Philosophiae Doctor - PhD / The United Nations (UN) Millennium Development Goals (MDGs) drafted eight goals to be achieved by the year 2015, namely: eradicating extreme poverty and hunger, achieving universal primary education, promoting gender equality and women empowerment, reducing child mortality, improving maternal health, combating HIV/AIDS, malaria and other diseases, ensuring environmental sustainability and lastly developing a global partnership for development. Many public health studies often result in complicated and complex data sets, the nature of these data sets could be clustered, multivariate, longitudinal, hierarchical, spatial, temporal or spatio-temporal. This often results in what is called correlated data, because the assumption of independence among observations may not be appropriate. The shared genetic traits in the studies of illness or shared household characteristics among family members in the studies of poverty are examples of correlated data. In cross-sectional studies, individuals may be nested within sub-clusters (e.g., families) that are nested within clusters (e.g., environment), thus causing correlation within clusters. Ignoring the structure of the data may result in asymptotically biased parameter estimates. Clustered data may also be a result of geographical location or time (spatial and temporal). A crucial step in modelling correlated data is the speci cation of the dependency by choosing the covariance/correlation function. However, often the choice for a particular application is unclear and diagnostic tests will have to be carried out, following tting of a model. This study's view of developing countries investigates the prospects of achieving MDGs through the development of flexible predictor statistical models. The first objective of this study is to explore the existing methods for modelling correlated data sets (hierarchical, multilevel and spatial) and then apply the methods in a novel way to several data sets addressing the underlying MDGs. One of the most challenging issue in spatial or spatio-temporal analysis is the choice of a valid and yet exible correlation (covariance) structure. In cases of high dimensionality of the data, where the number of spatial locations or time points that produced the observations is large, the analysis of such data presents great computational challenges. It is debatable whether some of the classical correlation structures adequately reect the dependency in the data. The second objective is to propose a new flexible technique for handling spatial, temporal and spatio-temporal correlations. The goal of this study is to resolve the dependencies problems by proposing a more robust method for modelling spatial correlation. The techniques are used for di erent correlation structures and then combined to form the resulting estimating equations using the platform of the Generalized Method of Moments. The proposed model will therefore be built on a foundation of the Generalized Estimating Equations; this has the advantage of producing consistent regression parameter estimates under mild conditions due to separation of the processes of estimating the regression parameters from the modelling of the correlation. These estimates of the regression parameters are consistent under mild conditions. Thirdly, to account for spatio-temporal correlation in data sets, a method that decouples the two sources of correlations is proposed. Speci cally, the spatial and temporal e ects were modelled separately and then combined optimally. The approach circumvents the need of inverting the full covariance matrix and simpli es the modelling of complex relationships such as anisotropy, which is known to be extremely di cult or Lastly, large public health data sets consist of a high degree of zero counts where it is very di cult to distinguish between "true zeros" and "imputed" zeros. This can be due to the reporting mechanism as a result of insecurity, technical and logistics issues. The focus is therefore on the implementation of a technique that is capable of handling such a problem. The study will make the assumption that "imputed" zeros are a random event and consider the option of discarding the zeros, and then model a conditional Poisson model, conditioning on all cases greater than 0.

Background: The prevalence of childhood overweight in the United States continues to be a national public health problem. The child care and household environments play an important role in the nutrition, physical activity, and screen-time behaviors of preschoolers. Aims: This dissertation aimed to (1) estimate the prevalence of overweight and obesity in 3-5 year old children enrolled in child care centers in Miami-Dade County; (2) identify early life, dietary, and screen-time risk factors of overweight, and (3) assess child care centers' level of adherence to nutrition, physical activity, and screen-time regulations by center socioeconomic location (SEP). Methods: A total of 366 children ages 3-5 years old from 34 child care centers participated in the study. Caregivers completed a questionnaire on socioeconomic, early life, dietary, and screen-time factors. We measured children's heights and weights. Chi-square and logistic regression analyses were used to examine the association between child overweight and determinants. Results: the prevalence of overweight was 29.8% in this sample. The middle-SEP group had the highest prevalence of overweight (35.3%) when compared to low and high-SEP groups. Being Hispanic was associated with a three-fold risk of overweight/ obesity (AOR: 2.91, 95% CI 1.36, 6.21). Lack of daily fruit consumption increased the risk of overweight in Hispanic children. Middle-SEP children reported lowest consumption of fruits and vegetables. There were significant differences in breastfeeding practices by ethnicity and SEP. Assessment of child care practices resulted in all child care centers adhering to two-hour screen-time regulation for children older than 2-years old. Low and middle SEP centers fared better in serving of fruits , vegetables, and low fat/ fat free milk. The centers had incorporated quite and active play in their routines. Conclusions: This is the first study to examine prevalence by SEP in Miami-Dade County. Findings highlight opportunities for improvement in early life nutrition, as well as dietary and screen-time practices in the household and child care environments.

More than 85% of American adults do not consume recommended amounts of fruits or vegetables. Preterm birth and hypertensive disorders of pregnancy are common adverse conditions affecting pregnancy and are leading causes of maternal and fetal morbidity and mortality. Preterm birth affects nearly 10% of all births in the United States and is on the rise, as are hypertensive disorders, which have increased by 25% over the last two decades. Pregnancy is a state of controlled inflammation, and dysregulation has been linked to preterm birth and other adverse gestational outcomes. A healthy diet is recommended in pregnancy, but little is known about the effect fruit and vegetable intake on perinatal outcomes. Omega-3 (n-3) fatty acids are essential dietary components and are known to affect inflammatory state, but little is known about how they affect inflammation in pregnancy. As current evidence is lacking, further research is needed to investigate the relationships between maternal nutrition in pregnancy, inflammation and birth outcomes. The purposes of this dissertation were to: 1) to review and evaluate the current evidence on the relationship between n-3 fatty acids and inflammation in pregnancy; 2) to evaluate the current state of the science on the impact of maternal dietary consumption of fruits and vegetables on preterm birth, gestational diabetes, preeclampsia, small for gestational age, gestational weight gain and measures of inflammation or oxidative stress in pregnancy; and 3) to examine relationships between maternal dietary intake of fruits and vegetables, cytokine expression in early and mid-pregnancy, preterm birth and gestational hypertension. A critical review of literature examining the relationship between inflammation and n-3 intake during pregnancy found that multiple inflammatory cytokines in maternal and fetal tissues were lower in women who received n-3 supplements. A second review of literature review supported an inverse relationship between fruit and vegetables and risk of preeclampsia and suboptimal fetal growth. The available evidence was insufficient to establish relationships between fruit and vegetable intake and gestational diabetes, preterm birth or inflammation. A study evaluating the relationships between maternal fruit and vegetable intake, inflammation and birth outcomes was conducted. This study provided evidence supporting a relationship between first and second trimester cytokine expression and maternal dietary intake of fruits and vegetables. Those who met recommended vegetable intake in the first trimester had higher first trimester serum CRP, IL1-α, IL-6 and TNF-α and lower first trimester cervicovaginal IL-6 levels. Those who met recommendations for first trimester fruit intake had 56% lower risk for preterm birth. Those who met second trimester vegetable intake recommendations had more than twice the risk of developing gestational hypertension. The results of this dissertation provide support for the beneficial effects of omega-3 fatty acids and fruit and vegetable intake in pregnancy. Maternal intake of these dietary components may promote optimal immune status during pregnancy. Supplementation of maternal omega-3 fatty acids may help regulate inflammation via the anti-inflammatory effects their bioactive eicosanoids exert. Fruit and vegetables have antioxidant and anti-inflammatory effects that may also help balance the inflammatory state during pregnancy. These dietary components may help promote favorable immune status during pregnancy and reduce risk of adverse perinatal outcomes such as poor fetal growth, hypertensive disorders of pregnancy and preterm birth.

The purpose of this study was to measure and evaluate parental knowledge and misconceptions with regard to asthma and its treatment, to identify parental concerns with regard to the disease and its effects on their children, and to identify selected socio-demographic and medical correlates of the above. A cross-sectional survey was conducted among 54 families with a child with asthma. The sample comprised all the parents of a consecutive series of asthmatic patients between the ages of two to eighteen years attending a family practice in Mandalay on the Cape Flats. Data were collected by means of a structured questionnaire administered to 52 mothers and 48 fathers, reflecting a 95.2 per cent response rate. Respondents completed the questionnaire in their homes. A 55 item Asthma Knowledge Test was developed and validated to assess medical knowledge. Parents obtained an average score of 72%. Scores of over 70% were obtained in the sub-sections of aetiology, symptomatology, pathophysiology, precipitants and environmental control. Parents were less informed in the sub-sections of asthma prognosis, general medical knowledge and asthma therapy. Misconceptions and deficiencies in asthma knowledge which could lead to inadvertent non-compliance were identified. The following misconceptions were shared by a significant number of parents: inhaler therapy weakens the heart, regular administration of medication leads to addiction and medicines becoming ineffective, and folk remedies are effective in asthma therapy. Parental educational status was the only significant correlate with performance on the Asthma Knowledge Test. There was no significant difference in the performances of mothers and fathers. 47% of parents smoked but there was no significant difference in the scores of smokers and non-smokers. Parental concerns centred predominantly on their lack of confidence to manage acute asthma attacks, followed by concern as to whether their children will outgrow asthma. Dependence on asthma medication and its perceived harmful effect on the heart and lungs were other concerns. The findings suggest the need for systematic asthma education especially with regard to acute attack management and preventive medications. The aims of such education should be to increase asthma knowledge, develop skills, improve attitudes, and develop positive expectations toward the outcome and effectiveness of treatment. An effort should be undertaken to discourage parental smoking in asthmatic families. Attention should be given to dispel misconceptions during educational programmes. The increased information needs of parents with a lower education should be addressed by health professionals. Parents should receive adequate information during the early stages of the disease to minimise their insecurity in coping with the illness and prevent the development of misconceptions that undermine their confidence in medications and care givers.

In the US, 8.4% of children are diagnosed with asthma by age 18, making asthma one of the most common chronic conditions among children. Additionally, 25% of children experience persistent wheezing by age 6, an indicator of childhood asthma. Both childhood asthma and persistent wheezing may be linked to inflammatory and immune mechanisms, which are associated with inadequate and excessive gestational weight gain. Studies investigating the relationship between gestational weight gain and offspring asthma and wheeze phenotypes are limited by self-reported gestational weight gain, early age at asthma and wheeze assessments, limited adjustment for potential confounders and no trimester-specific evaluations. Therefore, we investigated the association between total and trimester-specific gestational weight gain, offspring asthma and wheeze phenotypes among 2128 mother-child pairs in Project Viva, a prospective cohort study in eastern Massachusetts. Gestational weight gain was abstracted from medical records and self-reported prepregnancy weight, and defined both continuously and using Institute of Medicine guidelines. Offspring asthma was obtained via maternal report at approximately 7 years, while wheeze trajectories were derived via latent class mixed models based on presence of wheeze between 1 and 9 years, inclusively, via maternal report. We investigated the relationship between gestational weight gain, offspring asthma and wheeze phenotypes using multivariable regressions and predicted probabilities, adjusting for important covariates. Most women had excessive gestational weight gain (56%), while 31% had adequate gestational weight gain and 13% had inadequate gestational weight gain. Approximately 18% of children had current mid-childhood asthma, 13% had early transient wheeze and 13% had persistent wheeze. We found a non-linear association between total gestational weight gain and offspring current mid-childhood asthma. Additionally, there was a 36% decreased odds of early transient wheeze among children of mothers with excessive third trimester gestational weight gain (aOR= 0.64; 95% CI: 0.42-0.98). This study adds to the body of literature by incorporating adequate inclusion of confounders and risk factors for adjustment, as well as being the first study to evaluate the association between trimester-specific gestational weight gain, offspring asthma and wheeze phenotypes.

Background: Hypertension during pregnancy is a leading cause of birthing parent mortality and adverse pregnancy outcomes. Since non-metropolitan communities face higher rates of several risk factors for hypertension in pregnancy and shortages in obstetrical services, persons residing in non-metropolitan areas may be at increased risk for adverse outcomes compared to those living in metropolitan areas. Our study objectives were to examine by county of birthing parent residence (1) the prevalence of chronic hypertension (cHTN) and hypertensive disorders of pregnancy (HDP), and (2) the prevalence of adverse birthing parent and neonatal outcomes associated with hypertension. Methods: Using U.S. birth certificate data from 2016 to 2018, we described the prevalence of cHTN and HDP and the association of each with several birthing parent and neonatal outcomes, stratified by non-metropolitan versus metropolitan county of birthing parent residence. Multivariable Poisson regression models were used to calculate adjusted prevalence ratios for birthing parent and neonatal outcomes among individuals with cHTN or HDP who lived in non-metropolitan versus metropolitan U.S. counties. Results: The prevalence of cHTN and HDP for US live births was 2.2% and 7.4%, respectively, among non-metropolitan pregnant individuals and 1.8% and 6.6%, respectively, among metropolitan pregnant individuals. After adjusting for several sociodemographic characteristics among those with HDP, the prevalence ratio for an APGAR score < 7 at 5 minutes (aPR 1.34, 95% CI 1.29-1.38) and neonatal death (aPR 1.36, 95% CI 1.15-1.62) was increased among offspring born to women who resided in non-metropolitan counties. Similar results were seen among those with cHTN. Conclusion: The prevalence of cHTN and HDP is modestly more prevalent in non-metropolitan areas, but most pregnancy outcomes were similar among those residing in non-metropolitan areas compared to metropolitan areas. Further research should investigate the robustness of these findings using alternate definitions of rural and urban areas and the possible link between low APGAR score, low NICU admission, and neonatal death in non-metropolitan counties.

It takes two to tango! However, family planning programmes in most countries especially in Sub-Saharan Africa have focused almost solely on one - the female-invariably with little impact. The few attempts which have been made to involve males have concentrated on the adult male. It was felt the time had come to involve the adolescent males most of whom are already sexually active and after all are the husbands and fathers of tomorrow. Male high school students (N=240) out of a total of 2101 male students were randomly selected from all the six urban high schools in the Zwelitsha District of Ciskei (now part of the new Eastern Cape Province of RSA) and were surveyed to obtain information on KABP concerning family planning. The study was undertaken to provide information for planning of a family planning health intervention programme by the school health team in an attempt to address the high unplanned teenage pregnancy rate and STDs in the schools. The response rate was 83,3%. Important findings included the following: 90% reported they had already had sexual intercourse; the mean age at first sexual intercourse was 15.4 years; the interval from first intercourse to first contraceptive use was 2 years; knowledge of contraceptives was at times scanty and there were several misconceptions and myths concerning fertility, contraceptives and STDs; majority (71,5%) felt the decision to use contraceptives should be the responsibility of both male and female; 86,4% expressed the desire to use contraceptives in the future and 73,0% felt sex education should start in primary school. The adolescent male is interested in family planning and wants to be an active participant in the programme. Recommendations for improved family planning services in schools are made.

Background: Breastfeeding protects against a variety of adverse health outcomes for mothers and babies. Global best practices, known as the Baby-Friendly Hospital Initiative (BFHI), have been developed to support the initiation and exclusivity of breastfeeding during the post-delivery hospital stay. The aims of this study were to explore the literature related to the impact of the BFHI on breastfeeding disparities in the U.S.; compare the impact of exposure to these best practices on exclusive breastfeeding rates in Appalachian and non-Appalachian hospitals; and to understand knowledge, perceptions, and barriers to breastfeeding of postpartum mothers receiving care in a Northeast Tennessee OB/GYN clinic and regional International Board Certified Lactation Consultants’ (IBCLCs®) knowledge, perceptions, and barriers to implementation of the BFHI. Methods: A scoping review was completed to explore literature related to exposure to the BFHI and breastfeeding disparities using the Levac, Colquhoun, and O’Brien methodology. A linear regression analysis of Maternity Practices in Infant Nutrition and Care (mPINC) breastfeeding best practice scores and breastfeeding rates at discharge was conducted comparing this relationship in Appalachian and non-Appalachian hospitals. Finally, a qualitative study was conducted using semi-structured interviews and thematic analysis to gather information from postpartum mothers and regional IBCLCs®. Results: The BFHI has been found to reduce both geographic and racial/ethnic disparities in the U.S., but there are limited studies examining this topic. While there was a significant negative relationship between Appalachian hospitals and exclusive breastfeeding rates at discharge (p=0.0003), there was no significant difference in the relationship between total mPINC scores and exclusive breastfeeding rates at hospital discharge between the two designations (0.4539). Furthermore, both postpartum patients and regional IBCLCs® reported that support, education, and self-efficacy were all necessary to assist mothers on their infant feeding journey. Implications: These findings highlight the need for studies examining the impact of the BFHI on breastfeeding disparities. Research also needs to be conducted to better understand breastfeeding rates in economically distressed, rural areas of the country. Ultimately, risk-stratified interventions supporting the specific needs of a population should be identified or developed to support and empower postpartum mothers to achieve their infant feeding goals.

Neonatal Abstinence Syndrome (NAS) remains an ever-growing public health issue and a continued avenue for future research. The research question for this retrospective study was whether polysubstance exposure is related to the dose of medication the infant received or to the number of opioid-medications required to treat the infants’ withdrawal symptoms? The hypothesis for the retrospective study was there will be a significant relationship between polysubstance exposure and the dose of medication the infant received as well as the number of opioid-medications required to treat the infants’ withdrawal symptoms. A bivariate correlational indicated that there was not a significant association between the number of substances exposed to prenatally and the total number of drugs infants were treated with (n = 294, r = 0.093, p = .113). Additionally, within the largest group of pharmacologically treated infants (i.e., morphine), the highest dosage of morphine was not related to the number of drugs infants were exposed to prenatally, n = 195, r = -0.098, p = .172.

Women's control over their fertility is vital for both their health and that of their children. Although family planning methods are available at most health facilities in the country, the service does not enable many Black South African women to control their fertility successfully. This inadequacy of the present service is demonstrated, by a high rate of teenage pregnancy and abortion. Based on anecdotal reports, one of the barriers to effective use of contraceptive methods seemed to be the competence and abilities of the providers. This qualitative study was done in clinics in a peri-urban township to explore the knowledge and problem-solving abilities of the nurses providing family planning services. The aim was to use the information so gained to improve family planning services in the area by preparing a set of guidelines for the management of specific clinical problems and making recommendations to service organisers. The study tape-recorded 18 actual nurse-patient interactions to get an idea of the clinical problems faced by the nurses. A consensus panel was used to derive a set of "ideal" answers to the clinical scenarios the nurses faced in the consultations and the nurses' and panels' responses were compared. A focus group discussion with the nurses was then conducted and their opinions and reasons for the differences explored. The results revealed a general malaise affecting the services in this area. There were significant differences in the nurses and panels' handling of the problems especially in the areas of counselling and advice. In addition, the nurses were found to be inappropriate providers of family planning as their scope of practice prevented them from examining patients. They were also unable to rule out pregnancy because there were no pregnancy test kits available in the clinics. The focus group discussions indicated that many of the nurses knew how to handle the problems and what advice to give. They claimed that work and time pressures prevented them from doing this. They also alleged that patients were the problem and never told the truth. Poor communication skills and attitudes towards patients were other barriers identified. Nurses spoke to their patients like children and were often rude. In addition, nurses counselled patients infrequently on the use of methods and the side effects to be expected. Patients were offered a choice of method rarely and health education when given, focused on morality and did not mention issues like safe sex and HIV/ AIDS. The manual of guidelines will only address the problem solving of the nurses. The study therefore concludes by making recommendations to the Directorate of Maternal, Child and Women' s Health to carefully evaluate the use of enrolled nurses as providers with full consideration given to the quality of care that can be provided by them. The resources available and the practices related to supervision and in-service training also need to be reviewed and prioritised. A recommendation is also made to the Provincial Human Resources Directorate to develop policies for improving staff attitudes towards service users and disciplinary procedures for staff who are rude to service users. Recommendations are also made to supervisors to review the present training course and introduce the problem-solving approach and respect for patient autonomy into it. The supervision is also recommended to be facilitative and on-site and the providers must be involved in the solving of problems. The emphasis of the service must change from patient turnover to effective contraceptive use to enable women in this area to have any meaningful control over their fertility.