Exploring Risk Perception of an Emerging Environmental Health Risk: A case study of allergic disease in youth team sport in Ontario, Canada by Francesca Cardwell A thesis presented to the University of Waterloo in fulfilment of the thesis requirement for the degree of Doctor of Philosophy in Geography Waterloo, Ontario, Canada, 2019 © Francesca Cardwell 2019 Examining Committee Membership The following served on the Examining Committee for this thesis. The decision of the Examining Committee is by majority vote. External Examiner DR. CANDACE NYKIFORUK Professor, School of Public Health, University of Alberta Supervisor(s) DR. SUSAN ELLIOTT Professor, Geography and Environmental Management, Faculty of Environment, University of Waterloo Internal Member DR. JEAN ANDREY Professor and Dean, Faculty of Environment, University of Waterloo Internal-external Member DR. MARTIN TAYLOR Adjunct Appointment in School of Public Health and Health Systems, University of Waterloo Other Member(s) DR. DANIEL SCOTT Professor, Geography and Environmental Management, Faculty of Environment, University of Waterloo ii AUTHOR’S DECLARATION This thesis consists of material all of which I authored or co-authored: see Statement of Contributions included in the thesis. This is a true copy of the thesis, including any required final revisions as accepted by my examiners. I understand that my thesis may be made electronically available to the public. iii STATEMENT OF CONTRIBUTIONS Exceptions to sole authorship: Chapter 4: Cardwell, F.S., and Elliott, S.J. (Submitted). They Say “Kids with asthma don’t play sports”: Geographies of Asthma, Children’s Geographies. Chapter 5: Francesca S. Cardwell and Susan J. Elliott, “Investigating Youth Sport Coach Perspectives of an Asthma Education Module,” Journal of Environmental and Public Health, vol. 2018, Article ID 2512010, 11 pages, 2018. https://doi.org/10.1155/2018/2512010. Chapter 6: Cardwell, F.S., and Elliott, S.J. (To be submitted). Understanding an Emerging Environmental Health Risk: Investigating Asthma Risk Perception in Ontario Youth Sport, The Canadian Geographer. I hereby declare that as lead author on all three manuscripts, I was responsible for the research conceptualization, data collection and analysis. I was also responsible for drafting and submitting the articles for publication in the respective peer-reviewed journals, and addressing all comments from peer-reviewers. The other co-author adopted a supervisory role, and provided feedback during data collection and analysis, and on the draft manuscripts. Dr. Susan Elliott, as my supervisor, provided significant direction and assistance. iv ABSTRACT Asthma is the most common chronic disease among children worldwide, and approximately 3.8 million Canadians are diagnosed. Although the relationship is complex, participation in physical activity is recommended as part of a comprehensive asthma management plan, as it can reduce symptoms and improve wellbeing for those affected. Team sport participation is a common way for children and youth to engage in physical activity. The spaces in which team sport is experienced can present unique challenges for vulnerable children, and evidence suggests that those with asthma may be less physically active than their non- asthmatic peers. While asthmatic youth may experience barriers to sport participation, effective allergic disease management that includes coach consideration of the environmental contexts of sport can help asthmatic athletes maintain long-term engagement in activity. The research presented in this thesis therefore aims to increase understanding of how children, parents and organized youth team sport coaches in Ontario understand and manage the links between allergic disease, the environment and physical activity. The research focuses on three broad objectives: first, to explore the knowledge, attitudes, and practices of users and providers of child and youth team sport with respect to the links between the environment, allergic disease and physical activity; second, to investigate the impact of a coach education module related to coach attitudes and behaviours regarding the links between the environment, allergic disease and physical activity; and finally, to document the factors shaping the perception of asthma as an emerging environmental health risk in Ontario youth team sport. A mixed- methods case study approach was used in this research. There is an inherent geographic component to understanding how environmental factors impact allergic disease risk in organized team sport. Understanding how elements of the v environment are managed and risk is perceived amongst sport stakeholders is important for effective asthma management. In-depth interviews with coaches (n=18) and athletes with asthma (n=11) suggest that ensuring both the physical (e.g., recognizing potential triggers) and social (e.g., reducing stigmatization) needs of vulnerable athletes are recognized is important to maximize enjoyment and performance, and improve asthma management for those affected. Focus groups with coaches (n=12) indicate that while coaches perceived an education module related to the environment, physical activity and allergic disease as valuable, some content was considered less relevant, and barriers to its implementation (e.g., coach autonomy) were identified. Finally, multivariate analysis of two surveys (coaches, n=94; parents of athletes with allergic disease, n=90) suggests that various factors (e.g., exposure, education, propensity for risk, gender) contribute to how asthma risk is perceived amongst and between sport stakeholders, emphasizing the value of population-specific risk management communication. This research makes multiple important contributions. Theoretically, a place-based conceptual framework for understanding public experience of risk was applied; this framework informed research design, and recommendations (e.g., consideration of scale) with respect to future application are offered. The use of multiple and mixed methods, and including a potentially vulnerable group in the interviews, allowed for enhanced understanding of the factors that contribute to asthma management in sport. Substantively, this research contributed to the Geographies of Asthma literature, increasing understanding of asthma risk perception outcomes, and the environmental factors (e.g., sociocultural, political) that contribute to how asthma is perceived amongst sport stakeholders in Ontario. Considering the environmental contexts of risk is therefore critical to improve environment and health management in Ontario organized team sport, and reduce the future chronic disease burden associated with physical inactivity in Canada. vi ACKNOWLEDGMENTS First, I would like to thank my academic supervisor Dr. Susan Elliott. Not only has Susan supported me throughout my PhD, but helped develop my interest in health geography during my time as a Masters student. Susan – I will be forever thankful for your endless support and encouragement, valuable feedback and advice, and the interesting conversations related to other aspects of life that we have enjoyed over the years. I would also like to thank the other members of my committee; Dr. Jean Andrey, Dr. Daniel Scott, and Dr. Martin Taylor. I am extremely appreciative of your guidance, feedback and support. I have much appreciation for all the participants (coaches, parents, youth athletes) that agreed to take part in this research; your perspectives and input were extremely valuable. I would also like to acknowledge the support of the Social Sciences and Humanities Research Council of Canada (SSHRC), and the Ontario Graduate Scholarship (OGS) program. Further, The Allergy, Genes and Environment Network (AllerGen) and the University of Waterloo Graduate Studies Research Travel Assistantship program have provided opportunities for travel and research dissemination and I am extremely grateful for this support. I would also like to thank my friends and colleagues that have made my years as a graduate student enjoyable. I am extremely thankful for the friendship and laughter, support, and feedback that has been supplied throughout my time in the GoHelp Lab at the University of Waterloo. Finally, thank you to my parents for the endless support, interest in my work, and encouragement, and to Keifer for your sense of humour and positivity, thoughtful feedback, and for being so caring over the last few years. I am very fortunate to be surrounded by such loving family and friends. vii TABLE OF CONTENTS Examining Committee Membership………………………………………………………………ii Author’s Declaration ……………………………………………………………………………. iii Statement of Contributions ……………………………………………………………………… iv Abstract …………………………………………………………………………………….……..v Acknowledgments ……………………………………………………………………………… vii List of Figures …………………………………………………………………………………… xi List of Tables ………………………………………………………………………………….... xii Chapter One: Introduction ……………………………………………………………………...1 1.1 Research Problem ……………………………………………………………………………..1 1.2 Research Context ……………………………………………………………………………...2 1.3 Research Objectives ………………………………………………………………………….. 3 1.4 Thesis Outline …………………………………………………………………………….….. 4 Chapter Two: Literature Review ………………………………………………….…………....6 2.1 Introduction ………………………………………………………………………...…………6 2.2 Geographies of Health and Health Care …………………………………………...……….…6 2.3 Global Environmental Change and Health ………………………………………....………..10 2.3.1 Climate Change and Health ……………………………………………………………...11 2.3.2 Climate Change and Health