Background: In Pakistan, the prevalence of perinatal depression is high and is associated with adverse outcomes in both the mothers and their infant. Although effective psychosocial interventions have been developed for such settings, the scarcity of trained mental health professionals means that the majority of such women do not receive any intervention. The aim of this study was to explore the acceptability of peer volunteers (PVs) - volunteer lay women from the community with shared socio-demographic and life experiences with the target population – as delivery agents of a psychosocial intervention for perinatal depression in a rural area of Pakistan. Methods: This qualitative study was embedded in the pilot phase of a cluster randomised control trial. Participants included the entire sample of the pilot study: mothers (n=21), PVs (n=8), primary health care staff (n=5), husbands (n=5) and mothers-in-law (n=10). Data were collected, from these key stakeholders, through in-depth interviews and focus group discussions. Data analysis was underpinned by Framework Analysis involving five key stages: familiarisation, development of thematic framework, indexing, charting and interpretation. Results: All stakeholders viewed the PVs as acceptable delivery agents of a psychosocial intervention for perinatal depression. The PV’s personal attributes such as being local, empathic, trustworthy, approachable and of good reputation within their communities contributed to their acceptability. Their linkage with the primary health care system was vital to their legitimacy and credibility. Factors such as appropriateness of the intervention, effective training and supervision, perception of personal gain from the programme, and endorsement from their families and the community were motivational for them. Likely barriers to their work were women’s lack of autonomy, cultural beliefs around the perinatal period, stigma of depression, lack of some mothers’ engagement and resistance from some families. Conclusion: PVs are a potential human resource for the delivery of a psychosocial intervention for perinatal depression in this rural area of Pakistan. The use of such delivery agents could be considered for other under-resourced settings globally, and for other mental health conditions.

Background: In this paper, we examine the role of parents and teachers in inclusive education intervention programmes.  Developing countries mostly have inclusive education policies in place, but implementation in many of such nations remain a serious challenge. This implies that inclusive schools often require interventions   Aim: The aim of this study is to describe the role of teachers and parents in intervention programs targeted at improving developmental activities of children in need of support in inclusive schools in some low- and middle income countries of the southern part of Africa.   Method: A systematic review of literature was adopted. Four online databases were searched for relevant articles, using a number of pre-defined criteria. Useful data, related to the research questions were subsequently extracted from the studies   Results: Community-based rehabilitation, universal design learning, and professional development are some of the intervention types in use in the Southern part of Africa. Furthermore, teachers were observed to play the roles of education and clinical psychologists, while striving to develop relevant on-the-job skills. Parents, On the other hand, were mostly found to contribute financially to smooth running of poorly-equipped inclusive schools. Although child development was not outrightly described in the reviewed articles, it mostly served as the basis for intervention   Conclusion: This study observed that the role of teachers and parents in intervention programs will be more effective, when child developmental facilitators e.g. linking intervention to UN children convention, are boosted in schools within the Southern region of Africa. / <p>The defense of the thesis took place via zoom. My examiner sent the link for all the students in the group due for the presentation on the 19th of March, 2020 via ping pong </p>

Thesis advisor: Summer S. Hawkins / Thesis advisor: Mireya . Vilar-Compte / Child malnutrition, including overweight and stunting, is a public health concern that affects millions of families worldwide causing short- and long-term health, social and economic inequalities. The global prevalence of child overweight has increased over the past decades in countries across the economic spectrum. In contrast, the prevalence of child stunting has decreased globally yet remains the most prevalent form of child malnutrition commonly affecting children in the most vulnerable conditions in low- and middle-income countries (LMICs). Global initiatives have been adopted in response to the high burden of child malnutrition. In order to support these initiatives, researchers have focused on informing evidence-based, affordable and effective policies and interventions to prevent child malnutrition mostly within the programmatic timeframe of the first 1,000 days, conception through the first 2 years of life, and beyond. Breastfeeding has been identified as one of the key affordable and modifiable maternal health behaviors protecting against child malnutrition. However, the protective effect of breastfeeding on child malnutrition has been discrepant across findings from LMICs and high-income countries (HICs). These inconsistencies may be due to differential contextual factors in LMICs and HICs. Theoretically grounded in the World Health Organization (WHO) conceptual models on social determinants of health and childhood stunting, as well as in the Dahlgren and Whitehead model, and cultural perspectives, the goal of this 3-paper dissertation was to assess the effect of breastfeeding duration and individual, household and area factors on child malnutrition among Mexican children aged 0 to 35 months living in México (a LMIC) and in the US (a HIC). Paper 1, hereon referred to as chapter 2, assessed the association between breastfeeding duration and child overweight while sequentially controlling for individual, household and area factors in Mexican children, and also assessed a 2-level mixed-effects logistic model accounting for households clustered within areas. We curated a subset from the 2012 Mexican National Health and Nutrition Survey (ENSANUT). We found evidence for an association between breastfeeding duration and child overweight, and maternal obesity and offspring high birthweight were consistent risk factors for child overweight across models, suggesting genetic and shared environment influences. Paper 2, hereon referred to as chapter 3, used the same subset but incorporated relevant risk factors for child stunting while using the same analytical approach. We found no evidence for an association between breastfeeding duration and child stunting. However, children who were never breastfed were at higher odds for stunting compared to those breastfed <6 months. Consistent risk factors for child stunting across models were increased child age, being male, child low birthweight, maternal ethnicity (self-identifying as indigenous), maternal short stature, higher count of children aged <5 years per household, and household moderate to severe food insecurity. These findings support the intergenerational effect of early stunting and the burden of food insecurity, perpetuating the cycle of inequalities. Paper 3, hereon referred to as chapter 4, incorporated a binational approach examining the effects of breastfeeding duration and individual and household factors on child malnutrition in Mexican-American children, and then compared results with Mexican children by running separate and pooled analyses. Besides using the ENSANUT 2012 subset, we curated a new dataset using 4 waves of the 2007-2014 National Health and Nutrition Examination Survey (NHANES) which provided data for Mexican-American children aged 0 to 35 months. ENSANUT variables were recoded to match NHANES subset. We found a protective effect of breastfeeding duration on child overweight among Mexicans and in the pooled dataset. The only consistent risk factor for child overweight among Mexican and Mexican-Americans was high birthweight. Regarding child stunting, we found no evidence for an association with breastfeeding duration but low birthweight was a risk factor across both populations, while being male and living in moderate to severe food insecure households were risk factors only for Mexican children. In general, findings from this chapter coincide with previously described patterns meaning that child stunting was mostly prevalent in LMICs such as México, and that country of residence and cultural perspectives were relevant when examining child malnutrition among Mexican immigrants. Altogether, results advance the knowledge base by providing a comparison of Mexicans sharing a nurturing system while living in 2 different sustaining systems, a LMIC- and HIC-context. Findings provide evidence for shared risk factors for child malnutrition across Mexicans in both countries as well as identifying country-specific factors. While we acknowledge that the cross-sectional design of both surveys, from which we curated our subsets, limit our ability to infer causality, these results have pertinent policy and intervention implications. Pre- and post-natal culturally-sensitive components in policies and interventions need to be aimed towards preventing proximal and distal risk factors for child malnutrition within the first 1,000 days and beyond, including the promotion and support of positive maternal health behaviors such as breastfeeding. / Thesis (PhD) — Boston College, 2019. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social Work.

Introduction: Implementing low-intensity interventions, such as group-based parent education and training (PET), is a cost and time effective way of providing early intervention for families and their children with autism spectrum disorder (ASD) in low- and middle-income countries (LMICs). Relatively little empirical research demonstrates the effectiveness of parent education and training in this context. Methods: The study aimed to develop and pilot a group-based parent education and training (PET) programme (COMPAS) and determine its appropriateness and acceptability. Secondly, it aimed to investigate the clinical effectiveness of the programme to improve the communication interaction skills and self-efficacy beliefs of parents of young children with autism. The study followed an exploratory sequential mixed methods research design and used the Replicating Effective Programs (REP) framework. Sixty-one participants took part in the study which consisted of 3 phases. In phase one we developed the programme and teaching materials and activities. In the pre-implementation phase, we collected qualitative and quantitative data via questionnaires from two stakeholder groups (25 parents and 5 autism experts). In the implementation phase, we used a single group pre-test post-test design with 31 parents of children with autism to determine changes in parent-child interaction and parenting self-efficacy. The primary outcome of the implementation phase, parent-child interaction, was measured using the Parenting Interactions with Children: Checklist of Observations Linked to Outcomes (PICCOLO), and the secondary outcome, parenting self-efficacy, was measured using the Parenting Sense of Competence Scale (PSOC) and the Parenting Self-Efficacy Measuring Instrument (P-SEMI). Results: In the pre-implementation phase, a panel of experts agreed the training content was comprehensive and relevant, and that the manual was user-friendly. After the pilot study parents felt confident that they could use at least one of the strategies taught during everyday routines or play with their child. Results from the implementation phase indicated significant improvement in parenting interactions (p < .05, d = 1.26) and self-efficacy (p < .05, d = 0.35) after the training. Conclusion: We developed and piloted a training programme in a LMIC setting which resulted in increased interaction skills and self-efficacy for parents of young children with autism. This study indicates that brief, group parent education and training in a LMIC is feasible and can be effective in improving parenting skills and feelings of competence.

Philosophiae Doctor - PhD / The continuum of care is a public health framework for improving maternal health outcomes by providing comprehensive health services, at different levels of the health system and across the lifecycle. The framework emphasizes the importance of interventions to address the social determinants of health as well, alongside healthcare services. Although the framework is useful for visualizing service organization, it has not been adequately integrated into policy and practice in South Africa. In addition, there is currently no comprehensive approach to monitor and evaluate service provision along the continuum of care. The current approach is fragmented across programs and sectors and focuses on only a handful of indicators. This research explores an approach for measurement and monitoring of a comprehensive continuum of care for maternal health in South Africa, with implications for application in other low- and middle-income countries (LMICs).

Approximately 90% of adults start smoking during adolescence, with limited studies conducted in low-and-middle-income countries where over 80% of global tobacco users reside. The study aims to estimate prevalence and identify predictors associated with adolescents' tobacco use in Madagascar. We utilized tobacco-related information of 1184 school-going adolescents aged 13-15 years, representing a total of 296,111 youth from the 2008 Madagascar Global Youth Tobacco Survey to determine the prevalence of tobacco use. Gender-wise multivariable logistic regression models were conducted to identify key predictors.Approximately 19% (30.7% males; 10.2% females) of adolescents currently smoke cigarettes, and 7% (8.5% males and 5.8% females) currently use non-cigarette tobacco products. Regardless of sex, peer smoking behavior was significantly associated with increased tobacco use among adolescents. In addition, exposures to tobacco industry promotions, secondhand smoke (SHS) and anti-smoking media messages were associated with tobacco use. The strong gender gap in the use of non-cigarette tobacco products, and the role of peer smoking and industry promotions in adolescent females' tobacco use should be of major advocacy and policy concern. A comprehensive tobacco control program integrating parental and peer education, creating social norms, and ban on promotions is necessary to reduce adolescents' tobacco use.

Master of Public Health - MPH / South Africa had a stillbirth rate of 16.4/1000 in 2019. Umbiflow is a sophisticated portable continuous wave Doppler device with bidirectional indication of blood flow velocity in the umbilical cord. Umbiflow clinical trial results have indicated that several stillbirths were avoided by screening pregnant women classed as low risk. The study aimed to describe the perceptions of health professionals on the Umbiflow screening tool. The objectives were to explore the health professionals’ perceptions on the usability, acceptability and the perceived challenges with implementation of Umbiflow

In in low-and middle-income countries (LMIC), where there are very few trained physicians and nurses, community health workers (CHWs) are often the only providers of healthcare to millions of people. Such LMIC are countries that are classified, based on their geographic region and Gross National Income (GNI), as low-middle income by the World Bank Group, the worlds largest development bank. Research has shown digital health tools to be an effective strategy to improve the performance of frontline line health workers. The aim of this review was to systematically examine the literature on digital health tools that are used for decision support in LMIC and describe what we can learn from studies that have used these tools. As part of a larger parent study the following databases were searched: PubMed, Embase, Scopus, CINAHL, Global Health Ovid, Cochrane and Global Idex Medicus, to find ariticles in the following domains: training tools, decision support, data capture, commodity tracking, provider to provider communication, provider to patient communication and alerts, reminders, health information content. These domains were selected based on the World Health Organisation (WHO) framework for classifying digital health interventions. Content from all seven of these domains informed a series of reviews however this review focuses on how digital tools are used to provide decision support to FLHWs. Included studies were conducted in LMIC in Africa, Asia, North America and South America with the most common users of the tools being CHWs. Most tools for FLHW decision-support used in the interventions described in included articles were in either the pilot or prototype phases, and offered maternal and child health care services. Although decision support was the primary digital health function of all these studies, there was considerable variation in the number of digital health functions of each tool with most studies reporting decision support and data capture as their primary and secondary functions respectively. All the studies found their intervention to have beneficial effects on one or more of the following outcomes: beneficiary engagement, provider engagement, health effects and process/outputs. These findings show great potential for the use of decision support digital health tools as a means of improving the outcomes of health systems through; reducing the work load of FLHWs, reducing the costs of health care, improving the efficiency of service delivery and/or improving the overall quality of care.

Lack of access to drinking water remains widespread as 2.1 billion people live without safely managed service that includes improved water sources located on premises, available when needed, and free from contamination. Monitoring global access to drinking water is complex, yet essential, particularly in settings where households need to fetch water to meet their basic needs, as multiple factors that relate to accessibility, quantity and quality ought to be considered. The overall objective of this observational study is to increase knowledge surrounding monitoring and assessment of access to drinking water supply in low-and middle-income countries. The dissertation was comprised of five manuscripts which address the objective using various approaches including systematic review (manuscript 1), secondary data analysis (manuscript 2), and primary data analysis (manuscripts 3-5) to gather evidence towards improving access to drinking water. Primary data were collected through a seasonal cohort study conducted in Southern Malawi that included 375 households randomly selected in three different urban and rural sites. Methods used included structured questionnaires, observations, GPS-based measurements, and water quality testing. Findings from this study highlight the importance of conducting appropriate assessment of household behaviours in accessing drinking water in view of improving reliability of the indicators and methods used to monitor access to water. Seasonal variations that may affect water sources' reliability and household’s needs should be put forward to improve benefits of improving access to water and sustainable health outcomes. Further to target reliable and continuous availability from an improved water source at proximity to the household, interventions should aim to ensure safe quality of water at the point of use for mitigating the effect of post-collection contamination, and ensure sufficient quantities of water to allocate for personal and domestic hygiene. Focusing on the benefits of improving access to water at the point of consumption is essential to generate more realistic estimations, suitable interventions and appropriate responses to need. / Graduate

Background: Symptoms of depression and anxiety are highly prevalent amongst perinatal women in low-resource settings of South Africa, but there is no access to standardised counselling support for these conditions in public health facilities. The aim of this study was to report on the development of a maternal mental health counselling intervention for routine treatment of mild to moderate symptoms of depression and anxiety for primary healthcare in South Africa, as part of the Health Systems Strengthening in sub-Saharan Africa (ASSET) study. Methods: A four-phase study process informed the counselling intervention and training manual designed to train lay health workers. We first conducted a review of manuals from seven counselling interventions for depression and anxiety in low- and middle-income countries and two local health system training programmes to gather information on common counselling components used across maternal mental health and other evidence-based task-sharing interventions. Thereafter, semi-structured interviews were conducted with 20 health workers and 37 pregnant women from four Midwife Obstetric Units in Cape Town to explore mental health views and needs. In the third stage, multi-sector stakeholder engagements further informed the choice of intervention design and service provider. In the final phase, a four-day pre implementation pilot training with community-based health workers refined the counselling content and training material. Results: The manual review identified problem-solving, psychoeducation, basic counselling skills and behavioural activation as common counselling components across interventions. The interviews found that participants mostly identified symptoms of depression and anxiety in behavioural terms and lay health workers and pregnant women demonstrated their understanding through a range of contextual terms. Perceived causes of symptoms related to interpersonal conflict and challenging social circumstances. Stakeholder engagements identified a three session counselling model as most feasible for delivery as part of existing health care practices and community health workers in ward-based outreach teams as the best placed delivery agents. Pilot training of a three-session intervention with community-based health workers resulted in minor adaptations of the counselling assessment method. Conclusion: The study demonstrates how common therapeutic elements can be adapted to a local context and developed into an evidence-based manualised therapeutic programme while remaining sensitive to a health system's needs. While a problem-solving counselling approach, delivered in a structured format, was best suited for training lay health workers, input from health workers and perinatal mothers informed the manualised counselling content. The latter was a critical supplement to align the programme with contextual needs. Stakeholder engagements helped to align the intervention design to health system requirements and guidelines. Structured training practices and ongoing supervision of mental health workers are vital to develop counselling skills over time and to enhance personal support.