Despite improvements in health care services there are poor perinatal outcomes in the rural and remote regions of Morocco. A national plan was adopted as part of a WHO, UNICEF and UNFPA initiative to reduce maternal and neonatal deaths in underserviced regions. Strengthening the profession of midwifery was identified as a key component of the initiative. In 2008, a Moroccan framework for midwifery education, regulation and funding was established. There is evidence that funded midwifery care is not being accessed by women in rural regions. A scoping review was undertaken to examine the social barriers. The review was conducted using the Arksey and O’Malley’s 2005 framework for scoping reviews. The research stages included 1) identifying the research question; 2) identifying the relevant studies; 3) study selection; 4) charting the data; 5) collating, summarizing and reporting the results. The aim was to identify how the socio-cultural context can impede the uptake of midwifery care and thus impact maternal and neonatal outcomes. Language barriers, cultural differences and gender inequality were identified as key barriers that impact the acceptability of midwifery care in Morocco. / Thesis / Master of Science (MSc)

Background: Cervical cancer is a leading cause of death in Tanzanian women, with annual age-standardized mortality of 38 per 100,000. While organized screening programs have minimized cervical cancer rates in the developed world, a national prevention program has not yet been instituted in Tanzania. Though screening is available at clinics in the Kilimanjaro region, uptake of these services is reported to be low. The objectives of this thesis were: 1) to describe the knowledge, attitudes and practices of cervical cancer screening in rural and urban Kilimanjaro women, 2) to determine the main barriers preventing women from being screened, and 3) to identify important determinants of screening status and screening acceptability in the population. Methods: A cross-sectional survey was administered to 312 rural and 280 urban women in the region over June-July 2012. The sample was obtained through a multistage random sampling strategy. Descriptive statistics were performed to address Objectives 1 and 2, while multivariate logistic regression models were created using generalized estimating equations to address Objective 3. Results: Awareness of cervical cancer in the sample was high, but women had less knowledge of screening tests for the disease. The proportion of ever-screened women was significantly lower in the rural (4%) than in the urban (8%) sample. The most common barrier in never-screened women was not knowing that screening existed, followed by anticipated cost of the procedure. Travel distance was a more frequent concern in rural women. Older age, being married, cervical cancer knowledge and healthcare access factors were significantly associated with screening status in urban women, while only older age and condom use were associated in rural women. Personal beliefs about risk were associated with screening acceptability in never-screened women. Willingness to be screened was low in urban women with high socioeconomic status. Conclusions: Participation in cervical screening is extremely low in the Kilimanjaro region due to both access-related and personal barriers. While Tanzania awaits a national screening program, the identified determinants may inform regional screening and education initiatives aimed at increasing screening coverage in the Kilimanjaro area. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2013-09-30 14:24:36.139

Thesis advisor: Sarah Babb / Since 2000, the global health management approach of health systems strengthening (HSS) has gained support from many local and international stakeholders. This thesis investigates the diffusion of the HSS norm in the global health community and within two disease programs of malaria and tuberculosis. I show how strong support for HSS by the global health community has been overwhelmed by coercive pressure from resourcewielding funding and governance structures. Drawing on organizational theory, I argue that global health organizations and experts have engaged in strategic social reconstruction and avoidance tactics to rationalize hypocrisy towards the HSS norm. / Thesis (BA) — Boston College, 2017. / Submitted to: Boston College. College of Arts and Sciences. / Discipline: Scholar of the College. / Discipline: International Studies.

Throughout the past few decades, as global health trips for undergraduates and medical students began to increase in popularity, so did the topic of global health ethics. While there has been much research on the regulations for medical students' global health experiences, the same cannot be said for their undergraduate counterparts (Mccall & Iltis, 2014). Given the numerous pre-medical students attending these trips, it is vital to understand their motivations and bring light to the ethical issues that might occur. Intense literature analysis and a global health survey completed by students at the Lewis Katz School of Medicine were used in this paper to weigh the benefits against the costs of these trips. Although there are ethical dilemmas, comparing undergraduate global health trips to medical school trips shows that there may be steps that can be taken to improve trips and avoid severe ethical issues. Undergraduate universities and the Association of American Medical Colleges (AAMC) could vet and post approved programs for their pre-medical students. This and increased efforts to inform people of ethical problems associated with global health would allow students to benefit from their trip while minimizing ethical costs to the country and themselves. / Urban Bioethics

Cholera in Haiti has persisted since its introduction after the 2010 earthquake. The outbreak demonstrates how a combination of socioeconomic factors, mainly a lack of infrastructure, can cause an outbreak to become a much more serious epidemic and the current enduring endemic. Because cholera came to a previously unexposed nation through United Nations peacekeepers, the outbreak in Haiti offers a unique perspective on the impact of globalization on public health. In addition, it provides a deeper look into the disproportionate impact of diarrheal diseases on low-income countries. Several biological and socioeconomic factors have facilitated the outbreak. Biological risk factors include immunologically naïve populations, low gastric acidity, and blood type. In addition, socioeconomic factors include a lack of clean drinking water and sanitation as well as a fragile and over-taxed healthcare system. The persisting struggle surrounding water and sanitation combined with a lack of knowledge on cholera prevention have precipitated the outbreak into an epidemic and further into its current endemic status. Current efforts to battle cholera include water and sanitation improvements, a national vaccination campaign, as well as the mobilization of community health workers. However, without the construction of sustainable water and sanitation infrastructure, it is unlikely that cholera in Haiti can be eliminated.

Introduction: Despite the method existing for centuries, uses of crowdsourcing have been rising rapidly since the term was coined a decade ago. Crowdsourcing refers to ‘outsourcing’ a problem or task to a large group of people (i.e., a crowd) rapidly and cheaply. Researchers debate over definitions of crowdsourcing, and it is often conflated with mHealth, web 2.0, or data mining. Due to the inexpensive and rapid nature of crowdsourcing, it may be particularly amenable to health research and practice, especially in a global health context, where health systems, human resources, and finances are often scarce. Indeed, one of the dominant methods of health research prioritization uses crowdsourcing, and in particular, wisdom of the crowds. This method, called the Child Health and Nutrition Research Initiative (CHNRI) method, employs researchers to generate and rank research options which are scored against pre-set criteria. Their scores are combined with weights for each criterion, set by a larger, diverse group of stakeholders, to create a ranked list of research options. Unfortunately, due to difficulties in defining and assembling a group of stakeholders that would be appropriate to each exercise, 75% of CHNRI exercises to-date did not involve stakeholders, and therefore presented unweighted ranks. Methods: First, a crowdsourcing was defined through a literature review. Benefits and challenges of crowdsourcing were explored, in addition to ethical issues with crowdsourcing. A second literature review was conducted to explore ways in which crowdsourcing has been already used in health and global health. As crowdsourcing could be a potential solution to data scarcity or act as a platform for intervention in global health settings, but its potential has never been systematically assessed, a CHNRI exercise was conducted to explore potential uses of crowdsourcing in global health and conflict. Experts from both global health and crowdsourcing participated in generation and scoring ideas. This CHNRI exercise was conducted in-line with previously described steps of the CHNRI method for setting health research priorities. As three quarters of CHNRI exercises have not utilized a larger reference group (LRG) of stakeholders, and the public was cited as the most difficult stakeholder group to involve, we conducted a survey using Amazon Mechanical Turk, an online crowdsourcing platform, that involved an international group of predominantly laypersons who, in essence, formed a public stakeholder group, scoring the most common CHNRI criteria using a 5-point Likert scale. The resulting means were converted to weights that can be used in upcoming exercises. Differences in geographic location, and whether the respondents were health stakeholders were assessed through the Fisher exact test and Wilcoxon rank-sum test, respectively. The influence of other demographic characteristics was explored through random-intercept modelling and logistic regression. Finally, an example of a national-level CHNRI exercise, which is the largest CHNRI conducted to-date, exploring research priorities in child health in India is described. Results: A comprehensive definition of crowdsourcing is given, along with its benefits, challenges, and ethical considerations for using crowdsourcing, based on a literature review. An overview of uses of crowdsourcing in health are discussed, and potential challenges and techniques for improving accuracy, such as introducing thresholds, qualifiers, introducing modular tasks and gamification. Crowdsourcing was frequently used as a diagnostics or surveillance tool. The CHNRI method was not identified in the second literature review. In re-weighting the CHNRI criteria using a public stakeholder group, we identified differences in relative importance of the criteria driven by geographic location and health status. When using random-intercept modelling to control for geographic location, we found differences due to health status in many criteria (n = 11), followed by gender (n = 10), ethnicity (n = 9), and religion (n = 8). We used the CHNRI method to explore potential uses of crowdsourcing in global health, and found that the majority of ideas were problem solving or data generation in nature. The top-ranked idea was to use crowdsourcing to generate more timely reports of future epidemics (such as in the case of Ebola), and other ideas relating to using crowdsourcing for the surveillance or control of communicable disease scored highly. Many ideas were related to the United Nations’ Sustainable Development Goals (SDGs). Finally, a national-level exercise to set research priorities in child health in India identified differential priorities for three regions (Empowered Action Group and North Eastern States, Northern States and Union Territories, and the Southern and Western States). The results will be very useful in developing targeted programmes for each region, enabling India to make progress towards SDG 3.2. Conclusion: Crowdsourcing has grown exponentially in the past decade. Integrating gamification, machine learning, simplifying tasks and introducing thresholds or trustworthiness scores increases accuracy of results. This research provides recommendations for improvements in the CHNRI method itself, and for crowdsourcing, generally. Crowdsourcing is a rapid, inexpensive tool for research, and thus, is a promising data collection method or intervention for health and global health.

The field of global health has grown rapidly over the past two decades. In response, academic institutions have established new educational practices and training opportunities for students. One flourishing area of global health training is in international medical electives (IMEs) in which medical students experience medicine in a different political, cultural, and epidemiological context for a short period of time. Scholarly literature on IMEs has been published and disseminated widely, and various discourses establish the way that IMEs are understood and experienced. However, rather than offering neutral descriptions, discourses actively shape the world in favor of certain viewpoints. When accepted uncritically, dominant discourses can reproduce inequalities by legitimizing certain practices. In the field of global health, dominant discourses have been largely unexamined and unquestioned. Informed by social constructionist and post-structuralist views of language, this study critically examines IME discourses in 60 journal articles published between 2000 and 2011. A method for analyzing discourse influenced by the French philosopher Michel Foucault was used to emphasize the intricate relationship between discourse, knowledge, and power. The findings reveal that two dominant discourses cohere to produce commonly accepted and appropriate knowledge about IMEs. The discourse of “disease and brokenness” depicts IMEs as situated in faraway lands plagued by “exotic” diseases, and the discourse of “romanticizing poverty” portrays developing countries as trapped in time. These discourses emphasize and privilege certain meanings, while discrediting and silencing others. Moreover, IME discourses constitute uneven power relations and are characterized by a language that relies on dichotomies. In both of the identified discourses, medical students are privileged subjects while inhabitants are marginalized. As a result, inequalities between developed and developing countries are reproduced and the possibilities for forming mutually beneficial relationships during IMEs are constrained. Recognizing that reality is constituted through language, the findings indicate that prevailing representations are constructed rather than inevitable “truths”. Furthermore, this study suggests that dominant meanings can be resisted, articulates how current “truths” can be destabilized, and proposes a new way of conceptualizing IMEs. By critically reflecting on their work, students, researchers, and practitioners in the field of global health can engage in more socially just practices.

abstract: This thesis explores concept of "global bioethics" in both its development as well as its current state in an effort to understand exactly where it fits into the larger field of bioethics. Further, the analysis poses specific questions regarding what it may contribute to this field and related fields, and the possibility and scope associated with the continued development of global bioethics as its own discipline. To achieve this, the piece addresses questions regarding current opinions on the subject, the authorities and their associated publications related to global bioethics, and what the aims of the subject should be given its current state. "Global Bioethics" is a term that, while seen frequently in bioethics literature, is difficult to define succinctly. While many opinions are provided on the concept, little consensus exists regarding its application and possible contributions and, in some cases, even its very possibility. Applying ethical principles of health and medicine globally is undoubtedly complicated by the cultural, social, and geographical considerations associated with understanding health and medicine in different populations, leading to a dichotomy between two schools of thought in relation to global bioethics. These two sides consist of those who think that universality of bioethics is possible whereas the opposing viewpoint holds that relativism is the key to applying ethics on a global scale. Despite the aforementioned dichotomy in addressing applications of global bioethics, this analysis shows that the goals of the subject should be more focused on contributing to ethical frameworks and valuable types of thinking related to the ethics health and medicine on a global scale. This is achieved through an exploration of bioethics in general, health as a function of society and culture, the history and development of global bioethics itself, and an exploration of pertinent global health topics. While primarily descriptive in nature, this analysis critiques some of the current discussions and purported goals surrounding global bioethics, recommending that the field focus on fostering valuable discussion and framing of issues rather than the pursuit of concrete judgments on moral issues in global health and medicine. / Dissertation/Thesis / M.S. Biology 2011

Chapter 1 develops a two-period general equilibrium trade-theoretic model to examine if foreign aid discourages the recipient countries from pursuing trade liberalization. In the model, foreign aid is given to the recipient in period two and its amount is negatively related to the period-one real income. The recipient optimally chooses a tariff on imports. It can also choose domestic investment endogenously in period one, and this choice has an important bearing on our main result. We consider two variants of the model depending upon whether the recipient can or cannot have access to international borrowing. In the case without international borrowing, when domestic investment is exogenous, optimal tariff is zero. In contrast, when domestic investment is endogenous, optimal tariff is positive. This positive optimal tariff is induced by the link of aid negatively to the period-one real income. In the case with international borrowing, even though domestic investment is exogenous, optimal tariff is positive. But the reason for the positive tariff is its beneficial effect on an improvement in the terms-of-trade of international borrowing. When, in addition, domestic investment is endogenous, the tying of aid increases positive optimal tariffs further. Chapter 2 develops a microeconomic model of health policies and the optimal allocation of health aid in a poor recipient country. In the model, each poor household in the country chooses the optimal number of sick children taken to hospitals to maximize its lifetime utility. There are three policy options for policymakers to improve public health: raising the quality of health care, providing more preventive care and reducing the cost of health care. We examine how three policy options influence the optimal number of sick children who are medically treated. Also, the country's health authority allocates health aid for three policy options to support poor households' lifetime utility maximization. We find that more health aid should be allocated for cost reduction in health care so as to help poor households maximize their lifetime utility. Chapter 3 primarily examines the hypothesis that there is heterogeneity in health aid, that is, different types of health aid work differently for health outcomes in aid-recipient countries. In order to test our hypothesis, we first disaggregate health aid per capita data into three policy options: health aid per capita for improving the quality of health care, health aid per capita for providing preventive care and health aid per capita for reducing the cost of health care. Then, we empirically examine the effects of disaggregated health aid on three different health indicators: child mortality, life expectancy and death rate. Using a panel data set of 119 aid-recipient countries from 1975 and 2010, we find supporting evidence for the hypothesis of heterogeneity in health aid. We find no empirical evidence of the beneficial effects of health aid on reducing child mortality. In contrast, we find that an improvement in life expectancy and a reduction in death rate are driven mostly by health aid for reducing the cost of health care. We also find that there is heterogeneity in the allocation of health aid. Health aid for preventive care and the cost reduction of health care is allocated by the needs of the recipients. However, more health aid for the quality of health care flows to countries with better health status.

Rural areas in much of sub-Saharan Africa access needed health care from untrained and often poorly regulated drug vendor shops with concerns over the quality of products and services provided and their public health implications. The thesis undertook to understand market relationships in a rural retail drug market in the light of the structure-conduct-performance paradigm and isolate opportunities for potential policy interventions for improved access to quality and safer medicines. Data was collected from a sample of patent medicine vendors and drug purchasers in Katsina-Ala Local Government Area of Benue State, north central Nigeria, over 9 months in 2012. Information from drug vendors and drug consumers was generated through semi-structured questionnaires, in-depth interviews and systematic business transaction observations. Key state and national drug regulatory officials were also interviewed in-depth and related documentary data collected and evaluated. Data analysis focussed mainly on the relationships between market structure, provider conduct, consumer behaviour and the nature of regulation, with the aim of understanding market performance in relation to access to medicines and their rational use. The study established that patent medicine vendors were an important source of medicines for inhabitants of the local government for ambulatory primary health care. Drug retailers were said to be a reliable source of a wide range of drugs provided at relatively more affordable prices and in a convenient way that satisfied consumer expectations. However, a number of market failures existed: low quality of treatment due to poor provider knowledge of diseases and drugs and therefore inappropriate prescription and dispensing practices. Ineffective regulation was also demonstrated by way of inappropriate and inadequate regulatory regime, occasioned by wide spread regulatory infractions. To attain the desirable public health objective of sustained improvement in the quality of products and services obtainable at patent medicine vendor outlets, regulatory strategies must be contextually relevant, providers must be trained and offered financial and business incentives and consumers must be empowered by accessible and timely health information for informed choices against the backdrop of strengthened and better incentivized inspectorate unit in a systematically intertwined approach.