Thesis (M.P.H.)--University of Michigan, 1945.

Thesis (M.P.H.)--University of Michigan, 1945.

Thesis (M. S.)--Public Policy, Georgia Institute of Technology, 2010. / Committee Chair: Susan E. Cozzens; Committee Member: Barbara D. Lynch; Committee Member: Marilyn A. Brown. Part of the SMARTech Electronic Thesis and Dissertation Collection.

Thesis (doctoral)--Freie Universität Berlin, 1980.

Thesis (Ph.D.)--Aberdeen University, 2009. / With: Health status and health needs of the orphan children of Kathmandu Nepal : the findings of the pilot study / S. Sing, Edwin R. Van Teijlingen, P. Simkhada. Stupa Journal of health services. 2007: 3, 1-2. With: Health status and health needs of orphan children of Kathmandu Nepal / S. Sing, P. Simkhada, Edwin R. Van Teijlingen. Journal of Nepal Heath Research Council. 2007: 5, 2. Includes bibliographical references.

Thesis (M.S.)--University of Wisconsin--Madison, 1993 / Typescript. Includes bibliographical references (leaves 81-85).

Introduction Randomised controlled trials administering probiotic supplements to preterm infants to prevent sepsis and necrotising enterocolitis are already underway, despite the lack of a robust evidence base of normative values for gut microbiota, bacterial metabolites, and markers of inflammation and immunity. There are increasing calls for observational studies to establish baseline data in these infants. Most of these studies to date have involved the measurement of these analytes individually. In the studies presented in this thesis, we measured a range of stool markers collectively in a cohort of preterm infants in health and disease. Design 56 infants at <32 week gestation and less than 1500g birth weight were sequentially recruited from all three Glasgow Neonatal Units within week one of life after commencement of enteral feeds. Anthropometric, dietary and treatment data were collected. Stool samples were taken once weekly for the first four weeks, testing: short chain fatty acids; calprotectin, secretory immunoglobulin A; and microbial diversity by temporal temperature gel electrophoresis. Results Out of 61 live births meeting the study criteria, 56 infants were enrolled in the study, 62.5% of whom were female. 19.6% were between 24-26 weeks gestation, 28% were 26-28 weeks, 30% were 28-30 weeks, and 21% were 30-32 weeks. 5.3% were between 490-600g in birth weight, 17.8% were 600-800g, 21.4% were 801-1000g, 39.2% 1001-1250g, and 16% were between 1251-1500g. Feed regimen was heterogeneous, comprising 5 combinations of maternal, donor and formula milks. The highest social deprivation level as measured by the Carlisle ‘Depcat’ scoring system of level 7 was significantly higher in the study group than Glasgow or Scotland-wide averages. Sepsis rates were low, with a group median of only 1 per infant. Overall mortality: 7%. 32 with any NEC (56%), 20 with Bells’ ≥2a NEC. 8 (14%) with surgically treated NEC, 5 (8%) underwent ileostomy. SCFAs: (n=56) there were no correlations between gestation, weekly totals, feed type, or NEC and SCFA concentration. Acetate and lactate dominated each sample. Few significant changes were noted with respect to NEC, and these were in the less dominant SCFAs: stage 2a NEC showed higher concentrations of propionate in week 4 than week 3, and lower valerate in week 4 than 2. Stage 3b levels of isobutyrate and heptanoate were significantly lower in week 4 than 3. FC: (n=56) there were no significant differences in FC levels between each week in infants with or without NEC, although the former illustrated a trend to lower levels by week 4. There were no significant differences in NEC before and after clinical signs were apparent, or in those before NEC and after stoma formation for stage 3b NEC. However, significantly lower FC levels were noted in stage 3b NEC requiring ileostomy compared to the immediate pre-operative sample. SIgA: (n=34) Levels rose significantly week on week, and were considerably higher in weeks three and four than week one. There were no significant differences in stool SIgA concentration between infants with and without NEC. A significant increase in mean stool SIgA concentration appeared from week 2 to week 3 in NEC infants, and from week 1 to week 2 for those without. For all breastfed preterm neonates (n=6), the level of milk SIgA was significant higher on week 1 (colostrum) than week 2 and week 3. TTGE: (n=22) There was large variability between number (1-17) and species diversity (25-36 different species). Bacterial composition varied largely between the 2 sample points. No difference in species richness or similarity within the 2 feeding groups was observed. 4 bands were identified in >50% of infants. Intra-individual similarity varied greatly and ranged from a similarity index (Cs) of 0% to 66.8%. There was no statistical difference between the similarity indices of the feeding groups or between those with and without NEC. There were no significant correlations between any of the analytes. Conclusions Only extreme prematurity and extremely low birth weight were associated with NEC, which was at a strikingly high incidence. A limitation was therefore the unexpected onset of severe NEC resulting in prolonged paralytic ileus with low stool production. No correlations were found between analytes, indicating that each set of stool investigations may signify independent physiological, biochemical and immunological gut processes. Despite the severity of NEC, the levels of each analyte were remarkably consistent. High levels of deprivation within the study population may provide the constellation for an as of yet undefined genetic and epigenetic predisposition to NEC in this cohort, similar to that of other illnesses endemic to different geographical areas – notably Multiple Sclerosis in the North East of Scotland – and both follow up of these infants into childhood as well as further analysis of future inborn infants with NEC is planned.

Exclusive breastfeeding (EBF) for 6 months is recommended as the most cost-effective public health intervention to improve child survival particularly in Sub-Saharan Africa and is central to achieving Millennium Development Goal number 4 for child health. However, despite the benefits of EBF to infants and mothers, the rates continue to decrease as the age of the infant increases in an African cultural context including Malawi. There is increasing literature on the effectiveness of community-based peer counselling on EBF promotion in resource-poor settings but its effectiveness in the context of HIV and experiences of HIV positive women with the intervention remains a gap. The purpose of this thesis was to explore determinants of EBF using MaiMwana infant feeding peer-counselling intervention conducted in Mchinji, Malawi as a case study. Specifically, in this study I explored the effectiveness of the intervention to help HIV positive women to overcome the barriers and examine people’s experiences and perceptions towards the intervention with respect to HIV and poverty. I adopted qualitative in-depth interviews with 39 informants, including breastfeeding mothers, peer counsellors and key informants who were purposely selected. The data was analysed using a framework approach. I found that despite having good knowledge, women from rural communities face considerable challenges while practicing EBF. Cultural beliefs, economic constraints, lack of power and support, and fear of transmitting the virus to their infants were cited as major barriers that prevented them from practicing EBF. Overall, the findings from this study suggest that peer counsellors are well accepted by service-users and other community members as they positively viewed their frequent visits as providing additional support, reinforcing infant feeding messages and provide psychological support to women resulting in improved EBF rates. Furthermore, the presence of peer counsellors was viewed as “bringing services at their door step” which reduced time and cost to travel to the health facility. Nevertheless, the findings suggest that voluntary work in resource-poor settings presents considerable challenges such as: poor motivation due to lack of incentives, overworking, lack of knowledge and time to handle HIV positive cases and poor supervision. In order to effectively promote EBF in resource-poor settings, public health programme designers and implementers need to consider these barriers so as to design community-based interventions that suit the local context and create an enabling environment.

Domestic abuse puts children at risk. There is evidence that the health of these children is compromised. This thesis aims to explore whether specific health services to children living in refuges with their mothers who have fled domestic abuse should be targeted at this group. Method The epidemiological, comparative and corporate methods of health care needs assessment were used. Evidence for effective interventions to address the key health issues for this group of children was sought. Few other service models could be found against which to directly benchmark. Guidance for services to children in these circumstances was thus included in the review as a comparator. Professionals and Mothers were interviewed to explore their perspective on the needs of these children. Results Children in refuge have an increased risk of mental health problems and poor access to health services. They are more likely to have suffered maltreatment themselves. Refuges in Cardiff provide assessment and a programme of work and support for children. The specialist health visitor role uncovers unmet health needs in the under 5s. Professionals working with these children and their mothers are concerned about their mental health and are looking for more specialist CAMHS (Child and Adolescent Mental Health Service) help. A number of barriers stand between children and the health services they need. Referral criteria are not clear and timeliness of services and continuity of care is an issue for mobile families. Conclusions A model for health service is suggested for children in refuge using the logic model method. The Primary Mental Health Worker role should provide the advice and expertise Tier 1 workers require and demystify the referral criterion for specialist CAMHS. Timing and continuity of care for appointments requires joint decision making and a flexible service. Health staff requires training to provide an acceptable and accessible service to vulnerable families.

Children with Autism Spectrum Disorder (ASD) have difficulties with social interaction that affect their early learning through play. Systematic reviews were conducted on the effectiveness of Social Stories™ (SS™), Self Video Modelling (SVM) and Peer Video Modelling (PVM) to teach social behaviour to such children. Study 1 compared their effectiveness for teaching three core play skills to 18 young children with ASD: initiating play, turn taking and finishing play; using a counterbalancing design across skills and play materials so that each participant received each intervention. At intake, participants’ ages, Vineland Adaptive Behavior Scale and PLS-3 scores were assessed. The three core skills were observed with good interobserver (97.3%) and procedural (100%) reliability and quantified using a specifically designed scale. The social validity of target skills and interventions was assessed using a Likert scale. All interventions showed evidence of significant improvement. Non-parametric repeated measures ANOVA and post-hoc Wilcoxon tests showed that SVM was superior to SS™ and PVM. Such superiority was evident for initiating play and turn taking but not for finishing play. There was no significant association between the intake variables and either the degree of change between baseline and post-intervention or the post-intervention scores themselves for SS™. Change following SVM was positively related to the Vineland composite score and its motor skills domain score. Post-intervention scores for SVM were positively related to the Vineland composite scores and its communication, daily living and motor skills domain scores as well as all three PLS-3 scores. Change following PVM was related to the Vineland maladaptive score. The target skills and interventions had high social validity. Study 2 showed that more sustained intervention over time resulted in improvement for those who did less well initially. Overall, the research provides encouraging evidence that these interventions are effective in teaching play behaviours to young children with ASD.