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.

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.