. But, these people continue to face challenges in their life. The two most important challenges are substance use and social adversities. In this study, we compared several social factors between women with and without HIV. We also compared the patterns of substance use between these two populations. We used two data sets: 1) 1,422 women with HIV and 2) 46,851 women without HIV. We showed that a higher proportion of women with HIV reported living with low income (70.3% versus 28.1%). Severe food insecurity was more common among women with HIV (54.1% versus 10.2%). Poor social support, gender discrimination, and race discrimination were also more common among women with HIV. Poor/fair health status was more frequent among women with HIV. Except for alcohol, the use of other substances was more prevalent among women with HIV. As shown, a higher proportion of women reported living with these challenges. In the next step, we examined whether social factors tend to co-occur among women with HIV. To do this, we used data of 12 social factors. Using statistical models, we identified four unique groups: a) no social adversities (group 1; 6.6%), b) mainly stigma and discrimination (group 2; 18.0%), c) mainly economic difficulties (group 3; 30.2%), and d) most social adversities (group 4; 45.2%). We finally examined the association of these groups with substance use. We found that illicit drug use was significantly lower among women in group 1 versus the other three groups. The same findings were observed for heavy alcohol use. Social vulnerabilities were shown to be significantly associated with a greater risk of substance use. To reduce harms due to substance use, social adversities are required to be addressed. iv Co-Authorship Statement All chapters of this doctoral research dissertation were written by Mostafa Shokoohi as part of the fulfilment of requirements for his Doctor of Philosophy from the Department of Epidemiology and Biostatistics. Chapters 2 and 3 were based on secondary data made available to Mr. Shokoohi from the 2013-2015 Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS; time-point 1) as well as the 2013-2014 Canadian Community Health Survey (CCHS), and chapters 3 and 4 were based on data from the 2013-2015 and 2015-2017 Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS; (time-point 1 and 2). Mr. Shokoohi was responsible for conducting all statistical analyses in both CCHS and CHIWOS data sets, conducting literature review and the Introduction section of all papers and this thesis, writing Materials and Methods, Results, and Discussion sections of all papers. Mr. Shokoohi’s supervisory committee (Dr. Greta Bauer, Dr. Mona Loutfy, and Dr. Igor Karp) provided guidance and feedback in the conceptualization of research questions and interpretation of findings. While Mr. Shokoohi drafted the full text of all manuscripts (percentage of contribution to all the four published papers were more than 90%), supervisory committee members and colleagues (Dr. Greta Bauer, Dr. Mona Loutfy, Dr. Angela Kaida, Dr. Ashley Lacombe-Duncan, Ms. Mina Kazemi, Ms. Brenda Gagnier, Dr. Alexandra de Pokomandy, Dr. Carmen H. Logie, Dr. M-J Milloy, Dr. Elisa Lloyd-Smith and Dr. Allison Carter) were listed as co-authors where they assisted in clarifying the concepts, interpreting the findings, and revising the manuscripts. v Dedications This doctoral research is dedicated to: i) People living with HIV ii) Women living with HIV who took part in this community-based research (CHIWOS), and the Peer Research Associates (PRAs) who administered the survey and collected the data. vi Acknowledgement I would like to thank the support of the following people that appreciably helped me complete this doctoral research: First of all, I would like to express my sincere gratitude to my doctoral supervisor, Dr. Greta R. Bauer. The following email from Dr. Bauer in 2015 changed my journey, “I would definitely be interested in seeing your application for our PhD program.” Since then, Dr. Bauer has consistently provided supervision, guidance, encouragement, and support. Dr. Bauer: you have substantially helped me grow both professionally and personally. The current research would have been impossible without your support. I cannot thank you enough for all you have done for me throughout my PhD program! My supervisory committee, who enriched this dissertation with their constructive feedback and suggestions: o Dr. Mona Loutfy, the PI of the CHIWOS survey, who generously helped me conceptualize my research objectives and directions. Dr. Loutfy has also been co- author of all manuscripts derived from this research work. Thanks so much for everything! o Dr. Igor Karp, who has continuously supported me with his remarkable recommendations, and been always available to discuss and address my academic concerns. Thanks you! All members of the Health Equity and Epidemiology Research (HEER) Group, for their availability and support once needed (alphabetized by last name): Siobhan Churchill, Laura Douglas, Dr. Sandra Gotovac, Stephanie McConkey, Emily Nunez, Alma Rueda, vii Dr. Ayden Scheim, Gioi Tran Minh, and Chantel Walwyn. A special Gracias to Alma Rueda who translated the abstract of the fourth manuscript into Spanish! Faculty members at the Department of Epidemiology and Biostatistics: Dr. Saverio Stranges, Dr. Neil Klar, Dr. Kelly Anderson, Dr. Piotr Wilk, Dr. Mark Speechley, and Dr. Guangyong (GY) Zou. My classmates and colleagues at the Department of Epidemiology and Biostatistics: Dr. Sharifa Nasreen, Alexandria Augustine Ratzki-Leewing, Mary Aderayo Bamimore, and Artem Uvarov. The CHIWOS Survey, for having the opportunity of working with such a positive and supportive team. Special thanks to Dr. Angela Kaida, who has always been available to provide me with her excellent feedback and suggestions. Dr. Kaida: You are an incredible mentor. I would also like to express my special thanks to all 1,422 CHIWOS participants as well as the peer research associates (PRAs), without whom this doctoral research would not have been possible. Thank you all! My wonderful and