This study investigates the role that the notions of trauma and culture play in relation to the alleviation of distress within an war-affected population. It analyses how local, cultural conceptions of distress and those held by psychological service providers relate to one another, and how they contribute to improving the well-being of the displaced. Fieldwork was conducted with urban and rural displaced populations in the south-eastern province of Huila in Angola. Ethnographic, psychometric and participatory methods were used to examine issues of health, illness and distress amongst the displaced. Local idioms of distress in the form of pensamentos, mutima, madness and high and low blood pressure are common ways of expressing suffering related to war. The different explanatory models held about these illnesses and the various resources available in the popular, folk and professionals sectors of the health care system were explored. The religious and spiritual domains were found to be influential in the treatment of distress-related illnesses. The psychological services available in the war-displaced communities were examined in terms of their common theoretical and practical elements. These were then analysed in relation to the conceptualisations held by local populations, and points of similarity and difference were noted. Specifically, the conceptualisation of suffering as trauma and the cultural misunderstandings that arise as a result of this, and the representation of the displaced as traumatised and therefore dependent and passive people, are discussed. A particular subgroup in the community, the adolescents, was identified and participatory methods were employed to investigate the strategies and resources this group uses for coping with war-related distress. The youths predominantly make use of distraction, conselho, religious and cultural resources. The application of a PTSD scale, the EARAT, suggests that 71% of the adolescents had symptoms of trauma consistent with a diagnosis of PTSD. It is argued that for the vast majority such a conceptualisation does not reflect the adolescents' abilities to function on social, vocational, educational and physical levels. The implications of these findings for research and practice in the field of psychosocial work are discussed.

Ukraine is home to one of the world‘s fastest growing HIV epidemic and has received significant amounts of foreign aid to help it tackle the crisis. This study is an enquiry into the implementation of the Global Fund against AIDS, Tuberculosis and Malaria (GFATM) programmes in Ukraine, during the second decade of this country‘s post-Soviet economic and political transition. The discussion is positioned within a broader debate on aid effectiveness. By looking at the GFATM as an aid institution whose establishment was purported to improve the aid delivery process, the thesis offers a critical insight on the GFATM aid delivery model in the context of Ukraine. The thesis investigates the conduct and practice of INGO and national NGOs in their role as Principal Recipients of GFATM grants targeting HIV prevention in Ukraine. Based on ethnographical enquiry conducted in three oblasts in Ukraine, and in capital Kyiv, the thesis aims to understand how NGOs have implemented HIV prevention services in context of state-owned health care system and to determine the perceived effects of the GF programmes on the ground. The thesis situates analysis of NGOs into a broader socio-political context of post-Soviet Ukraine and questions their role as central actors in delivering essential HIV programmes in parallel with or instead of the state, as well as the consequences for sustainability of such programmes. Using the particular experience in Ukraine, the thesis shows the influence of global funding institutions on relationships between state and civil society and altering of civil society‘s roles in aid programmes. The thesis includes a comprehensive literature analysis about the Global Fund and other donor programmes working in Ukraine in the area of HIV/AIDS.

Immunization has been used as an upstream, protective measure in public health for decades. Although immunization programs have been introduced in Pakistan, new and emerging infectious disease remains a concern in the country. The province of Sindh, Pakistan is of special concern because of its large rural population.<p>The purpose of this study was to: 1) determine and compare complete and age-appropriate immunization uptake in children 12 to 36 months and birth to 9 months, respectively living in Sindh, Pakistan in 1994 and 1997; and 2) determine the correlates of complete and age-appropriate immunization in children 12 to 36 months and birth to 9 months, respectively living in Sindh, Pakistan in 1997.<p>This study reviewed data that was collected as part of the School Nutrition Program (SNP) and Family Health Project (FHP) in 1994 and 1997, respectively. Analyses included immunization data on 1877 children from the SNP survey and 1694 children from the FHP survey.<p>Females were found to have higher statistically significantly age-appropriate uptake than males in 1997 (p=0.015). Complete immunization status was also found to vary significantly by district of residence in 1994 and 1997 (p<0.001). Both complete and age-appropriate immunization status was found to decrease from 1994 to 1997.<p>Multivariable logistic regression revealed that not owning a radio, electricity, or bicycle was indicative of lower odds of complete immunization uptake (OR<1, p<0.05). Other correlates predictive of lower odds of complete immunization included owning a water pump (OR=0.360), not having a Lady Health Worker (LHW) visit the home (OR=0.489), living in a kucha house (OR=0.637), and living in Tharparkar (OR=0.290), Badin (OR=0.599), or Mirpur Khas (OR=0.271).<p>A similar regression analysis revealed childs sex, ownership of a refrigerator, and having heard of contraception to be correlates of age-appropriate immunization (p<0.05). Females had higher odds of age-appropriate immunization (OR=1.851) compared to males. Not having a refrigerator was indicative of lower odds (OR=0.079). Not having heard of at least one type of contraception was a predictor age-appropriate immunization (OR=1.925).

Immunization has been used as an upstream, protective measure in public health for decades. Although immunization programs have been introduced in Pakistan, new and emerging infectious disease remains a concern in the country. The province of Sindh, Pakistan is of special concern because of its large rural population.<p>The purpose of this study was to: 1) determine and compare complete and age-appropriate immunization uptake in children 12 to 36 months and birth to 9 months, respectively living in Sindh, Pakistan in 1994 and 1997; and 2) determine the correlates of complete and age-appropriate immunization in children 12 to 36 months and birth to 9 months, respectively living in Sindh, Pakistan in 1997.<p>This study reviewed data that was collected as part of the School Nutrition Program (SNP) and Family Health Project (FHP) in 1994 and 1997, respectively. Analyses included immunization data on 1877 children from the SNP survey and 1694 children from the FHP survey.<p>Females were found to have higher statistically significantly age-appropriate uptake than males in 1997 (p=0.015). Complete immunization status was also found to vary significantly by district of residence in 1994 and 1997 (p<0.001). Both complete and age-appropriate immunization status was found to decrease from 1994 to 1997.<p>Multivariable logistic regression revealed that not owning a radio, electricity, or bicycle was indicative of lower odds of complete immunization uptake (OR<1, p<0.05). Other correlates predictive of lower odds of complete immunization included owning a water pump (OR=0.360), not having a Lady Health Worker (LHW) visit the home (OR=0.489), living in a kucha house (OR=0.637), and living in Tharparkar (OR=0.290), Badin (OR=0.599), or Mirpur Khas (OR=0.271).<p>A similar regression analysis revealed childs sex, ownership of a refrigerator, and having heard of contraception to be correlates of age-appropriate immunization (p<0.05). Females had higher odds of age-appropriate immunization (OR=1.851) compared to males. Not having a refrigerator was indicative of lower odds (OR=0.079). Not having heard of at least one type of contraception was a predictor age-appropriate immunization (OR=1.925).

A mix of economic interests, humanitarianism, and political concerns over future regional security and stability drove twentieth century attempts to counter indigenous morbidity and depopulation in the Pacific. However, chronic under-resourcing impeded colonial health developments. An opportunity for change came in 1913, when the International Health Board of the Rockefeller Foundation negotiated with the British Colonial Office for joint programmes to control hookworm disease in Britain's tropical dependencies. After surveying the health situation and potential for work in the Pacific region in 1916, a short-lived campaign followed in Fiji (1917-1918). The American philanthropy then focused on Australia, where co-operative hookworm programmes advanced the objectives of the Foundation and increased Federal involvement in public health while and also served the interests of "White Australia". Under Dr. Sylvester Lambert, work in the Island Pacific resumed in 1920, to promote the health and economic viability ofindigenous labour in the Australian territories of Papua and New Guinea. Plantation interests supported survey and treatment work in the British Solomon Island Protectorate, and in 1922 the Fiji campaign re-opened. Lambert expanded the International Health Board's involvement from initial hookworm survey and treatment programmes in the British and New Zealand dependencies in the South Pacific, into other aspects of public health and medical services: water supplies and latrines; a bacteriological laboratory in Suva; hospital expansion; and medical education. Integrating local initiatives, Lambert advocated a Unified Pacific Medical Service, in which key elements were centralisation., rationalisation and affordability. The most radical aspect of his plan was the development of a Central Medical School for the Pacific territories, to provide targeted professional training for indigenous medical practitioners who had a crucial (although still subservient) role in economic service delivery and the diffusion of biomedical understanding among local communities. Also controversial - and Jess successful - were attempts to improve the career opportunities and standard of European Medical Officers, by creating a single medical service for the British Pacific dependencies. Attempts to achieve these goals influenced the shape and outcome of health and medical services which developed in the different island communities by 1939, when Lambert's retirement signalled an end to active Rockefeller Foundation involvement. This thesis examrnes the ways in which colonial administrations, medical staff, the Rockefeller Foundation, labour and mission interests, and Pacific Islanders interacted in the introduction of the dramatically new medical concepts and practices of western science (and specifically tropical medicine) and their effect on indigenous populations.

Adult women are disproportionately burdened by overweight and obesity in Sub-Saharan African (SSA) countries and there is limited understanding of the sociocultural context of this problem. In this qualitative research synthesis, we aimed to surface contextual influences that potentially predispose adult women and adolescent girls to overweight and obesity. PubMed, CINAHL, PsychInfo, PROQUEST, EMBASE, Web of Science were searched to locate qualitative research articles conducted in sub-Saharan African countries beginning in year 2000. After assessment for eligibility and critical appraisal, 16 studies were included in the synthesis. Textual data and quotes was synthesized using the methods proposed by the Joan Briggs Institute and a thematic analysis framework. The synthesized studies were conducted in South Africa, Ghana, Kenya and Botswana. The three overarching themes across these studies were body size and shape ideals, barriers to healthy eating, and barriers to physical activity with cultural and social factors as cross-cutting influences within the major themes. Culturally, the ideal African woman was expected to be overweight or obese, and voluptuous and this was associated with their identity. While overweight and obesity was not acceptable among adolescent girls, they also desired to be voluptuous. Healthy food choices among women and girls were hampered by several factors including affordability and peer pressure. Both adult women and girls experienced ageism and institutional discrimination as barriers to physical activity. This is the first qualitative research synthesis to amplify the voices of women and girls in SSA countries highlighting the challenges they face in maintaining a healthy weight. Sociocultural, institutional and peer-related factors were powerful forces shaping body size preferences, food choices and participation in physical activity. Our study findings provide insights for the design of contextually appropriate interventions and lay the foundation for further research studies.

Introduction: Toxoplasmosis is caused by infection with the protozoan Toxoplasma gondii (T. gondii), an obligate intracellular parasite. T. gondii infects a large portion of the world’s population, but uncommonly causes clinically significant disease. Those that are at greatest risk for more severe disease with toxoplasmosis are the immunologically impaired, fetuses, and newborns. T. gondii infection in immunocompetent patients can present as a self-limiting acute infection, or as an acute systemic disease. There are three main T. gondii genotypes, I, II, and III, with varying geographical prevalence. T. gondii is most commonly acquired via ingestion of infectious oocysts, from the environment, tissue cysts from contaminated food items, vertical transmission, or via organ transplantation from an infected donor. Diagnosis can be made via histological and serologic testing in suspected patients. Seropositive testing should be considered within the clinical context, as IgM antibodies may persist for months to years. IgG antibody avidity patterns further help delineate acute versus chronic infections. Histopathology from tissue biopsy of lymphadenopathy is more commonly pursued to establish diagnosis in immunocompetent patients. Case Report: We present a 37-year-old male who presented to the clinic with persistent bilateral non-tender occipital lymphadenopathy of two months duration. Patient also endorsed an acute fluid filled blister on the penis, recurrent cold sores, and significant fatigue. Review of systems were unremarkable. Patient’s immunizations were up-to-date. Patient is an active military serviceman with history of overseas deployment. Patient reports consuming undercooked meat overseas, as well as game meat preparation while hunting. Similar symptoms were also reported by another fellow veteran. Laboratory studies revealed normal CBC, CMP, and TSH. HIV, gonorrhea, and chlamydia testing were negative. Urology referral found no abnormalities. Aspiration biopsy of the right occipital lymph node demonstrated granulomas and aggregates of histiocytes compatible with reactive hyperplasia. Findings were suggestive of toxoplasmosis and no malignancy was found. Follow up T. gondii serological testing results revealed Ab IgM: 104 AU/ML (reference range 0.0-7.9). Toxoplasma gondii Ab IgG: >400 AU/ML (reference range 0.0-7.1), which were consistent for active infection. Patient was referred to Infectious Disease and supportive therapy was recommended. A three month follow up showed improvement in symptoms. Discussion: Although acute infections with T. gondii in immunocompetent patients typically are self-limiting, more serious systemic infections may occur. A pyrimethamine-containing antibiotic regimen is recommended for treating systemic infections. We propose educating high-risk individuals with appropriate preventive measures, which may be beneficial in preventing Toxoplasmosis.

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.

The protection of human health and the environment are two major goals of international environmental law. However, there has been little coherent scrutiny of their scope or implementation at international and domestic levels in developing countries and Africa in particular. This thesis shows that international environmental law regimes with a health protection objective have not maximized opportunities to reinforce the promotion and protection of public health in Africa. Through inter alia a study of sustainable management of shared freshwaters, trans-boundary movement of hazardous wastes and their disposal and international climate law, the thesis shows that a range of legal frameworks comprised of substantive, institutional and procedural law mandates States to advance the health objective in international environmental law. However, the thesis demonstrates the limits of these regimes and suggests options to enhance their potential in promoting and protecting public health. An enhanced framework of adaptive governance is proposed to improve environmental health governance. The thesis illustrates how the discourse on health in international environmental law can strengthen international environmental health governance to improve environmental and public health outcomes. It contains seven publications that analyse the strengths and weaknesses and options for reform of the international environmental law regime for health. The implications of these findings for theory, practice and public policy are discussed.