Background: International agencies such as the World Health Organisation have highlighted the potential of digital information and communications technologies to strengthen health systems, which are underpinned by the 'building blocks' of information, human resources, finances, commodities, leadership and governance, and service delivery. In high income countries, evidence of the positive impacts of 'eHealth' innovations on the cost-effectiveness of healthcare is growing and many governments are now providing incentives for their adoption. In contrast, the use of eHealth in developing countries has remained low and efforts to introduce these new approaches have experienced high failure rates. There is even scepticism regarding the feasibility of eHealth in low-resource settings, which may be hindered by high costs, indeterminate returns on investment, technical problems and socio-organisational barriers. More research is needed to document both the value of eHealth for strengthening resource-limited health systems and the challenges involved in their implementation and adoption, so that insights from such research may be used to inform future initiatives. While many studies of eHealth for patient care in low- and middle-income countries (LMIC) are taking place, evidence of its role in improving administrative processes such as financial management is lacking, despite the importance of 'good governance' (transparency and accountability) for ensuring strong and resilient health systems. The overall objective of this PhD was to elucidate the enablers, inhibitors and outcomes characterising the implementation and adoption of a modular eHealth system in a group of healthcare facilities in rural Malawi. The system included both clinical and billing modules. The specific objectives were (i) to understand the socio-technical, organisational and change management factors facilitating or hindering the implementation and adoption of the eHealth system, (ii) to assess the quality of data captured by the eHealth system compared with conventional paper-based records, and (iii) to understand how information within the eHealth system was used for service delivery, reporting and financial management. A further aim was to contribute to the corpus of mixed-methods case studies exploring eHealth system implementation processes and outcomes (including data quality) in LMIC. As described in the following chapters, the research also gave rise to unanticipated and serendipitous findings, which led to new lines of enquiry and influenced the theoretical perspectives from which the analysis drew.

In recent decades, there has been a seemingly inexhaustible rise in the use of caesarean section (CS) worldwide. The overall aim with this thesis is to explore the effects of and reasons for an increase in the CS rate at a university hospital in Dar es Salaam, Tanzania. In Study I, we analysed time trends in CS rates and maternal and perinatal outcomes between 2000 and 2011 among different obstetric groups. In Study II, we documented the occurrence and panorama of maternal ‘near-miss’ morbidity and death, and analysed their association with CS complications. We also strived to determine if women with previous CS scars had an increased risk of maternal near-miss, death, or adverse perinatal outcomes in subsequent pregnancies. Studies III and IV explored women’s and caregivers’ in-depth perspectives on CS and caregivers’ rationales for their hospital’s high CS rate. During the study period, the CS rate increased from 19% to 49%. The rise was accompanied by an increased maternal mortality ratio (odds ratio [OR] 1.5, 95% Confidence Interval [CI] 1.2–1.8) and improved perinatal outcomes. CS complications accounted for 7.9% (95% CI 5.6–11) of the maternal near-miss events and 13% (95% CI 6.4–23) of the maternal deaths. Multipara with previous CS scars had no increased risk of maternal near-miss or death compared with multipara with previous vaginal deliveries, and a lower risk of adverse perinatal outcomes (adjusted OR 0.51, 95% CI 0.33–0.80). Both women and caregivers stated they preferred vaginal birth, but caregivers also had a favourable attitude towards CS. Both groups justified maternal risks with CS by the need to ‘secure’ a healthy baby. Caregivers stated that they sometimes performed CSs on doubtful indications, partly due to dysfunctional team-work and a fear of being blamed by colleagues.  This thesis raises a concern that maternal health, interests, and voices are overlooked through the CS decision for the benefit of perinatal outcomes and caregivers’ liability. An overuse of CS should be seen as a sign of substandard care and preventing such overuse needs to be among the key actions when formulating new targets for the post-2015 era.

Zugl.: Vallendar, Wiss. Hochsch. für Unternehmensführung, Diss., 2006. / Hergestellt on demand.

Zugl.: Linz, Univ., Diss., 2007 / Hergestellt on demand

Microfinance has become one of the most promising tools for development and poverty alleviation over the past two decades. Millions of borrowers around the globe have utilized microcredit to start or expand their small businesses and raise their household income. One poverty-induced problem microfinance could potentially alleviate is child labor. Despite international legislation prohibiting it, child labor continues to deprive millions of children of their right to education. Without education, there is little hope for a country to increase productivity and wealth in the future. A number of scholars have highlighted a negative correlation between credit rationing and child labor. However, there are no studies that examine whether or not children are less likely to work in households that participate in microfinance programs. In some circumstances, microcredit may increase household income and induce parents to withdraw their children from work while in others, raising the household income level may lead children to work more. In low-income countries with numerous microfinance institutions, many children work despite their parents’ access to credit. In order to examine this paradoxical phenomenon, this thesis presents a number of econometric models which analyze both child labor and credit at the household level. Though these models are vital in explaining the relevant trends, a purely economic analysis fails to capture the political and cultural factors that also engender child labor. To illustrate this complex relationship between economics and mores, this thesis highlights the impact of microfinance on child labor in Bangladesh. Bangladesh is an ideal country for this study because microfinance and child labor are both endemic. Finally, conclusions drawn from this analysis inform policy recommendations to amplify the effectiveness of microfinance on diminishing child labor.

Introduction: Diarrhea remains one of the main causes of morbidity and mortality in children under five years of age especially in low-income countries. In Peru, epidemiological reports about enteropathogens related to acute diarrhea are scarce in rural areas. The aim of this study was to describe the etiology, epidemiology, and clinical characteristics of the principal causes of acute infectious diarrhea in in a northern rural region of Peru. Methodology: A prospective study was conducted from January 2011 to December 2012 to describe the main pathogens causing acute diarrhea using PCR assay. Results: A total of 117 children diagnosed with acute diarrhea were included in the study. A single etiological agent was identified in 41.03% of samples, being rotavirus followed by norovirus and Shigella. Co-infections containing virus and bacteria were found in 22.22% of samples. Vomiting was most commonly found symptoms in 58.97% cases followed by fever (54.70%). Malnutrition was detected in 14.53% of the children. Conclusions: High prevalence of rotavirus, as well as adenovirus and norovirus, was observed in the present study. Shigella was the most common bacteria found in acute diarrhea in the area. The implementation of a better surveillance system is mandatory in order to identify the principal etiologies of gastroenteritis in the rural areas of Peru and to develop of better prevention strategies and reduce diarrhea-associated mortalities.

Background: Low- and middle-income countries like South Africa carry the greatest suicide burden, with local general population suicide attempt rates of 2.9–22.7%, in comparison to 0.7–9% in international literature. Non-suicidal self-injury (NSSI) commonly co-occurs with suicidal behaviours and estimates range from 5.5% internationally to 19.4% in South Africa. As a subgroup of the general population, university students are at higher risk both of suicidal behaviours and NSSI (S/NSSI). Risk factors for S/NSSI include parenting style; however, very little is known about the relationship between parenting styles and S/NSSI in university students in the South African context. Objectives: In this dissertation we set out to perform a literature review relating to explanatory models and risk factors associated with S/NSSI and then proceeded to collect novel data from students at the University of Cape Town. This research study aimed to describe the rates of S/NSSI behaviours and to explore the relationship between the Baumrind parenting style typography and S/NSSI in university students. The study hypothesised that authoritative parenting would negatively correlate with S/NSSI. No a priori hypotheses were made about the other parenting styles investigated. Methods: In chapter 1, we performed a literature review of peer-reviewed publications on Pubmed, Psychinfo via EBSCOHost and MEDLINE via EBSCOHost identified through search terms that were relevant to the focus of the study. In chapter 2 novel data were collected. Students from all faculties at the University of Cape Town were invited to complete an anonymous, online electronic survey. Data collection included a socio-demographic questionnaire, Parenting Styles and Dimensions Questionnaire and Self-Harming Behaviours Questionnaire. Descriptive statistics quantified parenting styles, suicidal behaviours and NSSI. Spearman's correlation coefficients examined the association between parenting style and S/NSSI. Results: Literature review provided a topline review of explanatory models and risk factors associated with S/NSSI and identified relevant literature about parenting styles using the Baumrind typology. In the electronic survey of university students, the rate of suicidal attempts was 6.3% and of NSSI was 22.7%. Suicide threats, suicidal thoughts, and thoughts of dying were reported by 5.9%, 35.7% and 50.7% respectively. No significant differences were seen between male and female students. We observed no significant association between authoritative parenting and suicidal behaviours, but authoritative mothers and fathers were significantly associated with a history of NSSI. Both permissive mothers and fathers were associated with suicide attempts, threats, and thoughts, whereas only permissive mothers were associated with NSSI. Conclusion: This study replicated previously reported high rates of S/NSSI in South African university students in comparison to general population and international data. Contrary to our hypothesis, authoritative parenting style was positively correlated with NSSI, but not with suicidal behaviours. Further studies are warranted to examine parenting style, and permissive parenting, in particular, in relation to S/NSSI

Assay and impurity profiling of the pharmaceuticals are the key routine quality control methods employed worldwide for which High Performance Liquid Chromatography (HPLC) is the most widely used technique. The ability to carry out these routine laboratory procedures in low- and middle- income countries (LMICs) need the methods to be based upon simple instruments manageable with moderate levels of personnel skill and costs involved. Simple, convenient, and cost effective reverse phase HPLC methods were developed using phosphate buffer and methanol as mobile phase with C18 column as stationary phase for the impurity profiling and assay of beta lactam antibiotics. Isocratic elution and UV detection was employed in these methods. Impurity profiling method was developed for coamoxiclav tablets and ceftriaxone bulk drug. The method for ceftriaxone included a supplementary method to quantify one of its known impurity (Impurity D of ceftriaxone). This method involved use of acetonitrile where as the two main methods were achieved on the targeted method design, described above. With the exception of impurity A of ceftriaxone, the methods developed can successfully quantify impurities to the concentration as low as ≤0.05%, which is in accordance with the current guidelines for the impurity profiling of antibiotics issued by European Medicines Agency. As ensuring cost reduction was one of the key objectives of carrying out the method development exercise, in situ methods for the preparation of impurities were also identified and some new methods were introduced. The stability of beta lactam antibiotics and the choice of solvent were given due attention during the process of method development revealing information on the presence of new impurities. Deacetyl cefotaxime and 2-mercaptobenzathiazole were identified in this process as new impurities of ceftriaxone currently not listed under known impurities by United States Pharmacopoeia and European Pharmacopoeia. However, deacetyl cefotaxime is a known impurity of cefotaxime whereas the latter molecule is a degradation product of one of the synthesis impurities of ceftriaxone. This substance is reported to be carcinogenic and is resolved using the supplementary method developed for ceftriaxone, hence making its detection and quantification possible. A known inactive impurity of ceftriaxone (Impurity A, E-isomer of ceftriaxone) was` also shown to be produced by exposure to day light, thus warranting the light protection of the ceftriaxone solution, an information that is of critical importance in the clinical settings. A series of experimentation was carried out on the finished products of beta lactam antibiotics sampled from Pakistan and few other countries, to identify key quality issues in the samples. Though the limited sample size and convenient sampling did not provide results that could yield a decisive figure for the country status for prevalence of substandard and falsified medical products, but the experiments have clearly indicated that the problems in drug quality do exist and beta lactam antibiotics form a class of high-risk medicine with respect to surveillance for poor-quality medicines. Isolation of unknown impurities was also carried out along with the introduction of new and modified methods for preparation of impurities of beta-lactam antibiotics. In addition, detailed literature survey was carried out for understanding the complex problem of the poor-quality medicine, impact of poor quality antimicrobials on health care system and the magnitude of the problem at the global level. The country status of Pakistan regarding quality of medicines was recorded based upon the available documentary evidence. The current technologies and strategic options available for low- and middle-income countries in aiding fight for combating poor quality medicines was also laid down to design recommendations for Pakistan. A comprehensive review of the information technology tools used for identification and control of substandard and falsified medicines was also conducted. / Für die Bestimmung der Reinheit und des Gehaltes von Arzneistoffen wird weltweit maßgeblich die Hochleistungs-Flüssigchromatographie (HPLC) eingesetzt. Damit die entsprechenden Methoden auch in Entwicklungs- und Schwellenländern angewendet werden können, müssen sie zur Verwendung mit sehr einfachen Messgeräten geeignet sein und von auch weniger gut ausgebildetem Personal durchgeführt werden können. Zudem sollten die Kosten möglichst niedrig sein. Für die Reinheitsanalytik sowie die Bestimmung des Gehaltes von Betalaktam-Antibiotika wurden einfache, praktische und kostengünstige chromatographische Methoden unter Verwendung von Umkehrphasen entwickelt, die als mobile Phase Gemische aus Phosphatpuffern und Methanol sowie als stationäre Phase C18-Säulen verwenden. Die Methoden sind isokratisch, die Detektion erfolgt mittels UV/Vis-Spektrometer. Für Coamoxiclav-Tabletten sowie den Arzneistoff Ceftiaxon wurden Methoden zur Reinheitsprüfung entwickelt. Für die Reinheitsprüfung von Ceftriaxon wurde eine zweite Methode benötigt, um eine der bekannten Verunreinigungen (Ceftriaxon-Verunreinigung D) zu quantifizieren. Hierbei musste Acetonitril als Bestandteil der mobilen Phase gewählt werden, wohingegen die beiden Hauptmethoden dem beschriebenen Methodendesign folgten. Außer im Falle der Ceftriaxon-Verunreinigung A können mit den Methoden Verunreinigungen bis zu einem Konzentrationslevel ≤ 0,05 % bestimmt werden, was den Vorgaben aktueller Richtlinien für die Reinheitsanalytik der Europäischen Arzneimittelbehörde entspricht. Da es ein Kernziel während der Methodenentwicklung war, die Kosten für die Analytik möglichst gering zu halten, wurden in situ-Methoden für die Gewinnung von Verunreinigungen entwickelt und einige neue eingeführt. Während des Entwicklungsprozesses wurde besonders auf die Stabilität der Antibiotika und auf die Wahl des Lösungsmittels geachtet, wobei Erkenntnisse über die Anwesenheit neuer Verunreinigungen erlangt werden konnten. Desacetylcefotaxime und 2-Mercaptobenzathiazol wurden als neue Verwandte Substanzen von Ceftriaxon identifiziert und sind derzeit nicht als bekannte Verunreinigen in der United States Pharmacopoeia sowie dem Europäischen Arzneibuch aufgeführt. Desacetylcefotaxime ist eine bekannte Verunreinigung von Cefotaxime, wohingegen das zweite Molekül ein Abbauprodukt einer der Verunreinigungen ist, die während der Synthese von Ceftriaxon entstehen können. Es ist bekannt, dass diese Substanz karzinogen ist, und sie kann mit der erweiterten zweiten Methode für Ceftriaxon erfasst und quantifiziert werden. Unter Lichteinfluss bildete sich zudem eine weitere bekannte, inaktive Verunreinigung von Ceftriaxon (Verunreinigung A, E-Isomeres von Ceftriaxon), weshalb Ceftriaxon-haltige Lösungen vor Licht geschützt aufbewahrt werden sollten. Dieses Wissen ist besonders für den klinischen Bereich relevant. An einer Reihe von Betalaktam-haltigen Fertigarzneimitteln aus Pakistan und einigen anderen Ländern wurden mehrere Qualitätsuntersuchungen angestellt. Obwohl der geringe Probenumfang und die Methoden der Probensammlung kein eindeutiges Bild darüber zeichnen konnte, ob in einem bestimmten Land Arzneimittelfälschungen besonders häufig auftreten, konnte durch die Versuche dennoch festgestellt werden, dass es Probleme bei der Arzneimittelqualität gibt und dass Betalaktam-Antibiotika eine Hochrisikogruppe darstellen, die besonders gut hinsichtlich des Vorkommens minderwertiger Arzneimittel untersucht werden muss. Zudem wurden unbekannte Verunreinigungen aus den Proben isoliert und neue sowie modifizierte Methoden entwickelt, um Verunreinigungen der untersuchten Substanzen zu gewinnen. Zudem wurde eine ausführliche Literaturrecherche durchgeführt, um das komplexe Problem minderwertiger Arzneimittel, den Einfluss minderwertiger Antibiotika auf das Gesundheitssystem sowie das globale Ausmaß des Problems zu verstehen. Für Pakistan wurde der status quo der Arzneimittelqualität aufgrund vorhandener Dokumentation ermittelt. Außerdem wurde dargelegt, inwiefern die heutigen modernen Technologien und Strategien, die für Entwicklungs- und Schwellenländern zur Verfügung stehen, zur Bekämpfung von qualitativ minderwertigen Arzneimitteln in Pakistan beitragen können. Hierzu wurde eine Übersicht aktueller, moderner digitaler Techniken angefertigt, die für die Aufdeckung und Bekämpfung von minderwertigen und gefälschten Arzneimitteln verwendet werden können.

The physical environment in schools is an important factor that benefits the educational quality and has an essential role in the student's learning process. In the Philippines the physical environment is underdeveloped in the schools, since the main focus is on developing a basic foundation and on making sure that every child can go to school. This thesis studied the classrooms' physical environment in three selected schools in the Philippines. It presents improvements of the classroom’s physical environment. This study can be used as indicative guidelines when designing classrooms in the Philippines. This study is supported by the Minor Field Study scholarship, founded by SIDA.

The aim of this study was to determine the prevalence of extended-spectrum b-lactamase (ESBL)- producing Klebsiella pneumoniae isolated from urinary tract and bloodstream infections in a rural hospital in Manhic¸a, Mozambique. ESBLs were investigated among ceftriaxone-non-susceptible K. pneumoniae clinical isolates recovered between 2004 and 2009. Characterisation of blaCTX-M, blaSHV, blaOXA and blaTEM genes was performed by PCR and sequencing. Epidemiological relationships were established by phylogenetic analysis, repetitive extragenic palindromic PCR (REP-PCR), pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST), whilst plasmid transferability was evaluated by conjugation. In addition,the presence of class 1 and 2 integrons was studied.A total of 19 K. pneumoniae were analysed. The blaCTX-M-15 gene was found in all strains. Other ESBL genes were found concomitantly, including blaSHV-5, blaSHV-2, blaSHV-2A, blaSHV-12 and blaSHV-38. In addition, other b-lactamases such as blaTEM-1 and blaOXA-30 were also detected. REP-PCR identified 15 different epidemiological profiles. MLST analysis also showed great variability of sequence types. The blaCTX-M-15 gene showed a high transfer capacity. The presence of class 1 integrons was high. High levels of multidrug resistance were also found. In conclusion, these data show the dominance of the CTX-M-type ESBL, particularly CTX-M-15, supporting its worldwide dissemination, including in areas with limited access to third-generation cephalosporins. This finding is a matter of concern for clinical management as third-generation cephalosporins are an alternative for treating severe cases of multidrug-resistant infections in this community. / Revisión por pares