Maternal and child health (MCH) mortality is a formidable challenge for health systems around the world according to the World Health Organization. Health professionals and practitioners within the United Arab Emirates were studied to determine the extent they were involved in the policy-making process, and the potential impact that analysis may have on new or revised MCH policies. Research on MCH policy-making and development processes are limited. The Andersen model of healthcare services utilization provides an appropriate framework for this research, enabling the analysis that influences the policy-making process in the area of MCH. Independent variables included nationality, education, work experience, and organizational support, and the dependent variable included policy-making process. The quantitative methodology included the data collection from a sample of 380 health professionals and practitioners. The results of the study revealed statistical correlations where the most significant predictor of policy-making was organizational support, which explained the 42% variation in policy-making. This predictor was followed by nationality and education. The research adds value for decision-makers when considering and evaluating the extent of MCH policy, laws and regulations, current challenges, and strategies. The research findings could positively influence decision makers' action plan in formulating new guidelines, public policies, and strategies for the development of maternal and child health across the UAE region. Future research should aim to include other factors that may have an influence on the policy-making process.

Background Up to 34% of perinatal individuals experience childbirth as traumatic. These individuals are at increased risk for developing depression, anxiety, and posttraumatic stress disorder (PTSD) after the traumatic event. The objective of this study was to elicit the perspectives of individuals with a traumatic birth experience on barriers and facilitators to receiving mental health support in the postpartum period after a traumatic delivery. Methods Individuals who delivered within the last three years and perceived their birth experience to be traumatic (n=32) completed an hour-long semi-structured phone interview. The interview included screening for PTSD, depression, and anxiety with validated instruments including the Posttraumatic Stress Disorder Checklist for DSM-V (PCL-5), the Patient Health Questionnaire depression scale (PHQ-8), and the Generalized Anxiety Disorder scale (GAD-7), respectively. Qualitative data was analyzed using a modified grounded theory characterizing participants’ barriers and recommendations for mental health support after traumatic births. Results Among participants, 34.4% screened positive for PTSD, 18.8% screened positive for major depressive disorder, and 34.4% screened positive for anxiety. Qualitative themes revealed multi-level barriers involving lack of communication, education, and resources which prevented obstetric professionals from recognizing and supporting patients’ mental health needs after a traumatic birth. Recommendations from participants included that 1) obstetric professionals should acknowledge trauma experienced by any individual after childbirth, 2) providers of multiple disciplines need to be integrated into postpartum care, and 3) mental health support is needed before the ambulatory postpartum visit. Conclusions There are multi-level barriers toward detecting and responding to individuals’ mental health needs after a traumatic birth. Obstetric professionals need to use a trauma-informed approach and proactively follow-up and assess mental health care in the postpartum period.

The current exploratory study, as part of the Massachusetts Farm Fresh (MAFF) research project: 1) examined the effect sensory attributes (i.e. taste profile, color, shape, texture, growth pattern) of the target vegetables have on children’s willingness to explore and consumption and 2) compared these outcomes for: facilitator-guided (FG), vs. children’s self-guided (SG) exploration. We conducted a 6-week multi-sensory nutrition education intervention with Western Massachusetts Head Start preschoolers (3-5 years of age; n=94 children) using eight vegetable pairs; outcome measures were recorded by observers. Data were analyzed using SPSS version 20.0. Results are reported for 50 children with complete data at both baseline and follow-up. Willingness improved from baseline (40-50% of children = SCORE O) to follow-up (20-40% = SCORE 0) for all vegetables. Willingness scores (1) increased for “lower-sugar” vegetables (broccoli, cauliflower, green bean, radish) (p=.013) (2) were lower for white vegetables (cauliflower, parsnip) versus the other color categories (red, green, orange) and (3) were higher for both pod (sugar snap peas, green beans) and long-root (carrot, parsnip) versus root vegetables (beet, radish). Pre-post mean (SE) consumption (g) increased for carrots (p=.013) (2.45+/-.39 vs 3.49+/-.43) and radishes (p=.023) ( .90+/-.22; vs 1.45+/-.29) ). At follow-up consumption of ”higher-sugar” vegetables was greater (p=.000) and carrot-parsnip pair was higher than broccoli-cauliflower (mean difference 1.49+/-.51) (p=.005) and beet-radish1.01+/-.55) (p=.071) pairs. Overall, children’s willingness and consumption varied by sensory attributes of the vegetables. The multi-sensory approach successfully activated children’s senses while providing exposure to a variety of local vegetables in the Head Start setting.

Introduction: In recent years, high quality contraceptive care for adolescents has shifted away from tiered effectiveness counseling and toward youth-friendly, patient-centered counseling (YFPCCC). YFPCCC is essential in the South, which has higher rates of sexual activity, lower rates of contraception use, and higher teen birth rates. This study examined Southern clinics’ characteristics which support YFPCCC and youth’s perceptions of the contraceptive care they receive. Methods: This mixed methods study examined secondary data collected in two surveys and primary data collected through key-informant interviews. The first survey examined clinic characteristics impacting YFPCCC, and the second survey examined adolescents’ (aged 16-24) perspectives of their care. For each survey, outcome measures were dichotomized and examined through logistic regression models. Lastly, interviews with administrators at FQHCs and HDs in AL and SC and examined the facilitators and barriers to providing YFPCCC in these clinics. Results: FQHCs were 89% less likely to notify youth of their right to confidentiality (aOR 0.11, 95% CI (0.05, 0.26)) and 80% less likely to notify youth of their right to consent to care (aOF 0.20, 95% CI (0.10, 0.40)). Non-Hispanic Black youth were 47% less likely to receive patient-centered contraceptive care (aOR 0.53, 95% CI (0.40, 0.70)). Minor youth (ages 16-17) were 34% less likely to receive patient-centered contraceptive care (ages 20-24) (aOR 0.66, 95% CI (0.45, 0.98)). Clinic administrators noted the continued use of tiered effectiveness counseling. SC administrators noted that minor youth were allowed to consent to receiving the implant but could not consent to removing it. Discussion: Overall, clinic capacity to provide YFPCCC varied by clinic type, with FQHCs less likely to have notify youth of their rights to consent to and receive confidential contraceptive care. The receipt of YFPCCC varied by youth’s age and race/ethnicity, with minors and non-Hispanic Black youth being less likely to report YFPCCC. Clinic administrators noted that they continue to use the tiered effectiveness model of counseling, which may inadvertently pressure or coerce youth. To improve their capacity to provide YFPCCC, clinics should enhance their policies protecting consent and confidentiality and ensure that their providers are trained in patient-centered contraceptive care for youth.

Indoor tanning (IT) before the age of 35 increases one’s risk for melanoma by 75%, and epidemiological data show a 6.1% annual increase in the incidence of melanomas in white women younger than age 44 in the US. Population-based studies reveal that 15% of adolescents and 8% to 14% of their primary caregivers have engaged in IT in the past year. The compelling case for IT being a significant risk factor for melanoma, together with the high rates of IT in teen girls and their mothers, provided a strong rationale for conducting an antitanning intervention directed at mother-daughter dyads. This study evaluated a strategy designed to prevent skin cancer in adolescent girls by using mothers as change agents to effectively communicate the risks of IT and to encourage teens to avoid high risk IT behaviors. Mother-daughter dyads were recruited over the telephone, randomly assigned to the intervention or control group, and surveyed on IT risk constructs including tanning-specific knowledge and communication. Forty-two mother-daughter dyads completed baseline surveys in the summer of 2012. Mothers in the intervention group were given a handbook educating them on the dangers of IT and how to convey information about skin cancer prevention to their daughters and encouraged to talk with their daughters about the issues covered in the handbook over a 1-month period. Participants completed follow-up assessments in October 2012 and January 2013. Among teens, past 3-month IT frequency, intentions, and willingness decreased in intervention group teens, while intentions and willingness increased among control teens. Intervention teens exhibited lower IT attitudes and higher levels of perceived susceptibility to appearance damage and health effects from IT when compared to control teens. Intervention teens reported higher levels of maternal monitoring and lower levels of maternal permissiveness toward IT. Qualitative data indicated mothers responded positively to the handbook, and it encouraged tanning-specific discussions with their daughters. Mothers provided suggestions on how to improve the handbook, that once incorporated, should lead to improved intervention efficacy. Overall, study results indicated this intervention strategy is feasible, as mothers did communicate with their teens and were able to convey the antitanning messages.

<p>We defined hypertension in pregnancy as a composite of gestational hypertension, preeclampsia and eclampsia. The etiology of hypertension in pregnancy remains controversial. The three chapters of this thesis explore the risk of hypertension in pregnancy from various kidney conditions. Chapter 1 introduces the reader to the thesis. Chapter 2 is a systematic review that studied the risk of developing hypertension in pregnant women with chronic kidney disease but not on dialysis. We found that women with chronic kidney disease had at least a twofold higher relative risk of developing hypertension during pregnancy compared with women having no chronic kidney disease. Chapter 3 is a retrospective study looking at the risk of developing gestational hypertension and preeclampsia in women who had symptomatic gastroenteritis after drinking water infected with <em>E. coli</em> O157:H7 during the Walkerton outbreak in May 2000. We conducted this study using linked datasets at the Institute of Evaluative Sciences (ICES) Toronto, Ontario. We observed that there was no increased risk of developing gestational hypertension or preeclampsia among the symptomatic women compared with women from the neighbouring towns who were asymptomatic or did not drink the water. Chapter 4 is a protocol of a prospective cohort study recruiting female kidney donors and healthy non-donors as the comparative group to study pregnancy outcomes in these individuals. This is a multicentre study involving 12 transplant centres throughout Canada. There are 59 participants in this study to date (Feb 28, 2013) of which seven have been pregnant so far. Data collection for this study is ongoing.</p> / Doctor of Philosophy (PhD)

<p>Thank you to all who were involved in this research including Drs. Benicio Frey,<br />Sue Becker, Margaret McKinnon, Luciano Minuzzi, and Lauren Cudney and Marg Coote. I would like to express my very great appreciation to the midwives at Community Midwives of Hamilton for enabling me to visit the clinic and recruit their pregnant clients. Finally, I would like to thank Lorenda Williams, John Williams, and Eric Johnson for their continued support.</p> / <p>Postpartum depression (PPD) is a serious disorder associated with debilitating effects on mothers and their infants. A previous history of depression appears to be the strongest risk factor for PPD. Previous studies showed that individuals with history of depression accurately recall more negative compared to positive content. The objective of this study was to compare emotional memory for negative and positive images between pregnant women with previous depressive episodes and pregnant women with no lifetime depression. This is the first study to investigate emotional memory in pregnant women with or without previous history of Major Depressive Disorder (MDD). A total of 77<br />participants between the ages of 18 - 44 (mean age: 27.3  6.2yo) completed the study (14 pregnant women with previous depressive episodes, 30 pregnant women with no lifetime depression, 13 non-pregnant women with previous depressive episodes, and 20 non-pregnant healthy). Participants took part in an emotional encoding task consisting of positive, negative, and neutral images from the International Affective Picture System (IAPS) where they were asked to rate these images based on perceived emotional intensity. Participants returned a week later for a surprise incidental recognition memory task. A multivariate general linear model revealed a significant main effect of group (F(1,71)= 8.04, p=.01). Women with history of MDD demonstrated poorer memory performance than women with no history for negative images, but the two groups did not<br />differ on memory for positive images. This suggests that having a history of depression selectively impaired the memory recognition of negative images.</p> / Master of Science (MSc)

This dissertation was completed in partial fulfillment of the Doctor of Public Health program at East Tennessee State University. The dissertation follows the Manuscript Format which includes three manuscripts, these manuscripts regard familial sex trafficking and are as follows, a scoping review, an empirical study on regional familial sex trafficking, and a policy implications paper on criminal record relief for survivors of familial sex trafficking. The scoping review includes eight peer reviewed studies on familial sex trafficking and a summary of grey literature. Thematic analysis was used to map the existing literature onto the Three Ps of human trafficking: Prevention, Protection, Prosecution, and a 4th crosscutting element Partnership. The scoping review summarized these characteristics and found that familial sex trafficking remains widely understudied and needs better data, awareness, training, and collaborations. The empirical study interviewed 10 individuals who had expertise or lived experience working with perpetrators or victims/survivors of familial sex trafficking in East Tennessee. This study found that like previous literature, the social determinants of health influence this form of abuse. Further, it contextualized the experience of traffickers, their vulnerabilities, and how these vulnerabilities tempted them into familial sex trafficking to meet their basic needs. This study highlights gaps in awareness, training, and programming for prevention and survivor support. The final paper, the policy implication paper, leverages data collected from the empirical study to demonstrate the reality of forced criminality during familial sex trafficking victimization and how criminal records impact recovery. This paper further explores the implications for developing policy and promising practices to further inform policy development. In summary, these manuscripts were carried out in partial fulfillment of the Doctor of Public Health program at East Tennessee State University.

Opioid use disorder (OUD) impacts 5.6 million people in the US. Buprenorphine (BUP) is a commonly prescribed opioid medication used to treat OUD, including in pregnant women. However, opioid use during pregnancy is associated with poorer infant outcomes including reduced fetal growth, neurodevelopmental deficits, and neonatal opioid withdrawal syndrome (NOWS). Recent clinical data suggests that providing mothers with a lower dose of BUP may result in fewer negative outcomes in infants. Here, a preclinical rodent model of low-dose perinatal BUP exposure was used to study offspring health outcomes in the neonate, juvenile, and adolescent offspring. Dams were given clinically relevant doses of BUP prior to and throughout gestation, and continuing through weaning to mimic human doses and exposure. Although the lowest BUP dose still elicited signs of NOWS in offspring, there were fewer negative effects on overall brain morphology across the early lifespan than that of the higher BUP dose compared to controls.

This study offers insights into the impact of competition among Managed Care organizations (MCOs) on infant birthing charges and birth outcomes. Kentucky provides one of the nation’s first case studies to determine successes and failures of Medicaid MCOs, and by doing so, provides a prediction of the impact of Patient Protection Affordable Care Act (PPACA) competition on healthcare costs and birth outcomes. An analysis of a natural policy experiment in the state of Kentucky reveals that infants insured by a Medicaid MCO stay longer in hospitals, are less healthy, and cost more than those insured under Traditional Medicaid prior to a policy change. Utilizing a difference-in-difference-in-difference (DDD) estimation, this study found initial evidence in a competitive MCO environment of Traditional Medicaid average birth charges substantially more than births under a Medicaid MCO, while outcomes also revealed the incidence of normal delivery increased almost identical to that of private insurance. However, after a short time, average birth charges for infants born under Medicaid MCO climb higher than other payer-types and infant health begins to decline. Outcomes of this study signal that Managed Care infants are actually less healthy and cost substantially more than anticipated but it is possible that these outcomes can be attributed to insurance selection.