Philosophiae Doctor - PhD / Stroke is a known health challenge for the public as it is both incapacitating and fatal to many people world over. Malawi, one of the developing countries has stroke as the fourth leading cause of death, and is fast becoming even more significant due, primarily, to lifestyle changes and nature of healthcare practices. For these reasons, and particularly, the negative impact on quality of life, the management of people with stroke is a critical area of interest. While research activity throughout the world has advanced acute stroke-care interventions, patients in Low to Middle Income Countries (LMICs) benefit less from evidence-based stroke care practices due to less conventional applicability to the setting and continuing medical care and rehabilitation challenges. This doctoral project applied the results of a Diagnostic and Solution Phases to the development of a contextual model for in-patient stroke care and rehabilitation (MoC) in Malawi.

Postpartum hemorrhage (PPH) is the leading direct cause of maternal mortality worldwide, with the majority of deaths taking place in the least developed countries of the world. Low- and middle-income countries (LMICs) have increased rates of PPH due to lack of access to healthcare, inadequate number of care providers and availability of interventions and resources needed. PPH has four main etiologies: uterine atony, trauma, retained placenta and coagulopathy. The most common and challenging to treat is uterine atony, where a lack of uterine contractility leads to massive hemorrhage postpartum. Specific risk factors have been identified that increase a woman’s risk of developing PPH. Risk factors of PPH can be categorized as biological, demographical and social risk factors. Many people in LMICs experience a lot of the social risk factors like lack of providers, skilled facilities and resources available to them in case of an obstetric emergency. Home births are also a common practice in many LMICs, placing a woman further from any resources she may have had access to if she was at a health facility. PPH can also occur in women without risk factors and requires that providers always be prepared to treat it. Interventions to treat PPH are well known and encompass both pharmacological and non-pharmacological interventions that are usually tried in a least to most invasive order. The first line of intervention is often to administer a uterotonic drug, preferably oxytocin. This poses a challenge to LMICs because oxytocin requires a cold-chain storage, which many LMICs countries lack. Therefore, uterotonics and non-pharmacologic interventions have increasingly been used in these regions. The final and ultimate life saving measure to stop bleeding is a hysterectomy, which is often not available in these rural places where home births take place, and has led to higher mortality rates. Prevention measures of PPH include increasing antenatal care (ANC) use and practicing active management of the third stage of labor (AMTSL) with all pregnancies. Use of ANC and ultrasound technology can help identify the biological risk factors that make a woman more likely to experience PPH. Solutions to lowering the occurrence of PPH in LMICs involve increasing resources and access to healthcare. An important part to increasing access is increasing the number of skilled health facilities and health providers. Community health workers (CHW) and skilled birth attendants (SBA) are vital to increasing the amount and acceptability of care in these regions. These workers are trusted members of the community that can help educate and bring resources to women, as well as women to the resources. Solutions to stopping PPH need to consider the affordability, acceptability and accessibility in order to reach people in remote areas with limited resources. Both immediate short-term interventions and long-term, longitudinal healthcare reform are necessary to save mothers in LMICs.

Background: The prevalence of uncorrected refractive error among school-age children is on the rise with a detrimental effect on academic performance and socio-economic status of those affected. School vision screening appears to be an effective way of identifying children with uncorrected refractive error so early intervention can be made. Despite the increasing popularity of school vision screening programs in recent times, there is a lot of debate on its effectiveness in reducing the proportion of children with uncorrected refractive error in the long term especially in settings where resources are limited. Objective: To assess the effectiveness of school vision screening programs in reducing children with uncorrected refractive error in LMIC. Search Methods: To identify studies suitable for this systematic review, a comprehensive and systematic search strategy was employed. We searched various databases and the search was restricted to articles published in English. We included RCTs, cross-sectional studies, case-control studies, and cohort studies. Participants included school children who had undergone vision screening as part of school vision screening programs in the LMIC setting and found to have a refractive error. Two independent reviewers screened the result of the search output and performed a full-text review of the search result to identify papers that met the pre-defined inclusion criteria. Data extraction and risk of bias assessment for the included studies was performed by the two independent reviewers and discrepancies were resolved by consensus and through consultation. The certainty of the evidence was assessed using the GRADE approach. Main Result: We found thirty relevant studies conducted in ten different countries that answered our review questions. Our review showed that school vision screening may be effective in reducing the proportion of children with an uncorrected refractive error by 81% (95% CI: 77%; 84%, moderate certainty evidence), 24% (95% CI: 13%; 35%, moderate certainty evidence,) and 20% (95% CI: 18%; 22%, moderate certainty evidence) at two, six, and more than six months respectively after its introduction. Our review also suggest that school vision screening may be effective in achieving 54% (95% CI: 25%; 100%, moderate certainty evidence), 57% (95% CI:46%; 70%, low certainty evidence), 38% (95% CI: 29%; 51%, moderate certainty evidence) and 41% (95% CI: 24%; 68%, low certainty evidence) level of spectacle wear compliance among school children at less than three months, at three months, at six months and at more than six months respectively after its introduction. Our review further found moderate to high certainty evidence indicating that school vision screening together with the provision of spectacles may be relatively cost-effective, safe and has a positive impact on the academic performance of children. Conclusion: Result of this review shows that school vision screening together with the provision of spectacle may be a safe and cost-effective way of reducing the proportion of children with uncorrected refractive error with a long-term positive impact on academic performance of children. Most of the studies included in this review were however conducted in Asia and the applicability of this finding to countries in other regions especially those outside the LMIC circle is not clear.

Background: The use of evidence-based medications for the management of cardiovascular disease (CVD) is low worldwide. A key strategy to improving use of medications is to understand the barriers to their use. This thesis aims to identify barriers that may influence use of these medications in high, middle, and low income countries. Data on barriers in low and middle income countries are especially lacking. We postulate that in those settings lack of availability and affordability of proven medications are key barriers to medication use. Methods: We initially systematically reviewed the literature on barriers to medication use. Since data on these barriers for the management of CVD are sparse, the review included studies focused on hypertension, because it is the leading risk factor for CVD. Baseline data from the PURE study were then used to investigate whether availability and affordability of medications influence their use for secondary prevention of CVD. PURE is a prospective study that recruited adults between the ages of 35 to 70 years from 17 high, middle, and low income countries. Availability and affordability of medications were documented for each country income group, and the associations between these two potential barriers and medication use was explored after accounting for other factors that may influence medication use. Results: The review showed that in high income countries, non-healthcare system related factors, such as lack of knowledge and motivation, were more commonly reported as barriers, whereas in low and middle income countries healthcare system factors were most commonly reported as barriers to hypertension management. However, very few studies were conducted in low and middle income countries and so there is limited information on whether availability and affordability of medications affect their use. Results from the PURE study indicate that medications recommended for the secondary prevention of CVD were often not available and when available, they were not affordable for a high proportion of individuals in low and middle income countries. Lack of availability and low affordability were strongly associated with medication use in these settings. Conclusions: Barriers to medication use are context specific and interventions to improve use should be tailored to barriers depending on the setting. In high income countries where the medications are usually available and affordable interventions should target knowledge and motivation barriers. In low and middle income countries, the focus should be on healthcare system interventions to improve the availability and affordability of medications. / Dissertation / Doctor of Philosophy (PhD)

Introduction: The frailty phenotype is a commonly used tool to study frailty. Two characteristics evaluated as part of the frailty phenotype are “low” grip strength and “low” physical activity, defined by the lowest quintile thresholds for age and sex. In studies of frailty in different geographic regions of the world, it is not established whether these thresholds should be applied universally or whether region-specific thresholds of grip strength and physical activity should be applied. This study aims to determine which way of defining frailty is more appropriate. Methods: Using data from the Prospective Urban Rural Epidemiology study, two variations of the frailty phenotype were defined: universal frailty in which thresholds for low grip strength and physical activity were taken to be the lowest quintile of the entire study population and region-specific frailty, in which these thresholds were calculated separately for each region. Frailty prevalence was calculated for each definition and Cox proportional hazards modelling was used to determine which definitions predicted mortality. Likelihood ratio tests statistics, area under the receiver operating characteristics curve, and the net reclassification improvement index were also calculated. Results: Overall frailty prevalence was 5.6% using universal definitions of frailty and 5.8% for region-specific definitions of frailty. Across regions, universal frailty prevalence ranged from 2.4% (North America/Europe) to 20.1% (Africa), while region-specific frailty ranged from 4.1% (Russia and Central Asia) to 8.8% (Middle East). The hazards ratios for all-cause mortality were 2.66 (95% CI: 2.47-2.86) and 2.09 (95% CI: 1.94-2.26) for universal frailty and region-specific frailty respectively (adjusted for age, sex, education, smoking status and alcohol consumption); statistical tests indicated that universal frailty better fit survival data and predicted mortality slightly better. Conclusions: Frailty prevalence varies greatly across regions depending on how the thresholds for low physical activity and grip strength are calculated. Using region-specific thresholds does not help improve the predictive value of frailty when measuring frailty in heterogenous populations using the frailty phenotype. / Thesis / Master of Science (MSc)

This study aims at understanding the role of education in promoting disaster preparedness. Strengthening resilience to climate-related hazards is an urgent target of Goal 13 of the Sustainable Development Goals. Preparing for a disaster such as stockpiling of emergency supplies or having a family evacuation plan can substantially minimize loss and damages from natural hazards. However, the levels of household disaster preparedness are often low even in disaster-prone areas. Focusing on determinants of personal disaster preparedness, this paper investigates: (1) pathways through which education enhances preparedness; and (2) the interplay between education and experience in shaping preparedness actions. Data analysis is based on face-to-face surveys of adults aged 15 years [or older] in Thailand (N = 1,310) and the Philippines (N = 889, female only). Controlling for socio-demographic and contextual characteristics, we find that formal education raises the propensity to prepare against disasters. Using the KHB method to further decompose the education effects, we find that the effect of education on disaster preparedness is mainly mediated through social capital and disaster risk perception in Thailand whereas there is no evidence that education is mediated through observable channels in the Philippines. This suggests that the underlying mechanisms explaining the education effects are highly context-specific. Controlling for the interplay between education and disaster experience, we show that education raises disaster preparedness only for those households that have not been affected by a disaster in the past. Education improves abstract reasoning and anticipation skills such that the better educated undertake preventive measures without needing to first experience the harmful event and then learn later. In line with recent efforts of various UN agencies in promoting education for sustainable development, this study provides a solid empirical evidence showing positive externalities of education in disaster risk reduction.

Children around the world need care outside their families for a variety of reasons including poverty, war and epidemics such as HIV/AIDS. The majority of these children live in developing countries where there are limited resources to care for them. As a result of concerns about the effects of institutional care on children, and following trends in the developed world, there is a movement in developing countries to replace large residential institutions with a system of adoption, foster care and small group homes. The aim of this study is to examine the experience of orphan, abandoned, and neglected or abused children who grew up in residential institutions in the Caribbean nation of Trinidad and Tobago, to learn the positives and negatives of residential care in order to contribute to developing a model of care suited for high need, low resource countries. Oral history methodology was used to collect the stories of 24 alumni (12 men and 12 women) from seven homes in Trinidad and Tobago. The homes were categorized as 1) state— partially funded by the state but managed by the Anglican and Catholic dioceses, 2) faith-based— run by religious communities, and 3) community homes run by individuals in the community. The findings of the study show that overall experiences were positive. For poor and working-class children, life in the home was better than their life would have been if they had remained with their families. However, discharge and transition from the homes were less favourable. Alumni from the state-funded homes experienced more difficulties than the faith-based and community homes as a result of poor planning and a lack of post-departure supports. Women suffered more hardships than men, often leading to sexual exploitation. The findings also show that being admitted with siblings and staying at the same home over the duration of care—as was the norm—correlated positively with educational outcomes for the majority of alumni. Some life-long relationships were maintained with volunteers and with friends made among peers at the homes. The study concludes that large group care is not necessarily harmful for children. It may be even beneficial and may be cost effective—a factor that is very important for low resource countries. An aftercare plan, with planning beginning at admission might ease the transition process and gender must be considered in discharge and transition policies. / October 2016

Thesis advisor: Ce Shen / Civic engagement, involving people in public processes to achieve common goals, has received increased attention in the past several decades. This renewed interest was triggered by the seeming decline in civic engagement, particularly in the context of Western societies including the U.S. In addition, its potentially positive effects, such as psychological well-being at the individual level, have recently received much attention. Low-income people in developing countries suffer from double discrimination: first, the lack of opportunities to participate in civic matters due to their low socio-economic status (SES) and second, the lack of civil society culture in developing countries. However, less attention has been paid to civic engagement in the context of developing countries and low-income people, in spite of the importance of civic engagement to them. Given the significance of civic engagement for low-income populations in developing countries, this dissertation intends to fill the gaps left by previous scholarship. The following are specific objectives for the study: 1) Paper 1 aims to investigate the construct validity of an instrument to measure civic engagement among low-income populations in developing countries; 2) Paper 2 aims to examine the associations between country-level political and economic determinants and civic engagement among low-income people in developing countries; and 3) Paper 3 aims to examine the effect of civic engagement on subjective well-being through the mediating effect of sense of agency. Using the cross-national data set, the World Values Survey Wave 6 (2010-2014), this study first found that civic engagement among low-income individuals in low- and middle-income countries is defined in three dimensions: electoral behaviors, membership in civic organizations, and cognitive engagement. This result contributes to measurement development of civic engagement, especially among the low-income individuals in the context of developing countries, who have been neglected in policy-making processes. In Paper 2, I found that civic engagement increases in economically disadvantaged environments (low GNI per capita and high Gini coefficient). This finding may reveal the strength that low-income populations have. Lastly, the results of Paper 3 showed that electoral engagement and membership in civic organizations were directly related to well-being, but cognitive engagement had an indirect effect on well-being through a sense of agency. Also, the result of a non-recursive model showed that engagement in electoral behaviors leads to a sense of well-being, not in the reverse direction. The results from Paper 3 may demonstrate the mechanism by which civic engagement is related to well-being. / Thesis (PhD) — Boston College, 2018. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social Work.

The emergency of malnutrition, in all of its forms, and physical inactivity among children and adolescents as serious public health challenges, especially in resource-limited low- and middle-income countries is concerning and requires attention. Data on the prevalence of unhealthy weight status and levels of physical inactivity among children and adolescents in these low- and middle-income countries are limited, not systematically collected nor are they well documented. Accurate prevalence estimates, and an informed understanding of the relationships among movement behaviours and weight status of children and adolescents, are required to facilitate evidence-informed interventions and public health policies in these countries. The main purposes of this dissertation were to examine relationships between lifestyle behaviours and weight status among primary schoolchildren in Mozambique; compare body mass indices and movement behaviours of Mozambican schoolchildren to those of children from other countries; and use these findings to highlight important data gaps that exist in low- and middle-income countries. First, the Active Healthy Kids Global Alliance’s Report Card development methodology was used to conduct thorough narrative literature searches, identify data gaps and research needs which subsequently informed research questions and primary data collection. A published protocol that was developed for the multinational cross-sectional International Study of Childhood Obesity, Lifestyle and the Environment was adopted and used for primary data collection among urban and rural schoolchildren in Mozambique (n=683), to facilitate data comparability. Anthropometric (weight, height, percent body fat, bioelectric impedance, mid-upper-arm circumference, waist-circumference) and accelerometry (nocturnal sleep, sedentary time, various intensities of physical activity) data were objectively measured by trained personnel. Data about lifestyle behaviours (diet and movement behaviours), demographics and environmental (home, neighbourhood, school) factors associated with child weight status were collected using context-adapted questionnaires. As part of this dissertation, six manuscripts were developed and submitted for publication in peer-reviewed scientific journals. Overall, the narrative literature searches revealed a dearth of information about prevalences of unhealthy weight status, and key lifestyle behaviours among children and adolescents in low- and middle-income countries. Results from data collected in Mozambique showed overweight/obesity to be an emerging public health concern, especially among urban children (11.4%), while thinness still persists and is more prevalent among rural schoolchildren (6.3%). Moderate- to vigorous-intensity physical activity, active transport and mother’s body mass index were found to be important modifiable correlates of weight status for Mozambican children. Distinct differences in the prevalences and correlates of lifestyle behaviours (sleep and physical activity) were observed between urban and rural children in Mozambique. The findings showed that mean moderate- to vigorous-intensity physical activity was lower (82.9±29.5 minutes/day) among urban compared to rural Mozambican children (96.7±31.8 minutes/day). Compared to children from 12 other countries, on average, children from Mozambique had lower body mass indices, higher daily moderate- to vigorous-intensity physical activity, lower daily sedentary time and comparable sleep duration. For example, rural Mozambican children had lower mean BMI z-scores (-0.5±0.9) than the rest of the sample (0.4±1.3), 46 more minutes of daily moderate- to vigorous-intensity physical activity, and 99 less minutes of daily sedentary time than the other children. Furthermore, linear distributions of study site-specific body mass index (positive), minutes of daily moderate- to vigorous-intensity physical activity (negative), and daily sedentary time (positive) by country human development index were observed. Compared to others, children from the urban Mozambican site closely resembled those from Nairobi Kenya on body mass index and movement behaviours, whereas those from rural Mozambique were distinctly different from the rest of the sample on many indicators. Findings from this dissertation highlight the importance of including participants from low, medium, high, and very high-income countries in multinational studies investigating contextual and environmental factors related to childhood weight status. The findings revealed important differences between urban and rural children supporting the need to include both in study samples and especially in low- and middle-income countries where the majority of people live in rural areas. Finally, findings from this dissertation have demonstrated that despite the reported global progress in the availability of data about obesity and related factors among children and adolescents, gaps still exist and need to be filled in low- and middle-income countries.

Low and middle-income countries (LMICs) around the world are experiencing a global cancer crisis. For treatable disease, cancer specific mortality in LMICs is much higher than in high-income countries. Botswana is a middle-income country in Sub-Saharan Africa that had its population decimated by the AIDS epidemic. In the aftermath and due to the successful implementation of an anti-retroviral program, patients are living longer and are developing cancer. Cervical cancer is one of the leading causes of death in women around the world, but it is curable. Patients in Botswana live far from treatment centers and therefore often present with locally advanced disease that can be cured with a combination of chemotherapy, external beam radiation therapy and brachytherapy. The goal of this present study is to describe the challenges and implementation of brachytherapy in the country of Botswana in 2012 and to report its uses within the cervical cancer population between 2012 and 2014. The government of Botswana recognized that there was a need for in country brachytherapy to help reduce the cervical cancer burden. A public-private partnership was negotiated through the government of Botswana in order to bring brachytherapy into the country. In March 2011, a Nucletron HDR-Brachytherapy unit that uses Ir-192 was installed at Gaborone Private Hospital. Longitudinal support from international partners provided instruction in insertion, dosimetry, physics and management of complications. The initial burden of patients presented with severe cervical fibrosis and vaginal stenosis due to late presentation of disease. This resulted in numerous complications in the first treatments, which included failed insertions, perforations and bleeding. Following training and support from international partners, complications have been reduced. There are about 45 insertions performed each month, with an average of 3 insertions per patient. Introduction of HDR Brachytherapy to Botswana has led to decreased treatment time, reduced complications, increased patient compliance and projected improved survival. Implementation of brachytherapy was facilitated by a public-private partnership and onsite mentorship by expert clinicians. Further research is needed to evaluate impact on patient quality of life and survival, and whether this experience can be replicated for other tumor sites.