Maternal psychosocial well-being (MPW) is a comprehensive concept that covers the psychological (e.g., depression, distress, anxiety, coping, mental health,) and social (e.g., family and community support, empowerment, relationships, culture) aspects of motherhood. High rates of poor maternal mental health, with maternal depression the most prevalent condition, have been reported in the low and middle income countries, including Pakistan. Though evidence based interventions exist to address maternal depression, these have not been translated into policy because of various implementation barriers. Integration of these interventions into existing maternal and child health (MCH) programmes has been suggested as a strategy to provide accessible care to mothers. In the current study we developed and integrated a cognitive behavioural therapy–based MPW intervention (the 5 pillars approach) into a child nutrition and development program. Following qualitative research with community health workers (CHWs) and families, CHWs were trained in (1) empathic listening, (2) family engagement, (3) guided discovery using pictures, (4) behavioural activation, and (5) problem solving. A qualitative feasibility study in one area demonstrated that CHWs were able to apply these skills effectively to their work, and the approach was found to be useful by CHWs and mothers. This work provides vital information on the lessons learnt in the implementation of a maternal psychosocial wellbeing intervention for universal use. The facilitating factors included mothers being the central focus of the intervention, utilizing existing local CHWs whom the mothers trust, simple training and regular supervision, and an approach that facilitates, and does not add, to the CHWs’ work.

Background: Saudi Arabia is one of the Gulf Cooperative Council (GCC) countries which have common characteristics such as high-income governments, dominant expatriate populations, and under-developed healthcare systems, including healthcare financing. The dominance of the expatriate working population raises the question of how to find a mechanism that ensures expatriates have appropriate access to medical care whilst the employers bear the responsibility of healthcare expenses. Saudi Arabia is one of the few GCC countries to have reformed its private healthcare system through a Compulsory Employment-Based Health Insurance (CEBHI). The CEBHI was designed to mitigate some of the disadvantages of the Employment Sponsored Insurance scheme previously implemented in the United States; and this is the first study to investigate the impact of this form of private health insurance on access to medical care, in a country such as Saudi Arabia. The main aim of the study was to explore the influence of health insurance on access to medical care, in order to assist the Saudi Government in their deliberations about making CEBHI compulsory for all people (citizens and expatriates) within Saudi Arabia. This aim was investigated through the following objectives: 1) to review health financing in Saudi Arabia and compare it with other GCC countries and elsewhere in the world; 2) to compare the access to medical care of insured and uninsured expatriates in Saudi Arabia; 3) to develop a framework for understanding the complex relationship of health insurance and access to healthcare, 4) to make policy-relevant recommendations regarding the key question as to whether compulsory health insurance in Saudi Arabia should be expanded. Methods: Two methods were used to tackle the study objectives. Firstly, a framework for country-level analysis of healthcare financing arrangements was used to compare and analyse the national expenditure on healthcare within the GCC and other developing/developed countries. Secondly, a logistic regression analysis of data from a cross-sectional survey was undertaken to investigate the impact of health insurance on access to medical care, considering the main workplace and personal characteristics of the expatriates. Three access measures, access to usual medical care (Access 1), inability to access medical care (Access 2), and utilization of medical care (Access 3), were used to evaluate access to medical care for the expatriate population. Prior to the implementation of CEBHI the expatriate population accessed medical care through a variety of different avenues. These modes of access were used as classification of the expatriate population into four groups. Two of these groups were insured but had a different Previous Method of Paying for Healthcare (PMPHC) (Group B=insured, not paid, and Group D=insured and paid) and two groups were not insured but also had different PMPHC (Group A=not insured, not paid and Group C=not insured, but paid). A multistage stratified cluster sampling was used, and a sample selected from each sector and company size proportionately. The total sample size was 3,278. A simple conceptual framework for studying access to medical care was developed to guide the multi-variate regression techniques, and greatly assisted interpretation of the results. Results: The GCC characteristics impact on the healthcare financing strategies of GCC countries in three ways. First, GCC governments provide the majority share of the health budget, similar to high-income countries. Second, GCC countries use different strategies to control expatriates costs, but some of these strategies lead to increased out-of-pocket expenses, which is a characteristic of low-income countries. Third, health care financing systems in GCC countries are still being developed as they finance most of their public services, including health care services, with revenue from natural resources (i.e. oil or gas). Additionally, some of their health care indicators are identifiable with those from below upper-middle income countries. In addition, after CEBHI, private expenditure did not change but remained around 22.4%, which does not reflect the huge number of people having access to medical care though private sector only. However, there was a shift in the means of private sector expenditure from Out Of Pocket payments to private insurance expenditure. OOP expenditure decreased from 32.3% in 2006 to 28.4% in 2008, and private insurance expenditure increased as a percentage of private sector expenditure from 26.2% in 2006 to 36.7% in 2008. Analysis of the data from the survey demonstrates that health insurance is strongly associated with access to medical care, as measured by the three different access measures). Compared to uninsured workers, being enrolled in CEBHI increased the possibility of an expatriate’s access to usual medical care and utilisation of medical care by more than 10 (8.709-12.299, 95%), and 2.3 (1.946-2.750, 95%) respectively. However, the influence of PMPHC is greater than the influence of insurance alone on reducing the inability to access medical care (health insurance reduced the inability to access medical services by 42% (0.515-0.995, 95%), whereas PMPHC reduced the inability to access medical services by more than 65.% (0.273-0.436, 95%)).Therefore, the impact of health insurance on access to medical care is much greater for those expatriates previously having had healthcare costs met by their employer, than for those who had not. These impacts remained, when the odds ratios were adjusted for both workplace and personal characteristics. Conclusion: CEBHI has a clear positive impact on reducing out of pocket payments and increasing private insurance expenditure. However, overall, private healthcare expenditure has increased insignificantly. This indicates that the main impact of CEBHI on private expenditure, is the change in the mode of payment from out of pocket payments to private insurance expenditure. However, the actual impact on private sector expenditure is still minor. Access to medical care is influenced by health insurance. In addition, it is also influenced by PMPHC as a contributory role to play in the influence of health insurance on access to medical care. Workplace and personal characteristics play a small part in mediating the influence of health insurance on access to medical care. A framework was developed for understanding the complex relationship of health insurance and access to healthcare, which will be useful for further investigations regarding the influence of health insurance on access to medical care. Both long and short-term recommendations are proposed for increasing the expatriate population’s access to medical care, whilst reducing the burden on healthcare financing.

This thesis documents the development and evaluation of an mHealth intervention for sexual and reproductive health (SRH) referral from drugstores to health facilities in Mwanza Tanzania. SRH is an important factor for human development. Over the last 2 decades, provision and accessibility to SRH services has benefited from international and national health promotion interventions. In developing countries, use of close to community providers (CTC providers), such as village health workers, has been a key component of health promotion. This has been especially true in Tanzania where up to 70% of formal primary health care facilities lack health staff. CTC providers have been promoted through international initiatives such as the World Health Organization’s (WHO) task-shifting initiative. WHO’s recognition of CTC providers ranges from cadres at the grassroots level such as village health workers and drugstores to formal auxiliary providers based in health facilities, such as medical aides and nurses. In Tanzania, drugstores provide a range of SRH services ranging from simple advice on how to use a condom to complex prescriptions of antibiotics for STI treatment. Evidence has shown that drugstores – though more likely to have health-related training than any other informal CTC providers – lack skills necessary for provision of SRH services. This may contribute to poor SRH outcomes, such as increase in prevalence of sexually transmitted infections (STIs)/human immunodeficiency virus (HIV) and antibiotic resistance. Accessing SRH services at the formal health facility level is key to improving these outcomes. To create SRH service linkages and integration between drugstores and health facilities in Mwanza, Tanzania, an intervention that pioneered an mHealth SRH referral from drugstores to health facilities was designed and implemented for 18 months from September 2012 to February 2014. Referral between these two SRH providers using mHealth tools had not been attempted before. The intervention provided an electronic platform accessible to 52 drugstores and 18 health facilities in two districts of Mwanza region. Through a toll-free number and password, drugstores referred patients with SRH conditions to health facilities using the text-messaging feature on their mobile phones. From the platform’s in-built data collection tool, SRH uptake data demonstrated that 38% of patients referred from drugstores accessed HIV, STIs, family planning and maternal health services at the health facility level. A follow-up randomised household survey found that 72% of the participants would accept such type of referral in future, and among those who had ever visited drugstores for SRH services, 15% had heard about the intervention. At the end of the intervention, drugstores and health facilities confirmed that it was beneficial to their SRH service provision and that they would like to continue implementing it. In conclusion, this text messaging intervention pioneered community referral from drugstores to health facilities for SRH treatment by using mobile phones which appeared to be acceptable and effective in Mwanza Tanzania. With the growing use of mobile phones in Africa and the need to provide SRH services beyond the Millennium Development Goals (MDGs) era, mobile phone-based community referral through CTC providers, such as drugstores, could make an important contribution to achieving Universal Health Coverage targets.

Call number: LD2668 .T4 1925 D598 / Master of Science

"This investigation is a study of the health status of students, upon arrival and during their subsequent four years at Florida State University, for the purpose of determining the nature and extent of illness and injuries experienced by them from academic year to year as compared with their medical status upon arrival"--Introduction. / Typescript. / "January, 1956." / "Submitted to the Graduate Council of Florida State University in partial fulfillment of the requirements for the degree of Master of Science." / Includes bibliographical references (leaves 50-51).

This thesis examines issues related to cervical cancer epidemiology and prevention through screening, with the aim of informing policy regarding setting up an organised cervical screening programme in Hong Kong. There are five studies described here. The first, a case control study, indicated that screening is effective in preventing invasive cervical cancer among Chinese women. In addition, the main risk factors identified in other studies, were confirmed as risk factors in this population. Secondly, a cross-sectional study examined the pattern of cervical screening in Hong Kong. The screening system at that time achieved poor coverage, was inefficient, inequitable and potentially harmful. Thirdly, a cross-sectional study of practitioners showed the diversity in provision of services and the lack of consensus among practitioners in the management of abnormal smears. Fourthly, the use of an industrial quality management technique in monitoring quality, using inadequate smear rates as an indicator is assessed. It demonstrated that this is an efficient and useful method that can be applied to monitoring a screening programme. The last study was a randomised controlled trial showing that when women are given balanced information on cervical screening, with information on both the harms and benefits, relatively fewer chose to attend. The implications of these studies in relation to setting up a screening programme are discussed.

The increasing prevalence of obesity has been accompanied by an increase in the number of individuals at the extreme end of the obesity spectrum. The detrimental impacts of extreme obesity, defined as BMI ≥ 40.0kg/m2, on affected individuals' physical and psychological health have not been fully established. Furthermore, it remains unclear whether medical and behavioural interventions are effective at facilitating weight loss for individuals with extreme obesity. The efficacy of two treatment pathways within the Heart of England NHS Foundation Trust Specialist Weight Management Service were examined, with both demonstrated to facilitate clinically and statistically significant weight loss. A detailed profile of the characteristics of individuals entering the service highlighted the substantial physical and psychological co-morbidity associated with extreme obesity, revealing widespread impairment in quality of life and mental health. A systematic review of primary research examining the efficacy of medical and behavioural weight management interventions within lesser-researched extreme obese populations demonstrated the value of medically-supported programmes and also revealed the limited body of good quality research. This thesis has enhanced current understanding of extreme obesity, and recommendations generated from this work have been made in order to improve primary research examining weight management interventions and service provision for affected individuals.

Introduction: Smoking is a major risk factor for development of serious disease and smoking cessation greatly reduces this risk. The association between smoking, smoking cessation and mental health however, is less clear-cut, therefore this thesis aimed to further investigate this association. Methods: The first part of the thesis reports a systematic review and meta-analysis of longitudinal studies to determine the difference in change in mental health between quitters and continuing smokers. The second part of the thesis reports three prospective analyses of individual level-patient data from five trials for smoking reduction treatment. The first analysis examined the association between cessation and change in mental health using propensity score matching (PSM). The second analysis examined the association between cessation and risk of psychiatric disorder using PSM. The final analysis examined the association between change in mental health after quitting and odds of relapse. Results and interpretations: Cessation was associated with improvements in mental health compared with continuing smoking; there was no association between cessation and risk of psychiatric disorder, and no association between change in mental health after cessation and future relapse. Results support the misattribution hypothesis, and have implications for future research, smoking cessation treatment and public health policy.

Introduction: Obesity has been recognized as a major public health problem worldwide that requires preventive action. Prevention is best targeted at children, there is lack of quantitative and qualitative research on obesity prevention in children and most have been conducted in western countries. The aim of this study is to describe the prevalence of obesity among 6-7 years old school children, investigate contributing factors and identify potential components for an intervention programme to prevent obesity amongst children in the State of Qatar. Methods The study consisted of two distinct parts: cross sectional survey and focus groups with a range of stakeholders. Results: Whilst there was a high prevalence of overweight and obesity 16%, underweight was also prevalent (21.7%). The results of the focus group discussions indicate that causes of childhood obesity are multifactorial, and a multi-sector approach to prevention would be acceptable. Some of the important barriers that need to be considered in developing interventions were highlighted. Conclusion: In Qatar there is coexistence of underweight and obesity in primary school children. Qualitative results suggest that a multi-sector approach to prevention would be acceptable toward dietary and physical activity, and suggested potential components for an intervention programme in preventing obesity amongst children in the State of Qatar.

The research investigated: (i) potential missed opportunities for primary prevention of stroke and transient ischaemic attack (TIA) with pharmacotherapy through a retrospective case series analysis and (ii) fatigue, psychological and cognitive impairment following TIA through a systematic review and retrospective cohort study. The case series and cohort studies used electronic primary care medical records from The Health Improvement Network (THIN). The case series analysis found preventative drugs were under prescribed to people with clinical indications for these drugs prior to stroke or TIA. There were potential missed opportunities for prevention in 49% (7,836/16,028) of people with stroke or TIA who were eligible for lipid lowering drugs, 52% (1,647/3,194) for anticoagulant drugs and 25% (1,740/7,008) for antihypertensive drugs. Improving prescription of these drugs has the potential to reduce the incidence and subsequent burden of stroke and TIA. The systematic review revealed there were few high quality studies investigating residual impairments in people with TIA and minor stroke; however, there was limited evidence to suggest a relatively high prevalence of cognitive impairment and depression post-TIA and minor stroke. The retrospective cohort study found that TIA patients were significantly more likely to consult in primary care for fatigue, psychological and cognitive impairment compared to matched controls. This association remained when adjusted for the potential confounding variables and the presence of the impairment prior to TIA. These findings suggest that impairments exist after initial symptoms of TIA have resolved and challenge the ‘transient’ characterisation of TIA. Residual impairments should be considered by primary care clinicians when treating patients following TIA.