<p><strong>Introduction:</strong> The HIV/AIDS epidemic continues to claim millions of lives worldwide. Africa alone represents the majority of HIV/AIDS cases, where the young aged 16-30, are at greatest risk. In Ethiopia, the research suggests that knowledge of HIV transmission and positive attitudes among post-secondary students are decreasing. The purpose of this research is to explore the knowledge and attitudes of HIV/AIDS among post-secondary students in a southern Ethiopian city.</p> <p><strong>Methods:</strong> A cross-sectional study was conducted among 227 college and university students. The AIDS Attitude Scale and the HIV Knowledge Questionnaire were used to measure participants’ knowledge and attitudes on HIV/AIDS. Descriptive statistics, t-test, correlation and regression analysis were used for analysis.</p> <p><strong>Results:</strong> The results from the HIV Knowledge Questionnaire revealed lower knowledge on the various sexual modes of HIV transmission. The t-test demonstrated no difference between male and female HIV knowledge scores (t=0.6, df =225, p=0.4). The correlation analysis indicated a significant negative relationship between HIV knowledge scores and avoidant AIDS attitude scores (r=-0.2, p<0.01). The linear regression demonstrated for every one unit increase of AAS avoidant scores, HIV knowledge scores decreased 0.7 units (p<0.01); suggesting that students who scored higher in negative attitudes, achieved lower scores on HIV knowledge levels.</p> <p><strong>Conclusion:</strong> The study findings demonstrate the call to address this knowledge gap among a known population vulnerable to risky sexual behavior. Future research is needed such that HIV/AIDS awareness campaigns can be specifically tailored to the student population within the Ethiopian context.<strong> </strong></p> <p><strong> </strong></p> / Master of Science in Nursing (MSN)

Chronic noncommunicable diseases (NCDs) are the largest contributor to mortality rates worldwide including in low- and middle- income countries (LMICs) which already suffer from high rates of infectious disease. Among the four major NCDs that cause 38 million deaths annually, cardiovascular disease (CVD) causes 17.5 million of these annual deaths. The primary risk factor of CVD is hypertension. Kenya, a developing country in Sub-Saharan Africa, has a high rate of hypertension with low (2.6%) management rates. Prior research from our lab has identified a population of Kenyans with a high prevalence of hypertension that is not statistically correlated with typical known risk factors such as obesity, hypercholesterolemia, and behaviors of smoking and lack of exercise. This study investigated the hypothesis that high dietary salt consumption and low K+ dietary intake are contributing to the etiology of high blood pressure in this community. To test our hypothesis, two spot urine samples representing nocturnal excretions (evening and morning) and blood pressure measurements were collected from 135 participants. All samples were analyzed for Na+, K+ and Cl- content using the Smartlyte Electrolyte Analyzer. The average of each spot urine sample was extrapolated to an estimated 24-h value by the method of Mills, et al. The overall population mean urine electrolyte excretion values for Na+, K+ and Cl- were 170.6 ± 89.3 mmol/L, 82.0 ± 54.0 mmol/L, and 87.7 ± 42.1 mmol/L, respectively. While these values fall within the suggested levels for Na+ (40-220 mmol/L) and K+ (25-125 mmol/L), they are under normal excretion levels for Cl- (110-250mmol/L). Overall ion excretion was higher in females than males, although only K+ values were statistically significant (p < 0.05). Analysis of Na+ and Cl- excretion from individuals stratified by blood pressure, revealed significant differences (p < 0.05) between normotensive and hypertensive stage I individuals for both electrolytes (57.9 mmol/L vs. 88.9 mmol/L and 65.5 mmol/L vs. 96.7 mmol/L, respectively). Overall, these results suggest that our sample population consumes dietary salt within a normal range and thus, the observed prevalence of hypertension likely results from other genetic and environmental factors.

Objective: The overall aim of the work is to contribute to a better understanding of the dynamics between health sector reform policies and practices as well as the factors that determine and shape the thinking about global public health; and to try out a framework for understanding the inter-linkages and interactions between the determinants for and the elements of health sector reforms and their implementation. Methods: The object of study was a contemporary phenomenon, consisting of a diverse array of interventions in many different directions and fields within a complex political, social and economic environment. It is difficult to attribute the effects of the reforms to any single intervention or to establish exact boundaries between the phenomenon and the context. Therefore, a multi-stage case study research strategy, based on the work of R.K.Yin, was chosen. The study involved two major sub-units of analysis, i.e., the macro and the micro level. Each of these involved several sub-units of analysis. The analysis of the micro level further comprised a cross-case analysis of 10 individual case studies conducted in six developing countries. Results: Clear linkages were found between the greater societal processes and the shape and results of reforms during the decade. The reforms had not been completed in any of the countries studied, but appeared to be stuck with undesired effects, lacking energy to move forward. Contributing to this was the diminishing role of the state, which bordered abdication from public health in most of the countries, leaving the drive to the market and individual demands and interests. The net effect could well be a reversal of some of the public health achievements of the past - however, it was also found that reverting to dedicated disease control programmes would not be the answer, as these were found unsustainable and undermining the health systems. Conclusion: There is a divide between libertarian and utilitarian values on the one side and communitarian and egalitarian values on the other. Thus, it is not just about public health practitioners not being good enough to implement, it is more so about what we want to achieve and what it acceptable respectively not acceptable and reaching compromises. This place the societal processes at centre-stage for public health. However, it is also about implementation, it is about how public health policy-makers and reformers can effectively dialogue and facilitate achieving consensus and translate the societal 'wants' and 'want nots' into managerial bites. Implementation becomes a process of constant adjustment and readjustment oscillating between political and technocratic levels

Chagas disease caused by the protozoan Trypanosoma cruzi is the leading cause of heart disease in Latin America. After an acute phase that typically includes few symptoms, a chronic cardiac phase occurs for many infected individuals. The progression to chronic heart disease is not fully understood in Guatemala. The objective of this study was to determine the association between T. cruzi infection and progression to Chagas heart disease in Guatemala and determine if the relation is modified according to vector predominance. Using a community-based cross-sectional approach, 813 individuals from two areas of Guatemala were included in the study: 478 (58.8%) from Jalapa and 335 (41.2%) from Chiquimula. Data including serologic evaluation, electrocardiography (ECGs) and demographics were collected to compare the degree of detectable cardiac abnormalities in infected and uninfected individuals. Overall, T. cruzi seroprevalence was 28.8%, 247 (30.4%) presented an abnormal electrocardiography and 79 (9.7%) were diagnosed as Chagas heart disease. Seroreactivity was statistically (p-value<0.05) associated with abnormal ECG, Chagas heart disease, community, age, occupation, time living in the area, knowledge of the vector, ventricular condition defects and ST-T waves changes. The age and sex-adjusted association between a positive seroreactive and abnormal ECG was higher in Jalapa OR=2.0 (CI95% 1.2, 3.1) than in Chiquimula OR=1.2 (CI95% 0.9, 1.8). These results show the high Chagas-cardiac burden in this population and support the idea that the vector predominance plays an importance role in the association and that this should be taken into account in the design of intervention for vector control.

While the health sector has attracted significant foreign aid, evidence on the effectiveness of this support is mixed. This dissertation examines the allocation of health aid within the context of placement, service utilization, and benefit. The first paper examined the sub-national allocation of Chinese development aid projects across Africa. I determined how political preferencing of Chinese aid specifically, allocating aid to the birth region of the current political leader differs across sectors such as health, education, and transportation. I find some evidence that aid, more broadly defined, is subject to political preferencing in recipient countries, which could potentially limit its intended effects. The second paper examines the influence of health aid on malaria service utilization in Malawi. It tests the hypothesis that health aid boosts a facility’s readiness to provide malaria services, thereby increasing the utilization of malaria services in a facility’s service area. Findings indicate that while increased health aid is associated with increased health facility readiness to diagnose malaria, these improvements are not generally related to increased health care utilization. The final project focuses on population level health effects of health aid placement in the Democratic Republic of the Congo, specifically whether all‐cause child mortality is lower in regions receiving malarial aid interventions. Among the most promising evidence xi found on the potential benefit of health aid is that investments, such as malaria bed nets, are associated with reductions in child mortality, particularly in rural settings and among those with low malaria burden. These latter findings suggest health aid should be carefully targeted and should consider local disease risks to fully realize the benefits of population‐level improvements in child health. When taken together, my findings indicate that health aid is positively associated with limited improvements in health outcomes. Overall, these results support a need for researchers to avoid the temptation to aggregate aid flows and health outcomes at the country level, and instead examine sector‐specific aid flows at the lowest sub-national geographic unit possible in order to inform policies designed to allocate health aid.

Tobacco use is responsible for five million deaths annually and is one of the leading causes of preventable death worldwide. Many smokers initiate smoking behavior during adolescence. Adolescent smoking rates have been on the rise and there are a variety of different factors that contribute to the initiation of smoking behavior. While the World Health Organization (WHO) and the National Cancer Institute (NCI) have endorsed the claim that smoking in movies increases adolescents’ risk of initiating smoking, few studies have examined the impact of media on adolescent smoking in China following the expansion of transnational tobacco companies. The aim of this thesis is to compare the impact of entertainment media (movies, television programs, and music) on tobacco use among adolescents in both the United States and China. Using data from the China Seven Cities Study (CSCS), this thesis examined the impact of media on cigarette smoking among Chinese adolescents, as well as the relationship between smoking and Chinese adolescents’ preference for media from China, other Asian countries, and the U.S. Conducted in 126 middle- and high schools in seven major Chinese cities, the CSCS utilized student and parent surveys to gather information on the following measurements: Ever smoked, 30 day smoking, whole cigarette smoked, and daily smoking; origin of favorite movies, TV shows, and music; perceived stress, hostility, depression, and quality of life. These data indicated that Chinese adolescents who preferred forms of entertainment media from the U.S. or more developed nations of Asia were more likely to initiate tobacco use and experience depression, stress, and hostility than adolescents who preferred forms of entertainment media from China. As China develops and tobacco marketing continues to infiltrate Chinese society, these results suggest that Chinese adolescents will be at a higher risk for tobacco use and tobacco related disease. This thesis analyzes the global impacts of adolescent tobacco use and provides suggestions for future tobacco control campaigns for adolescents in China.

Focusing on the 1851 International Sanitary Conference, this dissertation analyses an important episode in the international regulation of health, trade, passengers, and cargo in a period of epidemic crisis. It argues that a group of diplomats and physicians appointed to represent 12 European nations instituted a new international forum that extended – and occasionally rivalled – national and local agencies for epidemic governance. Together, delegates endeavoured to establish a common sanitary policy in Europe and in the Orient. By creating shared surveillance and judicial mechanisms – while standardising definitions and practices – delegates aimed to engineer the flow of people, vessels, cargo, and diseases in the Mediterranean region. As a transnational forum, the Conference was a platform where doctors and diplomats reinterpreted models of public health and sanitary administration while creating institutions that challenged conventional concepts of borders, national policy, and state sovereignty. As a multinational event, the Conference marked the unprecedented transition from local, national and, bilateral public health policies into a coherent transnational project for the governance of epidemics. The dissertation is based on extensive research conducted in hitherto largely unexplored medical, diplomatic, and national collections in Britain, France, Italy, Portugal, Spain, and the United States of America. Sources ranging from diplomatic correspondence to medical publications and personal diaries, tie together multiple national and professional perspectives while untangling a diversity of personal and state agendas that fundamentally shaped the foundation of international public health mechanisms and contributed towards the crystallisation of medical concepts. Chapter one demonstrates how economic and political concerns about the impact of quarantine on international trade led to calls for international regulation and the standardization of quarantine practices in the Mediterranean region. Drawing on medical reports, pamphlets and diplomatic correspondence, the chapter exposes the multitude of quarantine practices in the Mediterranean region and a growing international demand for prophylactic reform. These exchanges, it is shown, culminated with the organization of the 1851 International Sanitary Conference in Paris. Chapter two argues that the Conference challenged previous diplomatic and medical protocols by including two professional groups in the process of regulating international public health. The lack of precedent allowed diplomatic and medical delegates to establish new rules for the conduct of the conference, which gave them a relatively high level of autonomy from the states they represented. Chapter three focuses on the problems of constructing a shared aetiological classification and regulating quarantine practices. It shows that, although doctors gained progressive control over the Conference, ultimately diplomatic agendas shaped the final outcome. In addition, it demonstrates that, rather than defending the elimination of quarantines, liberal states supported the continuation of quarantine practice in the Mediterranean; albeit that they managed to severely limit its operation in practice. Finally, chapter four examines how European and Oriental sanitary institutions were uniformly redesigned and new international judicial mechanisms created. These measures variously affected the sovereignty of the participating states by limiting their independent capacity to set national epidemic policies. However, the chapter argues that these negotiations took the shape of sovereignty bargains: by loosening control over specific elements of their sovereignty, states managed to advance their political, economic and sanitary agendas. By looking at the International Sanitary Conference of 1851, this dissertation shows how the foundations of international public health had consequences not only for the control of epidemic diseases and the circulation of goods and people in the Mediterranean region, but also for the authority and status of the nation states. By doing so, it reveals that international public health governance resulted from the amalgamation of a particular configuration of expert and diplomatic struggles and compromises. Moreover, the dissertation shifts the traditional local and national focus in the history of medicine to a wider and international context where local and national traditions struggled to produce coherent discourses and practices.

Underweight and stunting are highly prevalent public health problems in developing countries, particularly among populations exposed to food insecurity and chronic malnutrition. Underweight results from relatively recent malnutrition whereas empirical research has shown that early childhood malnutrition is a strong predictor of stunting. Dietary diversity has been recognized as an indicator of food security, with consumption of more food groups suggesting better nourishment. Greater dietary diversity has been associated with better nutritional outcomes and improved micronutrient intake. Zinc, an essential mineral, plays a critical role in child growth and development. A deficiency in Zinc may contribute to increased risk for stunting in childhood and adolescence. This cross-sectional study examined the independent associations between underweight, stunting, dietary diversity, and dietary intake of zinc among a sample of never-married adolescent girls (n=307) living in Kilosa District, Tanzania. Dietary, anthropometric, physical activity, morbidity and demographic data were collected. The associations between underweight (determined as weight by age less than 5th percentile of WHO reference) and dietary diversity (defined by the number of food groups consumed by adolescent girls); as well as stunting (determined as height by age less than 3rd percentile of WHO reference) and dietary intake of zinc were tested using multivariate analyses. We found that adolescent girls’ diets were largely deficient in macronutrients and micronutrients, with the mean intake of energy and protein being 810kcals/d and 21.9g/d, respectively. The rates of underweight and stunting were 16.2% and 62.2%, respectively. Greater dietary diversity was associated with decreased risk of underweight among adolescent girls, after adjusting for confounders including age, village location, school enrollment, pubertal status, socioeconomic status and energy intake, (OR, 0.55, 95%CI 0.39-0.98, p<0.05). Similarly, higher intake of zinc was found to be associated with lower risk of stunting, after controlling for age, physical activity, BMI, energy intake and individual’s dietary diversity (OR, 0.87; 95%CI, 0.76-0.99, p<0.05). In conclusion, these findings suggest that dietary diversity and nutrient intake, especially intake of zinc, may play an important role in the long-term nutritional health of adolescent girls. Longitudinal studies examining these associations in developing countries settings are needed.

Iron depletion (ID) is the most common nutrient deficiency worldwide and is the leading cause of anemia. Chronic arsenic (As) exposure is a major public health problem in Bangladesh and triggers inflammatory responses that render iron status assessment challenging. We assessed the prevalence of ID and iron deficiency anemia (IDA) in 147 arsenic-exposed Bangladeshi women (75 skin lesion cases; 72 controls), ages 18-33 years, who were part of a skin lesion study. Hemoglobin (Hb) was measured in whole blood; ferritin and hs-c-reactive protein (CRP) were measured in serum. The prevalence of anemia (Hb<120g/L) was 18%. Although the prevalence of ID (ferritin≤12mcg/L) did not differ between cases and controls, anemia was more common among cases (25% vs. 10%; p=0.02). Of anemic women, 27% (N=7) also had ID (Hb<120g/L and ferritin≤12mcg/L), indicating IDA. Women with normal iron status had higher toenail arsenic compared to iron-depleted women (2.9 vs 1.4 µg As/g toenail; p=0.00), and their water arsenic concentration was higher than that of iron-depleted women (18.8 vs 6.2 µg As/L; p=0.03); every 1µg increase in toenail As was associated with a 45% lowered risk of ID (OR=0.55, 95%CI=0.33,0.94). Much of the anemia in this cohort appears unrelated to ID, but could be linked to other nutrients, such as folate and vitamin B12, which are involved in both hematopoiesis and arsenic metabolism. It is possible that arsenic exposure in this cohort compromised folate and vitamin B12 status.

High levels of adherence have been identified as a key factor for effective pre-exposure prophylaxis medication (PrEP). Because PrEP is a new concept in HIV prevention, there are limited data on predictors of adherence, though initial findings indicate that sexual behavior could be an influencing factor. This study examines different aspects of sexual behavior and their associations with monthly rates and patterns of adherence. We enrolled 1147 HIV-negative individuals living in long-term serodiscordant relationships at three sites in Uganda. Sexual behavior was assessed via monthly in-person interviews and adherence was measured through electronic monitoring of pill bottle openings. We used generalized estimation equations to adjust for risk factors of low adherence to PrEP medication. Fifty-three percent of participants were male, 51% were aged between 18 and 34 years, the median number of years they had lived with the HIV-positive partner was 8.5 years and 24.2% were in polygamous relationships. Participants who had sex with other partners and also had less than 100% use of condoms were more than twice as likely to have less than 80% adherence (OR=2.48, 95%CI=1.70-3.62). Per electronic monitoring, 54.7% of cohort participants had at least one 72-hour consecutive gap in adherence. Participants who had sex with other partners and were also had also reported less than 100% use of condoms had a 50% increase in odds of having a 72-hour gap in adherence (OR=1.50, 95%CI=1.19-31.91). Low overall adherence and extended gaps in adherence were more common in participants that abstained from sex and those that reported sex outside their primary partnership. Despite high monthly adherence rates, many study participants had long periods of non-adherence during which they engaged in risky sexual behavior with potential for HIV acquisition.