Malaria continues to be a challenging problem in the developing world, and the burden of this life threatening disease continues to be borne by young children living in Sub Saharan Africa. One of the biggest challenges to the prevention and control of this problem lies in accurately diagnosing malaria, and distinguishing it from the many other febrile illnesses which present in children in this age group. Liberia is a West African country with a high burden of malaria. Very little is known about the presentation of severe malaria in children aged 5 years old and younger in Liberia. We undertook a prospective, hospital -based study of children 5 and under presenting to JKF Medical Center, the national referral hospital, with fever and signs and symptoms consistent with malaria. The aims of our study were to determine: 1) the frequency of confirmed malaria cases, 2) the frequency of non-malaria diagnoses, 3) the prevalence of anti-malarial drug resistance mutations, 4) the presence of other life threatening etiologies of febrile illness such as S. typhii and Dengue virus and 5) immunological profiling associated with severe malaria. We analyzed clinical and laboratory data from 462 children age 5 and under who presented to the national referral hospital in Monrovia, Liberia with signs and symptoms consistent with malaria over a one year period. Key findings included determining the demographic factors most closely associated with severe malaria in this population (age > 1yr and urban environment) and those that were negatively associated with the development of severe malaria (prior episodes of malaria, use of bednets and use of anti malarial medications prior to presentation). The clinical symptoms most closely associated with severe malaria in this population were found to be headache and vomiting. We found that 33% of children admitted and treated for severe malaria did not test positive for malaria by rapid diagnostic testing (RDT) or blood smear. These children had a case fatality rate that was 5 times higher than their RDT positive counter parts. Of the RDT negative children, 2 tested positive for salmonella typhii, but were not treated for this pathogen. Upon discharge from the hospital, 11% of children had resolved their symptoms, but had not cleared their malaria parasites. These findings will help to identify the children who present with true severe malaria in Liberia. They also underscore the need to expand diagnostic capabilities to determine which other types of pathogens cause febrile illness in this population, so that adequate treatment can be extended to these patients. The immunoprofiles of these children revealed 3 IgM antibodies (AMA-1, CSP and LSA-1) that were associated with the development of severe malaria. These antibodies also appear to be associated with initial infection with malaria. Such data will help to identify antigens could be potential targets for malaria vaccines, and which can play an important role in the development of new malaria diagnostics for this population.

The burning of biomass for cooking purposes without proper ventilation and filters poses a massive health and climate risk. Health implications from exposure to household air pollution from this type of fuel impacts women and children in many developing countries, who spend many hours a day cooking and gathering fuel. Climate implications from burning solid biomass results in increased carbon dioxide and black carbon emissions, which contribute to global climate change. This thesis aims to explore the issues associated with biomass cookstoves in terms of both health and climate, and seeks to understand how a new national clean cookstove program could be funded in India. This includes potential partnerships with United States agencies, nonprofit organizations, and other international funding sources. The topic of clean cookstoves has gained traction as a strategy to mitigate emissions and adapt to a changing climate, and with the recent passing of the United Nations Paris Agreement, funding is increasing to support programs that address climate impacts.

A comparison of the structure and effectiveness of recovery ecosystems for opioid use disorder in Portugal and Appalachia, with a focus on identifying areas for improvement within the Appalachian region.

Vitamin D deficiency is of particular concern among women in many south Asian countries due to low availability of vitamin D-rich foods, dark skin pigmentation, and cultural and religious practices that promote the wearing of concealing clothing. However, information regarding the vitamin D status of many subpopulations in south Asian countries is limited. The current study was conducted to assess the vitamin D status of 147 Bangladeshi women of reproductive age and determine whether vitamin D status influences susceptibility to arsenic-associated skin lesions (75 cases, 72 controls). Serum 25(OH)D3 levels were measured using a radioimmunoassay. The mean serum vitamin D level among the women in the current study was 60.1 nmol/L, which is well below the cut-off value of 75 nmol/L defining optimal vitamin D status. Over 81% of the women were below this cut-off value. Vitamin D status was not influenced by the presence of arsenic-associated skin lesions. Sun exposure and very low egg consumption were factors identified as significant predictors of vitamin D status (p<0.05, p<0.04, respectively). Every additional hour of sun exposure per week during work was associated with a 0.32 nmol/L, on average, increase in serum vitamin D levels. Very low egg consumption corresponded to a 10.85 nmol/L lower serum vitamin D level compared to frequent egg consumption. Public health efforts in Bangladesh should promote increased consumption of food sources rich in vitamin D. Vitamin D fortification or supplementation may also be viable options to improve the vitamin D status of the population.

Adult women bear a disproportionate burden of overweight and obesity in Sub-Saharan Africa (SSA). Precise information to understand disease distribution and assess determinants is lacking. Therefore, this dissertation aimed to: (i) analyze the prevalence of adult female overweight and obesity combined in lower-level administrative units; (ii) analyze the effect modification of educational attainment and age on the association between household wealth and adult female overweight and obesity; (iii) synthesize qualitative research evidence to describe contextual factors contributing to female overweight and obesity at different life stages. Bayesian and logistic regression models were constructed with Demographic and Health Survey (DHS) data to respectively estimate the prevalence of overweight and obesity and assess the interaction of education on the association between household wealth and overweight. The synthesis of qualitative research studies was conducted in accordance with PRISMA guidelines and findings were grouped by themes. Prevalence estimates revealed heterogeneity at second-level administrative units in the seven SSA countries examined, which was not visible in first-level administrative units. The combined prevalence of overweight and obesity ranged from 7.5 – 42.0% in Benin, 1.4 – 35.9% in Ethiopia, 1.6 – 44.7% in Mozambique, 1.0 – 67.9% in Nigeria, 2.2 - 72.4% in Tanzania, 3.9 – 39.9% in Zambia, and 4.5 - 50.6% in Zimbabwe. Additionally, education did not have a statistically significant modifying effect on the positive association between household wealth and overweight in the 22 SSA countries eligible for the study. Body shape and size ideals, barriers to healthy food choices and physical activity were key themes in the research synthesis encompassing four SSA countries. Positive symbolism, including beauty, was linked to overweight and obesity in adult women. Among adolescents, although being overweight or obese was not accepted, girls were expected to be voluptuous. Body image dissatisfaction and victimization characterized the experiences of non-conforming women and girls. Barriers to healthy nutrition included migration and the food environment. Whereas, barriers to physical activity included ageism. While additional work is encouraged to validate the prevalence estimates, overweight and obesity interventions must consider whether the determinants identified in this study are relevant to their context to inform improved outcomes.

The HIV/AIDS pandemic is currently one of the most pressing world-wide concerns regarding the health and well-being of our global population. Due to the lack of a cure, recent efforts have focused on prevention measures for the disease. HIV prevention, particularly with the youth population, has spawned creative programs, such as the use of sport as an educational tool to equip youth with the skills to avoid contracting HIV. Due to the potent effect sport-for-development efforts exhibit on both individual and cultural level change, it can be assumed that HIV prevention sport-for-development programs are worth maintaining. Within the use of sport-for-development programs comes the problem under investigation: the need to establish a uniform method from which to evaluate HIV sport-for-development program effectiveness- specifically in regards to cultural relevance, level of community ownership, and sustainability through partnership resources. In order to address this problem, this analysis used qualitative content analysis to examine the promotional documents of three best practice football-for-development organizations- Grassroot Soccer, Mathare Youth Sports Association, and WhizzKids United. The purpose was to determine whether the Community Organization Health Model (COHM) was reflected in the values promoted through each organization’s electronic promotional material. The content analysis showed a strong qualitative presence of all six of the COHM tenets in the promotional documents, as well as a meaningful theme of expanding partnerships to enhance sustainability. These findings indicate that the tenets of the COHM are valued by best practice football-for-development organizations, which presents the opportunity for this model to be used in creating an evaluation procedure able to bridge cultural differences in programs. Keywords: HIV prevention, football, sport-for-development, evaluation

Background Postpartum depression (PPD) is a major public health challenge and associated with poor maternal and infant health outcomes. Quality prenatal care decreases adverse outcomes in pregnancy and may reduce PPD risk factors. This study critically reviews the evidence about the role of prenatal care practices in reducing PPD prevalence across population groups and examines the association between prenatal care timing and counseling content with PPD prevalence. Methods A scoping review was completed across eight databases to synthesize evidence about prenatal care and PPD across different contextual settings. National data from the Pregnancy Risk Assessment Monitoring System (PRAMS) was used to examine the research questions. The key outcome was PPD symptoms as self-reported by postpartum women. Key independent variables were timing and content of prenatal care. Bivariate analyses used chi-square and t-tests, as appropriate, and a logistic regression analysis examined associations at the multivariable level while accounting sociodemographic characteristics, history of depression, and interaction effects. An issue brief was developed, triangulating findings from the scoping review and quantitative analysis. Results Forty-five studies were analyzed as a part of the scoping review and identified a strong association between robust prenatal care that included education about depression and increased awareness of PPD prevention among pregnant women. In the PRAMS analysis, women with a history of depression (aOR: 2.87; 95% CI: 2.74, 2.99) and those who initiated prenatal care in the third trimester or had no prenatal care (aOR: 1.54; 95% CI: 1.21, 1.85) had higher odds of PPD. Women who were not asked about depression during prenatal care had higher odds of PPD (aOR: 1.26; 95% CI: 1.21, 1.32). Women who were Asian, Black, and asked less than five questions on health-related topics during prenatal care were more likely to report PPD symptoms. Conclusion Blending education and counseling into routine prenatal care for pregnant women will increase awareness of depression, thereby preventing PPD. Prenatal care should, therefore, be accompanied by evidence-based systems for counseling, education, diagnosing, treatment, and referral of perinatal depression. To optimize the health of women, prenatal care should provide services and support tailored to each woman's needs.

Teaching in the field of public health needs to employ a global perspective to account for the fact that public health problems and solutions have global determinants and implications as well. International university partnerships can promote such a perspective through the strengthening of cooperation, exchange, and communication between academic institutions across national boundaries. As an example for such an academic network in the field of public health, we introduce the International Public Health Partnership—a collaboration between a university in Germany and universities in India, Turkey, and Nigeria. Formed in 2005, it facilitated the exchange of information, fostered discussion about the transferability of public health concepts, contributed to the structural development of the universities involved, and promoted an intercultural dialog through a combination of local and distance learning activities. Although well accepted by students and staff, different obstacles were encountered; these included limited external funding, scarce own financial, time and personnel resources, and diverging regulations and structures of degree programs at the partnership sites. In the present article, we share several lessons that we learned during our joint collaboration and provide recommendations for other universities that are involved in partnerships with institutions of higher education or are interested to initiate such collaborations.

Background: Non-medical use of prescription drugs (NMUPD) refers to the use of prescription drugs which are traditionally utilized to manage pain or treat psychiatric problems but without a doctor’s prescription. In 2010, an investigation by the Substance Use and Mental Health Services Administration (SAMHSA) revealed that 5.3% of young adults (18 to 25-year-olds) in the United States reported past-month NMUPD. NMUPD has become a growing concern owing to associations with consequences such as college dropout, poor academic achievement, and health jeopardizing behaviors. College students' NMUPD has been well documented in the United States. Limited studies, however, have been conducted among college students in China. The purposes of this study are to examine the prevalence and motives of NMUPD among college students in China, and to assess its relationship with stress (i.e., perceived stress and traumatic events), mental health problems (depression, anxiety, and post-traumatic stress disorder (PTSD)), utilization of healthcare, cultural orientation, and protective factors (i.e., resilience and future orientation). Methods: In Jan-April 2017, online data were collected using SONA system from a total of 720 undergraduates at Beijing Normal University (BNU) and University of Macau (UM) with an average age of 19.65. All participants reported their nonmedical use of prescription drugs (i.e., opioids, sedatives, stimulants, and anxiolytics) in their lifetime and the past three months, stress, mental health, utilization of healthcare, cultural orientation, and protective factors. Spearman’s rank-order corrections and logistic regression were employed for statistical analyses. Results: Findings indicate that 41.2% of Chinese students reported taking prescription drugs without a doctor’s prescription. The most commonly misused prescription drugs were opioids (40.5% lifetime use, 31.8% past-three-months use), followed by sedatives (1.8% lifetime, 0.8% past 3 months), anxiolytics (0.9% lifetime,0 .3% past three months), and stimulants (0.2% lifetime, 0% past three months). Bivariate analyses suggest significantly positive correlations of lifetime NMUPD with mental health problems (anxiety and PTSD), cultural orientation (individualism and collectivism), and utilization of healthcare (frequency of healthcare use, time spent for healthcare, and money spent for healthcare). Similar results were found in terms of past-three-month NMUPD. The results of logistic regressions indicate the significant association of lifetime NMUPD with individualism of cultural orientation, and frequency of healthcare use. Specially, individualism, frequency of healthcare use, and time spent for healthcare were found to be associated with lifetime opioid misuse, and depression was significantly associated with sedative misuse. Resilience was negatively associated with lifetime sedative misuse. Frequency of healthcare use was also found to be positively associated with past-three-month opioid misuse. Conclusion: Utilization of healthcare, cultural orientation, and mental health problems appear to be the factors associated with NMUPD among college students at BNU and UM. More discussion is needed in Chinese society about regulation of prescription drug use. Future culturally-tailored prevention intervention programs may be beneficial to reduce the risk of NMUPD among Chinese college students.

This dissertation examines the effectiveness of interventions related to family planning and the uptake of HIV-related preventive services among women in low-income settings. Women in low-income settings and living with HIV face many barriers to care, including limited access to services for family planning and HIV-related preventive care. At the same time, national, regional, and global efforts are looking for interventions to help control rapid population growth, create an HIV-free generation, and provide adequate preventive care for those living with HIV. This dissertation cuts across these issues and can help to inform debate and policies to address these issues. This dissertation comprises three discrete papers. Paper 1 (chapter 1) examines the effectiveness of a national scale-up of community-based distribution of family planning services on contraceptive use in Malawi’s rural areas during the period 2005-2016. The national-scale up of the intervention followed the success of a pilot of a similar intervention implemented in the period 1999-2004. As in the pilot, the scaled-up program distributed condoms and oral contraceptives and provided family planning education. Further, because education and income are important determinants of individual contraceptive use, the paper also examines whether the effectiveness of the national scale CBDs varies over these dimensions. The paper uses the Malawi Demographic and Health Surveys. The study finds that the intervention increased contraceptive use by 6.8 percentage points and the effects were greater among uneducated and low-income women. Paper 2 (chapter 2) conducts a cost-effectiveness analysis of a trial of cash incentives aimed at increasing the uptake of services for the prevention of mother-to-child transmission (PMTCT) of HIV. The trial was conducted in the Democratic of the Congo (DRC) as part of an effort to find ways of increasing uptake of PMTCT services in sub-Saharan Africa where uptake of these services remains low. The study is conducted from the societal perspective, relies on multiple sources within and outside of the DRC for cost data, and reports economic costs in 2016 International Dollars (I$). At a threshold of 3*GDP per capita for the DRC (I$2409), the study finds that the intervention is cost-effective. Paper 3 (chapter 3) examines the guideline concordance of the time to follow-up anal cancer screening in women living with HIV at high risk for anal cancer. In the US, the incidence of anal cancer in women living with HIV has increased significantly in the past 2-3 decades. However, early detection of anal cancer, through regular screening, can lead to effective secondary prevention of the disease. While guidelines for anal cancer screening exist, very little is known about the guideline concordance of the time to follow-up anal cancer screening in women at high risk of acquiring anal cancer. Hence this study. The study uses Medicaid Analytic eXtract files which compile claims of individuals enrolled in Medicaid—a public health insurance program largely for eligible low-income adults and the largest single payer for HIV/AIDS in the US. The study finds that time to follow-up screening is not guideline-concordant for most women living with HIV, particularly those with one of the two risk factors for anal cancer: a history of abnormal cervical test results or a history of genital warts.