Background: Globally, there are 10 million new cases of tuberculosis (TB) disease annually and 95% of cases occur in low- and middle-income countries (LMIC). More than 1 billion people use tobacco, and 80% of tobacco users reside in LMIC. Smoking approximately doubles the risk of TB disease and is associated with excess mortality during TB treatment. We aimed to estimate the proportion of annual incident TB cases and TB mortality attributable to tobacco smoking in high burden TB countries. Methods: To estimate population attributable fractions (PAF), we obtained country specific estimates of TB incidence and TB mortality rates from the WHO 2015 Global TB Report. Country specific smoking prevalence was estimated from WHO 2015 tobacco surveillance reports and the Tobacco Atlas. Risk ratios for the effect of smoking on TB incidence and TB mortality were obtained from previously published meta-analyses. Country specific PAF of smoking for TB disease were age and sex adjusted. Results: In high burden countries during 2014, an estimated 4.5 million adults developed TB disease and 163,000 people died from TB. An estimated 740 million adult smokers lived in those high burden countries in 2014. We estimated that tobacco smoking was attributable for 17.7% (95% confidence interval [CI] 8.6-21.9%) of TB cases and 15.0% (95% CI 1.9-31.6%) of TB mortality. Of the high burden countries, Russia had the highest proportion of smoking attributable TB disease (31.8%, 95% CI 16.0-37.8%) and death (28.1%, 95% CI 3.8-51.3%). India had the greatest absolute number of TB cases (233,000) and TB deaths (7,400) attributable to smoking. Men (30.5%, 95% CI 14.9%-36.9%) had a greater proportion of TB cases attributable to smoking than women (4.7%, 95% CI 1.9%-6.2%). Conclusion: In high-burden TB countries, nearly one-sixth of all TB cases and TB deaths were attributable to smoking. Our findings highlight the need for tobacco control in high TB burden regions and specifically among patients with TB. Reaching key populations and integrating smoking cessation efforts into TB programs will be essential to achieve global TB control goals.

Background: refugee children are children who have lost their homes, families, neighborhoods, and lifestyle routines and have moved to another country. They are at risk of mental health problems due to the traumatic experiences and stressors. 9 in 10 refugee children live in refugee camps in low and middle-income countries which have limited access to resources, services, and better living conditions. Four themes were identified as factors promoting children’s mental health in refugee camps. Positive relationships, education, access to health care services, and community support Methods: 274 articles were identified for this studying using the same search strings on all 5 selected databases (PsyINFO, Psychology database, Scopus, Pubmed, Sociological Abstract) 108 duplicates were removed, and the abstract and title screen was done for 166 articles. only 25 articles went through the full-text screening using specific inclusion and exclusion criteria. 7 articles were finally included in this study. Results: Results indicated that children feel happy, safe, and secure, and expressed positive behaviors when they are surrounded by quality family and peer relationships when they can have access to educational opportunities, and when they have a supportive and engaging community that provide them resources and recreational activities.

Region Östergötland engages in many international collaborations as a way to exchange knowledge and insights with other organizations. The organization has had a collaboration focused on patient safety with Moi Teaching and Referral Hospital in Eldoret, Kenya, since 2015. Kenya is considered a low and middle-income country, while Sweden is considered a high-income country. The aim of this study was to describe patient safety development using activity theory, with a special focus on how Region Östergötland supports patient safety development in a low and middle-income country’s healthcare system. Data was collected by conducting interviews with six participants involved in the patient safety collaboration, by visiting Eldoret to conduct a participant observation and by analyzing relevant policy documents. The results showed that many factors are involved in patient safety development, both within an organization and in supporting the development in a low and middle-income country’s healthcare system. Healthcare organizations should strive for commitment to patient safety development from all levels of the organization, and for a safety culture where staff members are comfortable reporting errors. The management must pursue patient safety questions and put aside resources for patient safety development. As Sweden and low and middle-income countries are different in many aspects, it’s important for the supporting part, in this case Region Östergötland, to be attentive to and understanding of prevailing differences caused by available resources, cultural norms, rules and organizational structures. Many of the requirements for an organization’s patient safety development, and for a successful collaboration between Region Östergötland and Moi Teaching and Referral Hospital, were shown to be achieved or at least functioning. Even though all requirements are not fulfilled, they are all matters that can be improved by the continuation of the collaboration. Region Östergötland can learn from the collaboration by seeing how results can be achieved in an organization with few resources, how efficiently changes can be made within an organization, as well as by gaining knowledge about another culture and country. These factors create opportunities for project participants to be inspired and question current methods and norms in their own organization, which can result in improvements of Region Östergötland as on organization in the future.

Background: Bangladesh is home to 36 million adolescents with the majority living in rural areas. Adolescence presents an additional window of opportunity to correct nutritional deficits among rural Bangladeshi adolescents. A high-quality, diverse diet is pivotal in this regard. Ultra-processed food (UPF) consumption is an emergent threat to public health. This study aimed to explore dietary diversity (DD) and UPF consumption in terms of gender and socio-economic stratification among rural adolescents in Matlab, Bangladesh. Methods: Adopting cross-sectional design 1441 adolescents were surveyed. Dietary diversity score and ultra-processed food consumption score (UFCS) were constructed through 24-hour recalls. Means and consumption proportions were compared across gender and socio-economic strata. Binary and ordinal logistic regression models were fitted to isolate socio-demographic variables associated with inadequate DD and higher UFCS respectively. Results: 43% of the adolescents had inadequate DD. Pro-boy gap in DD was evident, so was heavy reliance on rice and scant consumption of nutrient-rich foods. UPF consumption was low. Belonging to the richest and to food secure households were associated with lower odds of inadequate DD. Girls were more likely to have inadequate DD but less likely to have higher UFCS. Gender modified the effect of socio-economic status on UPF consumption. Conclusions: The diet of adolescents in Matlab lacked diversity, putting them at significant risk of nutritional deficiencies. Improving their DD requires pragmatic policies and tailored programs to tackle affordability and food insecurity issues, address social norms and intra-household dynamics that favor boys, and sensitize the adolescents to importance of consuming diverse diet. / 15-year Follow-up of MINIMat Trial

No description available.

It is often not clear how values are incorporated into policy decision-making about health systems. This is perhaps not surprising given the complexity of decision-making about health systems, the wide range of values prioritized (and advocated for) by different stakeholders, the broad array of sources for or mechanisms available to identify values, and the many ways in which values can drive policy decisions, as well as the reality that policymakers often do not want to be explicit about the values used in policy decision-making process. Using synthesis and qualitative research methods, this dissertation investigates the role of values in policy decision-making about health system financing in Latin America and contributes to the understanding of this field by providing insights for policy and research. The dissertation moves from a general and descriptive focus to a specific and explanatory focus. First, a critical interpretive synthesis was used to develop a theoretical framework that identifies how and under what conditions values inform policy decision-making about health system financing in Latin American countries. In chapters 3 and 4, the focus narrows by using an embedded multiple-case study design that analyzes two specific decisions in each of Chile and Colombia. Frameworks that explain government agenda setting and policy development and the theoretical framework developed in chapter 2, are used to analyze these decisions. The second study (chapter 3) is a discourse analysis which qualitatively assess how declared values inform the four decisions in Chile and Colombia. The third study (chapter 4), draws on in-depth qualitative interviews to understand how and why policymakers and stakeholders use declared and undeclared values in those four decisions in Chile and Colombia. The research chapters build on each other and make substantive, methodological and theoretical contributions. The dissertation provides a rich understanding of the roles of values in health system financing decisions through a critical interpretive synthesis and two qualitative studies, adding to the evidence base that stakeholders and policymakers can draw from when making or shaping policy decisions. These studies collectively build an understanding about what values inform the health policy process in Latin America, how those values work, under what conditions they come to be influential, how they are applied in real decisions, and why policymakers and stakeholders perceive that values play a role in real decisions. All of this evidence has contributed to the development a new theoretical framework about the roles of values in health systems. / Thesis / Doctor of Philosophy (PhD) / Values are important at all stages of the policy process. However, it is often not clear how they are incorporated into policy decision-making about health systems. In Latin America, the study of the role of values and how they inform the prioritization, development, and implementation of policies in different contexts, is an emerging field. This dissertation addresses key gaps in understanding by: 1) developing a framework, which can be used as a tool by policymakers and stakeholders to identify which values support or compete with their initiatives, how to make initiatives more socially supported, and how to focus policies according to the goals of the government and the health system; 2) analyzing how, based on media reports and governmental and non-governmental documents, values have informed two health system financing decisions in each of Chile and Colombia; and 3) examining the views and experiences of policymakers and stakeholders about how and why values were used in decision-making processes related to the same two policy decisions in each of Chile and Colombia.

Children and adolescents in low- and middle-income countries (LMIC) suffer heightened vulnerability for the development of mental health conditions which is exacerbated due to enduring socioemotional, economic, and biological risk factors. The constellation of co-occurring adverse childhood experiences (ACEs; e.g. poverty, maltreatment, household dysfunction, exposure to violence) confer heightened vulnerability for the development of mental health disorders that may persist into adulthood. Although the mechanisms for transmission from one generation to the next has not yet been fully elucidated, contemporary evidence has converged primarily on maternal mental health as a key mediator between childhood exposure to ACEs, and the subsequent mental health of her children. Access to mental health assessment or treatment resources in Kenya are limited or non-existent. Due to the heightened risk for intergenerational transmission of mental health problems across generations, with support from the World Health Organization and key stakeholders in Kenya, the development of task-sharing approaches to address the unmet psychological needs of children and mothers has been advocated for. Task-sharing involves the rational redistribution of mental health care tasks from higher cadres of mental health professionals to non-specialized community health care workers in order to increase the capacity for, and access to, mental health services across Kenya. This dissertation seeks to explore: 1) the development of a partnership between the Africa Mental Health Research and Training Foundation and McMaster University to explore the use of task-sharing in the development of a technology-supported assessment for common mental disorders in children and adolescents; 2) the validity and reliability of the newly developed International Mobile Assessment for Children and Teens (IMPACT) administered by non-specialized community health workers when compared to a gold-standard assessment, the MINI-KID, when administered by trained psychology graduate students, and finally; 3) the association between maternal exposure ACEs and the subsequent mental health of her children, mediated by maternal mental health. The first study outlines the process of the development of the IMPACT using a novel blending of emic-etic approaches, and the practical evaluation of the IMPACT by ten local community health workers. Results from this study demonstrated the demand for, and utility of, the IMPACT and outlined the practical considerations of conducting field work of this nature. The second study examined the diagnostic agreement (e.g. validity) of mental health conditions in Kenyan school children (n=189) between the IMPACT and the MINI-KID. The results of this study demonstrated relatively high agreement between the diagnosis of common mental disorders in children between the IMPACT and the MINI-KID. The third study explores the relationship between ACEs (Y-VACS) of mothers (n=149) and the socioemotional wellbeing of her children (e.g. internalizing and externalizing problems; CBCL), mediated by maternal mental health (CBCL). The results of this study demonstrate the association between maternal ACEs and child internalizing and externalizing behaviours, mediated by maternal mental health and moderated by maternal education. Collectively, the results of these dissertation studies support the use of task-sharing approaches for the assessment of common mental disorders in children and adolescents, by non-specialized community health workers and that the transmission of mental health problems between generations is associated with a multitude of complex and inter-related factors (e.g. maternal ACEs and maternal mental health), exacerbated by chronic and co-occurring adversity. Additionally, the results of these studies demonstrated the need for further research that prioritizes the equitable accessibility interventions that target the mental health related-sequelae experienced by maternal-child dyads exposed to chronic and enduring adversity in LMIC. / Dissertation / Doctor of Philosophy (PhD) / Children who grow up in circumstances of chronic poverty and adversity suffer heightened risk for mental health problems as they grow up. This is especially true of children who live in low- and middle-income countries, where children are more likely to experience chronic and co-occurring forms of adversity. Access to mental health services in these contexts are limited or non-existent, conferring heightened vulnerability for mental health problems that may persist across the lifespan. The risk for mental health problems can be transmitted across generations. Although it is not fully understood how mental health problems can be transmitted from a mother to a child, one commonly studied mechanism is the role of maternal adversity and maternal mental health. Because the barriers to mental health care are abundant, the needs of children and mothers with mental health problems are frequently left unmet. The World Health Organization proposes a task-sharing solution, whereby less specialized community health care workers are trained to provide services to improve access to assessment and treatment in low income countries. Using data collected in rural Kenya, this dissertation seeks to explore: 1) the development of a partnership between the Africa Mental Health Research and Training Foundation and McMaster University with the aim of working together to create mental health assessment for children, using a task-sharing approach, 2) to compare the results of the novel mental health assessment to a gold-standard, and 3) to evaluate maternal adversity, maternal mental health, and the transmission of mental health problems between mothers and children in Kenya. Collectively, the results of this dissertation demonstrate that utilizing a task-sharing model for the development of a mental health assessment for use by community health workers is a valid method for assessing and diagnosing mental health problems in children, and that the transmission of mental health problems across generations is associated complex factors (e.g. maternal exposure to adversity and maternal mental health) as a result of exposure to chronic and enduring adversity in LMIC.

Aim: The aim of this work was to broaden the understating of the role of parental engagement and learning materials at home, in promoting high cognitive and social emotional development. The study assessed the connection between maternal and paternal engagement, having 3 or more books and 2 or more types of playthings, towards the cognitive and social-emotional development of children. Methods: Data from the Multiple Indicator Cluster Surveys (MICS) was used, involving 2517 children in Zimbabwe. Unadjusted logistic regression was conducted to assess the possible confounders. Logistic regression was performed between parental engagement, children having 3 or more books and 2 or more types of playthings, towards the outcome of interest. Results: The results indicate that 91% of the children acquired high cognitive development and 63.4% social emotional. There has not been a significant association between maternal engagement and children’s cognitive or social-emotional development. Similarly, no correlation was found between paternal engagement and children’s development. Nevertheless, households having 3 or more books, reported increased odds of children having high cognitive development and lower odds of social-emotional development. Similarly, children with 2 or more types of playthings, depicted a positive association for social-emotional growth, whereas cognitive development decreased further. Conclusion: The association between having 3 or more books and 2 or more types of playthings remained significant, although parental engagement was insignificant. Future research on parenting practices in different cultural contexts is suggested, concerning the developmental status of children. In addition, more developmental, age-related assessment items are needed.