Neglected Tropical Diseases (NTDs) are both causes and manifestations of poverty in developing countries. Recent advocacy efforts have increased the profile of NTDs, and led to bold new control and elimination targets set for 2020 by the World Health Organisation. However there are multifaceted challenges in effectively implementing NTD interventions in resource-poor contexts that need to be understood and engaged. While there is a growing call by researchers and international agencies for a science of global health delivery to understand these complexities, the exact nature of this science remains contested. This thesis contributes to these debates by advancing a critical social science perspective on the factors that mediate intervention effectiveness for NTD control. Grounded in a social constructivist approach using mixed methods, it critiques prevailing orthodoxies by unpacking the nature, processes and outcomes of three large-scale NTD prevention programmes in Eastern Africa. Focused on different diseases, these case studies represent different types of intervention approaches: top-down, participatory and public-private partnership. The thesis traces the social, technical and environmental processes that mediate the delivery, adoption and use of particular health technologies, such as pit latrines, insecticides and vaccination. Together, these case studies reveal surprisingly similar reasons for why many interventions do not perform according to expectations. Despite new approaches that claim to overcome stereotypical challenges of top-down planning, narrow technocratic perspectives continue to play a defining role in maintaining disjunctions between global aspirations, local realities and intervention outcomes. New perspectives and changes in orientation are needed that emphasise flexibility, learning and adaptability to local contexts. Towards this end, the thesis outlines a conceptual framework based on a comparative analysis of the case studies that highlights five interrelated domains where effectiveness is determined: geographical/livelihood variation, local agency, incentives, the socio-materiality of technology and planning/governance. I argue that addressing the shortcomings of contemporary interventions requires that programme planners actively engage these domains by seeking to “order complexity.” Greater integration of social science perspectives into the management of NTD programmes would provide significant benefit. In these ways, the thesis contributes to wider debates about the nature of global health interventions and the influence of local contexts in mediating efforts to improve the health and wellbeing of the world’s poor and marginalised.

Introduction: In the new century, worldwide health professionals face new pressures for changes towards more cost-effective and sustainable health care for all populations. Globalization creates daunting challenges as well as new opportunities for institutions and health professionals being more connected and rethink their strategies toward an interprofessional practice. Although Health professionals are paying increased attention to issues of global health, there are no current competency assessment tools appropriate for evaluating their competency in global health. This study aims to assess global health competencies of family medicine residents, nursing, physiotherapy and occupational therapy students in five universities across Ontario, Canada Methods: A total of 429 students participated in the Global Health Competency Survey, drawn from family medicine residency, nursing, physiotherapy and occupational therapy programs of five universities in Ontario, Canada. The surveys were evaluated for face and content validity and reliability. Results: Factor analysis was used to identify the main factors to be included in the reliability analysis. Content validity was supported with one floor effect in the “racial/ethnic disparities” variable (36.1%), and few ceiling effects. Seven of the twenty-two variables performed the best (between 34% and 59.6%). For the overall rating score, no participants had floor or ceiling effects. Five factors were identified which accounted for 95% of the variance. Cronbach’s alpha was >0.8 indicating that the survey items had good internal consistency and represent a homogeneous construct. The results of the survey demonstrated that self-reported knowledge confidence in global health issues and global health skills were low for family medicine residents, nursing, physiotherapy and occupational therapy’ students. The percentage of residents and students who self-reported themselves confident was less than 60% for all global health issues. Conclusion: The Global Health Competency Survey demonstrated good internal consistency and face and content validity. The new century requires professionals competent in global health. Improvements in the core competencies in global health can be a bridge to a more equal world. Institutions must offer interprofessional approaches and a curriculum that exposes them to a varied learning methods and opportunities to improve their knowledge and skills in global health.

The covid-19 pandemic confronted the world with one of the biggest challenges of the future: global health security. Analyzing the pandemic through the lens of securitization theory can create a deeper understanding of the connection between global health and international politics. This thesis underlines the deeply political character of (de)securitization and the impact that new types of security threats can have on the international system. It analyzes the effects of (de)securitization on the behavior of states towards each other and argues for a more comprehensive and cooperative approach to the threats of the future. This can be achieved by incorporating the concept of risk into the framework of securitization as well as by broadening the political understanding of the process.

Cholera is a diarrhoeal disease caused by the infection of the intestine with bacterium vibrio cholera. The diarrhoeal disease is a recurrent feature of Zimbabwe's post 1990s history. From 1993 to 2018, the country has experienced several cholera outbreaks in both rural and urban areas. The country's worst cholera outbreak occurred in 2008/2009 and resulted in over 4000 deaths. The dissertation analyses three global health actors' responses to persistent cholera outbreaks in Harare, the capital city of Zimbabwe. Building on previous scholarship of water, cholera and politics, the dissertation compares global health actors' responses to the 2008/2009 and September to November 2018 cholera outbreaks. The dissertation used the qualitative research method including analysis of existing academic literature, Zimbabwean national legislation, non-governmental organisation (NGO) publications and conference reports, news articles and Zimbabwean government policy documents. In-depth interviews with personnel from the World Health Organisation, United Nations Children's Fund, Médecins Sans Frontierès (Doctors without Borders) and the Harare City Council Health Department were conducted in Harare, Zimbabwe from June to July 2019. The dissertation demonstrates that the scope and speed of global health actors' emergency cholera interventions in Harare are shaped by Zimbabwe's political climate and the state of Harare's health, water and sanitation infrastructure.

Engaging students in class when first-hand experience is not available is challenging. Three teaching strategies, flipped classroom, a guest speaker, and technology, engaged students during a global health class. Students were given a graded preclass assignment, which was used to guide the class session when an expert physician from Zambia joined us using technology. On the day of class, students were engaged and asked questions of the physician related to global health and culture. Combining the three strategies was an innovative and effective way to engage students, with many sharing with faculty that this was their favorite class day.

Background: The direct and indirect impact of the SARS-CoV-2 virus and its mitigation measures have exacerbated the global mental health crisis. Digital mental health interventions (DMHIs) may have the potential to address health system gaps and global health inequalities in low-and middle-income countries (LMICs). Purpose: This thesis aims to map the current state of DMHIs available in Nigeria and illustrate their progress, limitations, and challenges. This study aims to expand upon the findings of recent studies in LMICs by incorporating the perspectives of individuals who play a prominent role in global mental health. The lessons learned in the Nigerian context can inform the delivery of DMHIs in other low-resource settings. Methods: This research was conducted using case study methodology. Twenty semi-structured interviews were conducted with mental health researchers, healthcare providers, digital health experts and policy makers. Data sources such as news articles, websites, research papers, and interviews were used. Interviews were recorded and transcribed, and data from multiple sources were then converged, coded, and analyzed using Dedoose via thematic analysis. Findings: The vast majority of DMHIs in Nigeria are private mental health service delivery platforms that connect directly to mental health professionals. The target audience for most DMHIs are broad and encompass all mental health conditions and ages. Advantages of DMHIs include increasing efficiency, accessibility, addressing stigma, and filling the mental health service gap. Disadvantages include skepticism in DMHIs, limitations of applicability, lack of accessibility to internet and technology, lack of sustainability, and lack of infrastructure, funding, and policies. Conclusions: There is a need to leverage DMHIs within the Nigerian population for mental health promotion. Future research should examine feedback from users and providers of DMHIs to allow for comparative analysis, more conclusive and replicable results to inform DMHI design and implementation. / Thesis / Master of Science (MSc)

Short-Term Medical Missions (STMMs) seek to provide healthcare services to people where poverty remains prevalent and limited healthcare access remains prevalent. While STMMs increase access to quality healthcare, contributions may not yet be optimal. Traveling medical professionals make a diagnosis and treatment plan based on previously established knowledge. While these treatment plans may prove to be acceptable, plans may not fully consider local customs, or ongoing medication access. A comprehensive literature review was conducted to determine best practices in developing a formulary for STMMs to investigate if an evidence-based Diagnosis & Treatment Formulary (D&TF) improves cost and time efficiency. The World Health Organization (WHO) executive summary, global essential medicines list, and the International Pharmaceutical Federation and WHO joint guidelines on good pharmacy practice were reviewed for best practices and formulary guidance. The National Institutes of Health’s PubMed, Cumulative Index to Nursing and Allied Health Literature, and the Web of Science Core Collection were searched using keywords cost-effective, evidence-based, formulary, missions, and pharmacy. Fourteen articles were identified and reviewed with inclusion criteria including English language and both within the U.S. and outside the U.S. Exclusion criteria included reviews, editorials, letter publications, and publications prior to 2005. Current best practices for STMM formularies include utilizing the WHO’s sample formulary and guiding principles to develop a team formulary. Formularies for STMMs should be specific to the WHO region, address primary health needs while including medications based on disease prevalence, utilize locally available and affordable medications, and incorporate easy-to-read pictorial medication dispensing labels in the region’s native language. Through literature review, considerations for development and implementation of WHO regional D&TFs have been identified. Appropriate diagnoses and provision of optimal medication regimens relevant to a region’s primary health needs are critical in delivering healthcare services during STMMs. Improving provider confidence in prescribing, increasing team efficiency in medication provision, and advancing equitable health care that is patient-centered and safe, are possible benefits of improved formulary practices. D&TFs go beyond a list of medications by providing an evidence-based treatment regimen for each diagnosis. A need for D&TFs for STMMs that can be further individualized has been identified. The recommended prescription for developing a D&TF for STMMs is for it to include evidence-based treatment plans, utilize essential medicines, be cost-effective, and locally relevant. Pictorial labels should be developed, utilizing local language on any text. STMM teams will need education on the prescription utilized to develop the formulary and its expected benefits to assist with implementation.

Introduction: In 2003, Purdue University College of Pharmacy (PUCOP) in West Lafayette, Indiana, began the Purdue Kenya Partnership (PKP) in collaboration with the Academic Model Providing Access to Healthcare, Moi University, and Moi Teaching and Referral Hospital, in Eldoret, Kenya. PUCOP's involvement utilized a tripartite approach of engagement, education, and scholarship to provide and expand sustainable access to high quality care. Objective: This paper discusses outcomes and impacts of this academic partnership. Methods: Purdue Kenya Partnership's progress in achieving its stated mission was evaluated using an outcome-approach logic model. This model highlighted inputs, activities, and results which encompassed outputs, outcomes, and impact. A comprehensive set of ratios were calculated to quantify annual change in PKP investments against estimated metrics for engagement, education, and scholarship. These metrics were weighted by involvement level and pharmacist effort in various clinical domains. Descriptive statistics were completed that identified cumulative and totals per year for each collected data type of data collected. Results: Purdue Kenya Partnership implementation utilized initial inputs of human resources, financial capital, and strategic partnerships. These inputs supported pharmacy involvement in 16 distinct care programs in both inpatient and outpatient settings which supported the care of 457 833 individual patients and grown a clinical pharmacy staff from 0 to 22 practicing clinical pharmacists. Five unique educational programs have been established which have graduated 457 trainees. Purdue Kenya Partnership has generated over $6.2 million in grant funding and disseminated 302 peer reviewed manuscripts, posters, and oral presentations combined. Ratios describing trends in engagement, education, and scholarship as a result of using the locally focused PKP approach highlight higher initial costs compared with much lower costs per outcome several years into the partnership. Conclusion: The PKP's global health approach of prioritizing the population's care needs (“leading with care”) has enabled the development of sustainable engagement, education, and scholarship infrastructure with significant gains in all three domains.

Background: In the face of overwhelming need and increasingly scarce resources, the humanitarian charge of “saving lives and alleviating suffering” is often reduced to simply saving lives. In 2014, World Health Assembly Resolution 67.19 called for the strengthening of palliative care as a key component of comprehensive care. However, even when palliative care is the only available option (ie. 2014-2015 Ebola Crisis), there is little evidence showing it is available in the field. More research is needed to understand this dissonance between policy and practice, and to ensure that humanitarians are providing ethical and contextually appropriate care. Methodology: Twelve individual, in-depth, semi-structured interviews were conducted in English and French with humanitarian healthcare policy makers from North America, Europe, and the Middle East, average 10+ years of experience representing various international organizations. Interviews were transcribed and coded using NVivo11 and an interpretive description framework. Findings: Participant comments suggested the existence of an institutionalized rescue culture, characterized by the fear of failure, equating of death with failure of the humanitarian healthcare professional, and a resultant systemic devaluation of palliative- type care in disaster contexts. The indoctrination of this culture may begin as early as medical school, and manifests clearly in the lack of consistent nomenclature and awareness of palliative care, treatment of palliative-triaged individuals, and resources allocated to palliative care in humanitarian contexts. Palliative care provision is a moral obligation as a final bastion of the human right to dignity and to health. Discussion & Conclusion: In order for palliative care to be integrated into the humanitarian mandate, a significant cultural shift must first take place. The findings of this thesis and the larger Humanitarian Health Ethics study will provide key guidance for the adoption and adaptation of policies that help humanitarians maintain the dignity of individuals in their most vulnerable moments. / Thesis / Master of Science (MSc)

Background: Since the 1980s, there has been a growing interest in research to focus on positive mental health instead of narrowing attention toward risk factors and to foster resilience instead of treating trauma. There is substantial empirical evidence that despite being exposed to the same risk; individuals react differently to the same stimuli. The ability of some people to successfully cope and adapt despite adversity is what constitutes resilience. In the context of forced migration, resilience research examines the elements that ameliorate wellbeing and positive adjustment rather than focusing on the pathological consequences of trauma. However, little is known about how the construct of resilience is conceptualized within the field of forced migration research. This research aims to critically appraise and map the existing literature on resilience in the forced migration population, and to analyze how the concept of resilience is defined, operationalized, and applied in refugee research. Methods: Arksey and O’Malley scoping review framework was followed to search 5 online databases. Numerical and thematic analysis were both conducted to examine the breadth of the literature and to chart the relevant data. Results: A total of 20 studies were selected for the scoping review. The findings included a description of the literature regarding geographic distribution, recruited methods, and targeted populations. In addition, the results investigated definitions of resilience, measures used to operationalize resilience, the relationship between resilience and mental health illnesses, internal and external protective factors contributing to fostering resilience processes, and resilience across cultures and languages. Conclusion: There is an increase in interest to understand the concept of resilience through synthesizing both qualitative and quantitative data. However, longitude and evaluation studies remain the exception. Further research is needed to validate resilience instruments across cultures and languages. The interactions between mental health illnesses and resilience should be better understood in the context of forced migration as well. / Thesis / Master of Health Sciences (MSc)