Stroke survivors in low-resource settings like Rwanda often face high levels of disability, and access to rehabilitation care is limited. To effectively allocate resources, it is crucial to understand and address the most significant concerns of stroke survivors and explore contextually appropriate approaches to post-stroke care. We conducted a needs assessment survey of 337 patients from six hospitals in Rwanda, collecting data at discharge and three months post-stroke. Rwandan stroke survivors have similar unmet functional needs as those in high-resource settings. However, over half of the participants still reported moderate to severe mobility, usual activities, and social/recreational activities needs at three months post-discharge. Stroke survivors indicate that limited access to services was a significant barrier to addressing these needs. Community-based interventions may be an important method for addressing these needs; however, rehabilitation services are limited, warranting the need to consider alternative strategies to address these needs. The thesis explores the potential of involving community health workers (CHWs) in providing rehabilitation interventions for stroke survivors in community settings. Although the effectiveness of CHWs in providing physical rehabilitation interventions in low-resource settings remains uncertain and sustainability of these interventions outside the studied context is also unclear. Subsequent the use of CHWs for post-stroke rehabilitation is a worthwhile endeavor. To facilitate the implementation of CHW-delivered interventions, two crucial steps were considered: the development of an intervention and establishing an operational team that will ensure implementation success. A multi-phased process was used to design a new evidence-informed post-stroke community-level mobility intervention suitable for low-resource settings. The Rehabilitation Treatment Specification System enabled the intervention design and description toward facilitating its accurate replication. The next step is to test the intervention’s feasibility, effectiveness, and implementation in low-resources settings. / Thesis / Doctor of Philosophy (PhD) / The issue of post-stroke disability is significant in Rwanda due to limited resources for stroke survivors. To improve the resources available for stroke survivors in such settings, it is important to understand their specific needs and explore alternative approaches to provision of interventions. We surveyed 337 patients from six hospitals in Rwanda to describe their functional unmet needs after stroke and at three months. Within 90 days of stroke, Rwandan stroke survivors have more moderate to severe functional needs in almost all usual activities, which is twice compared to post-stroke unmet needs for stroke survivors living in areas with post-stroke resources. Three months after leaving the hospital, over half of the participants still have moderate to severe functional needs in mobility and other usual activities, working, and social/recreational activities. Rwandan stroke survivors identified that not being able to use therapy services made it difficult to address these needs. These data indicate it is crucial to focus on community-based interventions to address the needs of stroke survivors. In my research, I investigated whether Community Health Workers (CHWs) could administer rehabilitation treatment in resource-limited areas. Although the effectiveness of physical rehabilitation by CHWs is uncertain, there is potential for CHWs to participate in delivering rehabilitation. It is worth considering the use of CHWs for post-stroke rehabilitation. In order to successfully implement CHW-delivered interventions, two important steps were considered. First, an intervention was developed. Second, an operational team is being established to ensure the intervention’s success. The process of designing a new evidence-informed post-stroke community-level mobility intervention suitable for resource-limited areas, consisted of multiple phases. The Rehabilitation Treatment Specification System was used to design and describe the intervention accurately so that it could be replicated easily. The next phase involves examining if the intervention is practical, efficient, and can be successfully implemented in areas with limited resources.

Student Number : 8403267 - PhD thesis - School of Pathology - Faculty of Health Sciences / Sub-Saharan Africa is the eye of the HIV epidemic. This study was conducted when treatment for the majority of HIV-infected patients in low resource settings was considered unattainable and the risks of diagnosing HIV often outweighed the benefits. Coupled with the complexities of HIV diagnosis in infancy, children typically were only diagnosed once already ill or not at all. Key strategies to address the paediatric epidemic focused on preventing mother to child transmission and reducing mortality and morbidity of infected children predominantly with co-trimoxazole prophylaxis. Both strategies required early diagnosis of HIV infection in infancy for monitoring prevention programs and identifying infected children respectively. The diagnostic algorithm for resource limited settings recommended the use of inexpensive, technically simpler HIV antibody detection assays that are unsuitable for use in HIV-exposed children under 12-months of age. Paradoxically this algorithm provided a barrier to HIV diagnosis in children because of high loss to follow-up rates and death in the first year of life. The objective of this study was to establish an accurate, affordable diagnostic algorithm for early diagnosis of HIV infection that could be rapidly implemented in South Africa and benefit other resource limited settings. The HIV infection status of 300 vertically exposed infants was determined according to first world criteria in a prospective, cohort study at Coronation Hospital, Johannesburg over 21 months. This status was used to assess the accuracy of clinical examinations and HIV assays in diagnosing HIV at 6-weeks, 3-, 7- and 12-months of age. The average cost of determining an infant’s HIV infection status was measured. A single HIV DNA PCR test at 6-weeks of age proved highly accurate in determining HIV status at a marginally increased cost to government and was incorporated by the South African Department of Health into national policy. The ultrasensitive p24 antigen assay and HIV antibody detection assays on serum and oral fluid were identified as valuable candidates where PCR testing is unavailable. Dried blood spot samples from heelpricks are critical for policy to be translated into practice since skills to perform venesection in 6-week old babies are limited. The next challenge lies in operationalising these findings at a clinical and laboratory level to the benefit of the 300 000 South African children annually exposed to HIV at birth. The urgency of early diagnosis has been increased by the availability of highly effective antiretroviral therapy.

This study examined the dynamics, challenges and opportunities of developing innovation systems in low resource settings with a particular focus on Uganda. It applied perspectives of technoscience and concepts of innovation systems, triple helix as university-industry-government relationships, mode 2 knowledge production and situated knowledges in understanding the context, identifying key policy issues and suggesting ways to address them. A mixed methodology combining both quantitative and qualitative methods was used in the study. It involved review of key policy documents, key informant interviews, focus group discussions and meetings with scientists, business leaders in the target organizations and firms, community members as well as observations of production processes in firms. Findings underscore the need for greater interaction and learning among actors in the emerging innovation systems in Uganda and eastern Africa. An opportunity for this to happen may be the growing number of entrepreneurial initiatives at the university and some public research organizations in the country. These entrepreneurial initiatives are driven by scientists, who are enthusiastic about moving their research results and innovations to market. This makes it plausible, in low resource settings like in Uganda, to promote the university working closely with public research organizations and firms as a locus for research and innovation. However, enabling conditions, which foster interaction and learning among actors, should be put in place. First, there is need to formulate specific policies and strategies with clear goals and incentives to promote growth of particular innovation systems. Second, a clear national policy for financing research and innovation is needed, which involves on the one part core funding to universities and research organizations, and on the other, competitive grants for research and innovation. Third, business incubation services should be established and/or supported as places where entrepreneurial scientists and other persons develop and test their business ideas and models. Fourth, there is need for institutional reforms to make administrative processes less bureaucratic, more costeffective and efficient. These reforms are necessary for example in processes involving procurement and financial management, research project approvals (for ethics and safety), technology assessments, contracting and licensing and other registration services. The findings and conclusions from this study demonstrate that technoscientific perspectives and innovation systems approaches can be adapted and used as a framework for identifying and explaining conditions that promote or hamper innovation in low resource settings as well as policy options to address them.

No / A culturally sensitive approach needs to be adopted in disseminating evidence-based preventive programs internationally, and very little is known about effective dissemination into low-resource settings such as low and middle income countries. Following guidelines on optimizing the fit of evidence-based parenting programs worldwide, a cultural relevance study was conducted in Panama, Central America. Parents (N = 120) from low-resource communities were surveyed to explore cultural relevance of material from the Triple P-Positive Parenting Program. Intention to participate and views on delivery formats and program features were also examined. Descriptive statistics and regressions were carried out to analyze the results. Parents found program materials highly relevant and reported that they would be willing to participate in a program if one was offered. A large proportion of the sample expressed a preference for self-directed formats such as books, articles and brochures (77.6 %). Regression analyses suggested that most parents considered material as relevant, interesting and useful, regardless of other factors such as socio-economic status, gender, the level of child behavioral difficulties, parental stress, parental confidence and expectations of future behavioral problems. The study provides a potential approach for dissemination of research and offers an insight into the needs and preferences of a particular segment of the world’s population—parents in low-resource settings. Strategies for meeting the needs and preferences of these parents in terms of service delivery are discussed.

A sharp increase in caesarean section (CS) rates at the Muhimbili National Referral Hospital (MNH) – a tertiary referral hospital in Tanzania – by 50% in 2000–2011, was associated with concomitant increase in maternal complications and deaths and inconsistent improvement in newborn outcomes. The aims of this thesis were to explore care providers’ in-depth perspective of the reasons for these high rates of CS, and to evaluate and improve standards of care for the most common indica-tions of CS, obstructed labour and fetal distress, which are also major causes of adverse maternal and neonatal outcomes. This thesis reports an investigation performed at MNH, Tanzania. For Paper I, qualitative methods were employed and demonstrated how care providers dismissed their responsibility for the rising CS rate; and, instead, projected the causes onto factors beyond their control. Additionally, dysfunctinal teamwork, transparency, and previous poorly conducted clinical audits led to fear of blame among care providers in cases of poor outcome that subsequently encougared defensive practise by assigning unnecessary CS. Papers II and III evaluated stand-ards of care using a criteria-based audit (CBA) of obstructed labour and fetal dis-tress. After implementing audit-feedback recommendations, the standards of diag-nosis of fetal distress improved by 16% and obstructed labour by 7%. Similarly, the standards of management preceding CS improved tenfold for fetal distress and doubled for obstructed labour. The impact of the CBA process was evaluated by comparing the maternal and perinatal outcomes categorized into Robson groups (Paper IV) of all deliveries occurring before and after the audit process (n=27,960). After the CBA process, there was a 50% risk reduction of severe perinatal morbidi-ty/mortality for patients with obstructed labour. The overall CS rates increased by 10%, and this was attributed to an increase in the CS rate among breech, term preg-nancies (Robson group 6), and preterm pregnancies (Robson group 10) that specifi-cally had reduced risk of poor perinatal outcome. The overall neonatal distress rates were also reduced by 20%, and this was attributed to a decrease in the neonatal distress rate among low-risk, term pregnancies (Robson group 3). Importantly, the increased rates of poor perinatal outcomes were associated with referred patients that had higher risk of neonatal distress and PMR than non–referred patients, after CBA process.  In conclusion, the studies managed to educate the care providers to take on their roles as decision-makers and medical experts to minimize unnecessary CS, using the available resources. Care providers’ commitment to achieve the best practice should be sustained and effort for stepwise upgrading quality of obstetric care should be supported by the hospital management from the primary to tertiary referral level.