A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / This systematic review focuses on improving recognition and treatment of acute medical conditions in pregnant women, infants and children in low and middle income countries by Community Health Workers (CHWs). By examining critically selected articles from different electronic databases, this review seeks to organize and present the important characteristics of a training program aimed at reducing maternal, neonatal and childhood mortality. Data in the form of peer‐reviewed and published articles were collected using three public databases – PubMed, Ovid and EMBASE – using specific search terms. Greater than 300 articles where found using the specific search terms. Those articles were then processed through a series of inclusion and exclusion criteria resulting in a cohort of papers which were then individually analyzed for content. After critical analysis of all 15 publications included in the study, it becomes clear that training programs are incredibly diverse. These four aspects of training programs appear to be the most variable between the studies: size of the training program, length of the training program, training assessment and follow‐up refresher courses. Training programs that are shorter in duration or greater in class number do not seem to be any less effective than longer programs with fewer participants. Future studies should be performed in which one training program with identical training techniques, lengths, and focuses is taught in different regions. The impact that this study has on the literature is as follows: Training programs of shorter duration seem to be as effective as their longer counterparts. Finally, there is a clear need for more robust, standardized and geographically and culturally diverse training programs to more effectively study training methods.

Maternal, neonatal and infant mortality is still high globally, but worse in low-resourced countries such as Kenya. Progress in reducing maternal mortality in Kenya is slow, with an estimated maternal mortality ratio of 400 deaths per 100,000 live births. Similarly, the infant mortality rate is tabulated at 39 deaths per 1000 live births. Given the high prevalence of maternal and newborn mortality and morbidity in low-income countries such as Kenya, it is vital to maximize nurses’ and midwives’ capacity to contribute to the reduction of this burden of disease during the perinatal period. As the main healthcare providers in rural Kenyan facilities, nurses and midwives are best positioned to provide effective maternal, newborn, and infant health (MNH) services. They provide both health promotion and disease prevention care throughout pregnancy, labor and delivery, and the early postpartum period. One way of achieving this is through effective postpartum care, a period of perinatal care that is plagued with high rates of pregnancy-related complications. A significant amount of research has been conducted on improving MNH in developing and low- to middle-income countries. However, there is a paucity of literature examining the experiences of nurses and midwives providing postpartum care in these settings. As is evident in the existing literature, nurses’ and midwives’ experiences and perspectives have not been explored to the fullest. This study, therefore, was guided by critical theory and Foucault’s concepts of knowledge and power. Using focused ethnography (FE) as the research methodology, the study had four specific objectives: 1) To describe how the sociopolitical and cultural contexts of healthcare influence the provision of postpartum care by nurses and midwives; 2) To identify the facilitators influencing nurses’ and midwives’ ability to competently provide postpartum care; 3) To identify the barriers to nurses’ and midwives’ ability to competently provide postpartum care; and 4) To explicate nurses’ and midwives’ current knowledge regarding best practices in postpartum care. As consistent with FE methods, this study employed individual in-depth interviews and focus groups to obtain data. Thematic analysis based on Braun and Clarke (2006) was used to analyze data. Credibility, transferability, dependability, and confirmability were used to ensure the trustworthiness of the research process. The analysis of data generated six themes: 1) Provider-Client Relationships; 2) Fostering a Healthy Work Environment; 3) Barriers to Postpartum Care; 4) Transcending Adversity; 5) Social Support Systems; and 6) Policies and Infrastructure Influencing Postpartum Care. The study findings demonstrated that nurses and midwives providing postpartum care in rural Kenya are the backbone of the healthcare system and greatly influence the health outcomes of the people they serve. Facilitators and barriers to the nurses’ and midwives’ work while providing postpartum care in this complex environment were identified. In this study, I have shown how gender, class, and power relations may be influencing the perinatal care that the nurses and midwives provide to postpartum women. The study also shines a light on how maternal and infant health may be influenced by power, politics, and policies. Therefore, I propose that use of an intersectionality lens to examine the experiences of nurses and midwives providing perinatal healthcare in rural Kenya could illuminate power dynamics within the healthcare sector. This study recommends relevant education, healthcare policies, and practice guidelines that support building the capacity of nurses and midwives through an inclusive, structured process, creating a robust environment in leadership, education, research, and nursing/midwifery practice.

Philosophiae Doctor - PhD / Stroke is a known health challenge for the public as it is both incapacitating and fatal to many people world over. Malawi, one of the developing countries has stroke as the fourth leading cause of death, and is fast becoming even more significant due, primarily, to lifestyle changes and nature of healthcare practices. For these reasons, and particularly, the negative impact on quality of life, the management of people with stroke is a critical area of interest. While research activity throughout the world has advanced acute stroke-care interventions, patients in Low to Middle Income Countries (LMICs) benefit less from evidence-based stroke care practices due to less conventional applicability to the setting and continuing medical care and rehabilitation challenges. This doctoral project applied the results of a Diagnostic and Solution Phases to the development of a contextual model for in-patient stroke care and rehabilitation (MoC) in Malawi.

Background: The health systems in many low-middle income countries are faced with an increasing number of patients with non-communicable diseases within a high prevalence of infectious diseases. Integrated chronic disease management programs have been recommended as one of the approaches to improve efficiency, quality of care and clinical outcomes at primary healthcare level. The South African Department of Health has implemented the Integrated Chronic Disease Management (ICDM) Model in Primary Health care (PHC) clinics since 2011. Some of the expected outcomes on implementing the ICDM model have not been achieved, and there is a dearth of studies assessing implementation outcomes of chronic care models, especially in low-middle income countries. This thesis aims to assess the degree of fidelity, moderating factors of fidelity and costs associated with the implementation of the ICDM model in South African PHC clinics. Methods: The study was a cross-sectional study design using mixed methods and following the process evaluation conceptual framework. A total of sixteen PHC clinics in the Dr. Kenneth Kaunda (DKK) health district of the North West Province as well as the West Rand (WR) health district of the Gauteng Province, that were ICDM pilot sites were included in the study. The degree of fidelity in the implementation of the ICDM model was evaluated using a fidelity criterion from the four major components of the ICDM model as follows: facility reorganization, clinical supportive management, assisted self-support and strengthening of the support systems. In addition, the implementation fidelity framework was utilized to guide the assessment of ICDM model fidelity moderating factors. The data on fidelity moderating factors were obtained by interviewing 30 purposively selected healthcare workers. The abbreviated Denison Organizational Culture (DOC) survey was administered to 90 healthcare workers to assess the impact of three cultural traits (involvement, consistency and adaptability) on fidelity. Cost data from the provider's perspective were collected in 2019. The costs of implementing the ICDM model current activities for three (facility reorganization, clinical supportive management and assisted self-management) components and additional costs of implementing with enhanced fidelity were estimated. Costs data was collected from budget reviews, interviews with management teams, and other published data. Descriptive statistics were used to describe participants and clinics. Fidelity scores were summarized using medians and proportions and compared by facilities and health districts. Qualitative data were analysed thematically. Pearson correlation coefficient was utilized to assess the association between fidelity and culture. The annual ICDM model implementation costs per PHC clinic and patient per visit were presented in 2019 US dollars. Results: The 16 PHC clinics had comparable patient caseload, and a median of 2430 (IQR: 1685-2942) patients older than 20 years received healthcare services in these clinics over six months. The overall implementation fidelity of the ICDM model median score was 79% (125/158, IQR: 117-132); WR was 80% (126/158, IQR: 123-132) while DKK was 74% (117/158, IQR: 106-130), p=0.1409. The highest clinic fidelity score was 86% (136/158), while the lowest was 66% (104/158). The fidelity scores for the four components of the ICDM model were very similar. A patient flow analysis indicated long (2-5 hours) waiting times and that acute and chronic care services were combined onto one stream. Interviews with healthcare workers revealed that the moderating factors of implementation fidelity of the ICDM model were the existence of facilitation strategies (training and clinical mentorship); intervention complexity (healthcare worker, time and space integration); and participant responsiveness (observing operational efficiencies, compliance of patients and staff attitudes). Participants also indicated that poor adherence to any one component of the ICDM model affected the implementation of the other components. Contextual factors that affected fidelity included supply chain management, infrastructure and adequate staff, and balanced patient caseloads. The overall mean score for the DOC was 3.63 (SD = 0.58), the involvement cultural trait had the highest (3.71; SD = 0.72) mean score, followed by adaptability (3.62; SD = 0.56), and consistency (3.56; SD = 0.63). Although there were no statistically significant differences in cultural scores between PHC clinics, culture scores for all three traits were significantly higher in WR (involvement 3.39 vs 3.84, p= 0.011; adaptability 3.40 vs 3.73, p= 0.007; consistency 3.34 vs 3.68, p= 0.034). The mean annual cost of implementing the ICDM model was $148 446.00 (SD: $65 125.00) per clinic, and 84% ($124 345.00) was for current costs while additional costs for higher fidelity accounted for were 16% ($24 102.00). The mean cost per patient per visit was $6.00 (SD:$0.77). Conclusion: There was some variability of fidelity scores on the components of the ICDM model by PHC clinics, and there are multiple (context, participant responsiveness, intervention complexity and facilitation strategies) interrelated moderating factors influencing implementation fidelity of the ICDM model. Organizational culture needs to be purposefully influenced to enhance adaptability and consistency cultural traits of clinics to enhance the ICDM model's principles of coordinated, integrated, patient-centred care. Small additional costs are required to implement the ICDM model with higher fidelity. Recommendations: Interventions to enhance the fidelity of chronic care models should be tailored to specific activities that have low degree of adherence to the guidelines. Addressing some of the moderating factors like training and mentoring of staff members, role clarification and supply chain management could contribute to enhanced fidelity. Organizational culture enhancements to ensure that the prevailing culture is aligned with the planned quality advancements is recommended prior to the implementation of new innovative interventions. Further research on the cost-effectiveness of the ICDM model in middle-income countries is recommended.

Postpartum hemorrhage (PPH) is the leading direct cause of maternal mortality worldwide, with the majority of deaths taking place in the least developed countries of the world. Low- and middle-income countries (LMICs) have increased rates of PPH due to lack of access to healthcare, inadequate number of care providers and availability of interventions and resources needed. PPH has four main etiologies: uterine atony, trauma, retained placenta and coagulopathy. The most common and challenging to treat is uterine atony, where a lack of uterine contractility leads to massive hemorrhage postpartum. Specific risk factors have been identified that increase a woman’s risk of developing PPH. Risk factors of PPH can be categorized as biological, demographical and social risk factors. Many people in LMICs experience a lot of the social risk factors like lack of providers, skilled facilities and resources available to them in case of an obstetric emergency. Home births are also a common practice in many LMICs, placing a woman further from any resources she may have had access to if she was at a health facility. PPH can also occur in women without risk factors and requires that providers always be prepared to treat it. Interventions to treat PPH are well known and encompass both pharmacological and non-pharmacological interventions that are usually tried in a least to most invasive order. The first line of intervention is often to administer a uterotonic drug, preferably oxytocin. This poses a challenge to LMICs because oxytocin requires a cold-chain storage, which many LMICs countries lack. Therefore, uterotonics and non-pharmacologic interventions have increasingly been used in these regions. The final and ultimate life saving measure to stop bleeding is a hysterectomy, which is often not available in these rural places where home births take place, and has led to higher mortality rates. Prevention measures of PPH include increasing antenatal care (ANC) use and practicing active management of the third stage of labor (AMTSL) with all pregnancies. Use of ANC and ultrasound technology can help identify the biological risk factors that make a woman more likely to experience PPH. Solutions to lowering the occurrence of PPH in LMICs involve increasing resources and access to healthcare. An important part to increasing access is increasing the number of skilled health facilities and health providers. Community health workers (CHW) and skilled birth attendants (SBA) are vital to increasing the amount and acceptability of care in these regions. These workers are trusted members of the community that can help educate and bring resources to women, as well as women to the resources. Solutions to stopping PPH need to consider the affordability, acceptability and accessibility in order to reach people in remote areas with limited resources. Both immediate short-term interventions and long-term, longitudinal healthcare reform are necessary to save mothers in LMICs.

Background: Low- and middle-income countries like South Africa carry the greatest suicide burden, with local general population suicide attempt rates of 2.9–22.7%, in comparison to 0.7–9% in international literature. Non-suicidal self-injury (NSSI) commonly co-occurs with suicidal behaviours and estimates range from 5.5% internationally to 19.4% in South Africa. As a subgroup of the general population, university students are at higher risk both of suicidal behaviours and NSSI (S/NSSI). Risk factors for S/NSSI include parenting style; however, very little is known about the relationship between parenting styles and S/NSSI in university students in the South African context. Objectives: In this dissertation we set out to perform a literature review relating to explanatory models and risk factors associated with S/NSSI and then proceeded to collect novel data from students at the University of Cape Town. This research study aimed to describe the rates of S/NSSI behaviours and to explore the relationship between the Baumrind parenting style typography and S/NSSI in university students. The study hypothesised that authoritative parenting would negatively correlate with S/NSSI. No a priori hypotheses were made about the other parenting styles investigated. Methods: In chapter 1, we performed a literature review of peer-reviewed publications on Pubmed, Psychinfo via EBSCOHost and MEDLINE via EBSCOHost identified through search terms that were relevant to the focus of the study. In chapter 2 novel data were collected. Students from all faculties at the University of Cape Town were invited to complete an anonymous, online electronic survey. Data collection included a socio-demographic questionnaire, Parenting Styles and Dimensions Questionnaire and Self-Harming Behaviours Questionnaire. Descriptive statistics quantified parenting styles, suicidal behaviours and NSSI. Spearman's correlation coefficients examined the association between parenting style and S/NSSI. Results: Literature review provided a topline review of explanatory models and risk factors associated with S/NSSI and identified relevant literature about parenting styles using the Baumrind typology. In the electronic survey of university students, the rate of suicidal attempts was 6.3% and of NSSI was 22.7%. Suicide threats, suicidal thoughts, and thoughts of dying were reported by 5.9%, 35.7% and 50.7% respectively. No significant differences were seen between male and female students. We observed no significant association between authoritative parenting and suicidal behaviours, but authoritative mothers and fathers were significantly associated with a history of NSSI. Both permissive mothers and fathers were associated with suicide attempts, threats, and thoughts, whereas only permissive mothers were associated with NSSI. Conclusion: This study replicated previously reported high rates of S/NSSI in South African university students in comparison to general population and international data. Contrary to our hypothesis, authoritative parenting style was positively correlated with NSSI, but not with suicidal behaviours. Further studies are warranted to examine parenting style, and permissive parenting, in particular, in relation to S/NSSI

Background: The prevalence of uncorrected refractive error among school-age children is on the rise with a detrimental effect on academic performance and socio-economic status of those affected. School vision screening appears to be an effective way of identifying children with uncorrected refractive error so early intervention can be made. Despite the increasing popularity of school vision screening programs in recent times, there is a lot of debate on its effectiveness in reducing the proportion of children with uncorrected refractive error in the long term especially in settings where resources are limited. Objective: To assess the effectiveness of school vision screening programs in reducing children with uncorrected refractive error in LMIC. Search Methods: To identify studies suitable for this systematic review, a comprehensive and systematic search strategy was employed. We searched various databases and the search was restricted to articles published in English. We included RCTs, cross-sectional studies, case-control studies, and cohort studies. Participants included school children who had undergone vision screening as part of school vision screening programs in the LMIC setting and found to have a refractive error. Two independent reviewers screened the result of the search output and performed a full-text review of the search result to identify papers that met the pre-defined inclusion criteria. Data extraction and risk of bias assessment for the included studies was performed by the two independent reviewers and discrepancies were resolved by consensus and through consultation. The certainty of the evidence was assessed using the GRADE approach. Main Result: We found thirty relevant studies conducted in ten different countries that answered our review questions. Our review showed that school vision screening may be effective in reducing the proportion of children with an uncorrected refractive error by 81% (95% CI: 77%; 84%, moderate certainty evidence), 24% (95% CI: 13%; 35%, moderate certainty evidence,) and 20% (95% CI: 18%; 22%, moderate certainty evidence) at two, six, and more than six months respectively after its introduction. Our review also suggest that school vision screening may be effective in achieving 54% (95% CI: 25%; 100%, moderate certainty evidence), 57% (95% CI:46%; 70%, low certainty evidence), 38% (95% CI: 29%; 51%, moderate certainty evidence) and 41% (95% CI: 24%; 68%, low certainty evidence) level of spectacle wear compliance among school children at less than three months, at three months, at six months and at more than six months respectively after its introduction. Our review further found moderate to high certainty evidence indicating that school vision screening together with the provision of spectacles may be relatively cost-effective, safe and has a positive impact on the academic performance of children. Conclusion: Result of this review shows that school vision screening together with the provision of spectacle may be a safe and cost-effective way of reducing the proportion of children with uncorrected refractive error with a long-term positive impact on academic performance of children. Most of the studies included in this review were however conducted in Asia and the applicability of this finding to countries in other regions especially those outside the LMIC circle is not clear.

Background: The use of evidence-based medications for the management of cardiovascular disease (CVD) is low worldwide. A key strategy to improving use of medications is to understand the barriers to their use. This thesis aims to identify barriers that may influence use of these medications in high, middle, and low income countries. Data on barriers in low and middle income countries are especially lacking. We postulate that in those settings lack of availability and affordability of proven medications are key barriers to medication use. Methods: We initially systematically reviewed the literature on barriers to medication use. Since data on these barriers for the management of CVD are sparse, the review included studies focused on hypertension, because it is the leading risk factor for CVD. Baseline data from the PURE study were then used to investigate whether availability and affordability of medications influence their use for secondary prevention of CVD. PURE is a prospective study that recruited adults between the ages of 35 to 70 years from 17 high, middle, and low income countries. Availability and affordability of medications were documented for each country income group, and the associations between these two potential barriers and medication use was explored after accounting for other factors that may influence medication use. Results: The review showed that in high income countries, non-healthcare system related factors, such as lack of knowledge and motivation, were more commonly reported as barriers, whereas in low and middle income countries healthcare system factors were most commonly reported as barriers to hypertension management. However, very few studies were conducted in low and middle income countries and so there is limited information on whether availability and affordability of medications affect their use. Results from the PURE study indicate that medications recommended for the secondary prevention of CVD were often not available and when available, they were not affordable for a high proportion of individuals in low and middle income countries. Lack of availability and low affordability were strongly associated with medication use in these settings. Conclusions: Barriers to medication use are context specific and interventions to improve use should be tailored to barriers depending on the setting. In high income countries where the medications are usually available and affordable interventions should target knowledge and motivation barriers. In low and middle income countries, the focus should be on healthcare system interventions to improve the availability and affordability of medications. / Dissertation / Doctor of Philosophy (PhD)

Introduction: The frailty phenotype is a commonly used tool to study frailty. Two characteristics evaluated as part of the frailty phenotype are “low” grip strength and “low” physical activity, defined by the lowest quintile thresholds for age and sex. In studies of frailty in different geographic regions of the world, it is not established whether these thresholds should be applied universally or whether region-specific thresholds of grip strength and physical activity should be applied. This study aims to determine which way of defining frailty is more appropriate. Methods: Using data from the Prospective Urban Rural Epidemiology study, two variations of the frailty phenotype were defined: universal frailty in which thresholds for low grip strength and physical activity were taken to be the lowest quintile of the entire study population and region-specific frailty, in which these thresholds were calculated separately for each region. Frailty prevalence was calculated for each definition and Cox proportional hazards modelling was used to determine which definitions predicted mortality. Likelihood ratio tests statistics, area under the receiver operating characteristics curve, and the net reclassification improvement index were also calculated. Results: Overall frailty prevalence was 5.6% using universal definitions of frailty and 5.8% for region-specific definitions of frailty. Across regions, universal frailty prevalence ranged from 2.4% (North America/Europe) to 20.1% (Africa), while region-specific frailty ranged from 4.1% (Russia and Central Asia) to 8.8% (Middle East). The hazards ratios for all-cause mortality were 2.66 (95% CI: 2.47-2.86) and 2.09 (95% CI: 1.94-2.26) for universal frailty and region-specific frailty respectively (adjusted for age, sex, education, smoking status and alcohol consumption); statistical tests indicated that universal frailty better fit survival data and predicted mortality slightly better. Conclusions: Frailty prevalence varies greatly across regions depending on how the thresholds for low physical activity and grip strength are calculated. Using region-specific thresholds does not help improve the predictive value of frailty when measuring frailty in heterogenous populations using the frailty phenotype. / Thesis / Master of Science (MSc)

This study aims at understanding the role of education in promoting disaster preparedness. Strengthening resilience to climate-related hazards is an urgent target of Goal 13 of the Sustainable Development Goals. Preparing for a disaster such as stockpiling of emergency supplies or having a family evacuation plan can substantially minimize loss and damages from natural hazards. However, the levels of household disaster preparedness are often low even in disaster-prone areas. Focusing on determinants of personal disaster preparedness, this paper investigates: (1) pathways through which education enhances preparedness; and (2) the interplay between education and experience in shaping preparedness actions. Data analysis is based on face-to-face surveys of adults aged 15 years [or older] in Thailand (N = 1,310) and the Philippines (N = 889, female only). Controlling for socio-demographic and contextual characteristics, we find that formal education raises the propensity to prepare against disasters. Using the KHB method to further decompose the education effects, we find that the effect of education on disaster preparedness is mainly mediated through social capital and disaster risk perception in Thailand whereas there is no evidence that education is mediated through observable channels in the Philippines. This suggests that the underlying mechanisms explaining the education effects are highly context-specific. Controlling for the interplay between education and disaster experience, we show that education raises disaster preparedness only for those households that have not been affected by a disaster in the past. Education improves abstract reasoning and anticipation skills such that the better educated undertake preventive measures without needing to first experience the harmful event and then learn later. In line with recent efforts of various UN agencies in promoting education for sustainable development, this study provides a solid empirical evidence showing positive externalities of education in disaster risk reduction.