BACKGROUND: Haitian women in Massachusetts experience higher than average rates of low birth weight, C-section and inadequate prenatal care. Given the disparities in Black maternal health in the U.S., creative and innovative care models are necessary to improve outcomes. Culturally specific care models have been found to improve satisfaction and uptake of prenatal care among immigrants. A mixed methods case study was conducted at Boston Medical Center with the aims of describing maternal health outcomes of Haitian women, understanding Haitian women’s experiences and barriers to care and the feasibility of culturally specific maternity care models. METHODS: Electronic medical records were used to obtain and analyze retrospective data about patients’ socio-economic factors, baseline health maternity characteristics, maternity care utilization characteristics, perinatal complications and obstetrical outcomes stratified by ethnicity from 2015-2019. Chi square analysis was performed to measure statistical significance. Four focus groups and three in-depth interviews were performed with Haitian pregnant and postpartum women (n=25). Key informant interviews (n=14) were conducted with hospital clinical providers and clinical program directors. The 3 delays model, respectful maternal care and cultural competence frameworks were applied, using Nvivo for coding and organizing emerging themes. RESULTS: Haitian women demonstrate significantly higher than average proportions of advanced maternal age {40.9 %; (<.001)}, obesity {43.8.8%; (<.001)}; delayed entry to prenatal care {49.5; (.007)}; and pre-eclampsia {7.0%; (.001)}. Inadequate access to insurance and transportation contributed to delays in accessing care. Disrespectful and poor coordination of care negatively affected Haitian women’s experience and perceived quality of care. Haitian women desired culturally competent, personalized heath care services. Barriers to cultural competence and the development of culturally specific care models include lack of staff diversity, finances, health care structural design and lack of training. CONCLUSION: Haitian women may benefit from additional social resources and culturally specific, tailored health programs such as group prenatal care. Recommendations to improve cultural competence include diversifying the workforce, collecting data on racial and ethnic disparities, and trainings to integrate culturally competent principles into clinical practice. Additional research needs include design, implementation and evaluation of culturally specific tailored maternal health interventions with the Haitian population.

The population of the United States is projected to become more racially and ethnically diverse, yet Black and Latinx physicians remain underrepresented in the medical professions. Pipeline programs are a long-standing strategy to increase the proportion of physicians from underrepresented minority (URM) backgrounds. Pipeline programs incorporate structured educational and experiential activities designed to prepare students for careers in medicine. However, little is known about the organizational sustainability of these programs over time, especially after they experience organizational disruptions such as changes in leadership or lapses in funding. This research explores how characteristics related to the sustainability of pipeline programs are reported in the literature, how organizational leaders responsible for implementing pipeline programs conceptualize and plan for sustainability, and how individual, organizational, and environmental factors contribute to the sustainability of pipeline programs. The first study is a systematic scoping review that explores how the sustainability of pipeline programs is characterized in the literature on pipeline programs. Overall, none of the 24 articles identified in this study described sustainability as a programmatic outcome. However, a majority of studies reported on programmatic and organizational factors that facilitated program sustainability. In the second study, qualitative interviews with 24 managers of pipeline programs were utilized to explore how they conceptualize and plan for sustainability as well as the barriers and facilitators to sustainability they encountered. Overall, there was significant heterogeneity in how respondents conceptualized sustainability. Furthermore, few program managers had created plans to ensure program sustainability. Lastly, the third study is a case study of a single pipeline program located in a school of medicine that has been able to sustain its pipeline program over the last two decades despite multiple organizational threats. Findings of this study indicated that the program was able to maintain operation despite not having a plan for sustainability. This was due in part to committed program staff, supportive senior leaders, and adaptable policies and procedures. Overall, these studies provide insight into the multitude of factors that influence pipeline program sustainability. This research also emphasizes the need to build the capacity of stakeholders responsible for pipeline program implementation to engage in long-term sustainability planning.

Includes abstract. / Includes bibliographical references. / Community health workers (CHWs) play an important role in health care in South Africa and similar countries, but relatively little is known about CHW motivations and experiences in the provision of care. This thesis considers these issues in three parts: 1. A protocol for a study of community health work in Khayelitsha, an impoverished peri-urban settlement near Cape Town, which is home to a number of ‘flagship’ public health interventions aimed at HIV/AIDS and TB. 2. A review of literature on community health work exploring naturalistic versus economistic discourses around care work, and the complex intersections of these discourses. 3. An ethnographic account of CHWs who provide a wide range of community-based care work in Khayelitsha.

Includes bibliographical references. / It has been found that South Africa has very limited costing information of health services at both primary and higher levels of care. Therefore, a study was conducted in Ingwavuma health district, a rural setting in KZN, evaluating costs of primary health care (PHC) services. The primary objective of the study was to evaluate the costs of providing PHC services in a rural setting and to compare costs of providing PHC services at different levels of care. Costs data were collected through interview and record reviews from Manguzi hospital, a district hospital, and nine clinics operating within the hospital's catchment area. Cost comparisons between Manguzi clinics and between the clinic and hospital levels were undertaken. Variations in terms of costs between similar facilities (clinics) were discovered, with some clinics being more costly compared to others. Such variations can be explained by some input costs, e.g. personnel which varied considerably between facilities. Variations in the personnel costs between similar facilities were found to be linked with staff distribution patterns and facility utilisation. In addition, variations in terms of costs were also discovered between services provided within one facility. For instance, expenditure figures revealed that the largest proportion of resources was spent on curative services. Tuberculosis and mental health services consumed a minimum amount of resources, namely about 1%. Further comparison of Manguzi results with those of the Centre for Health Policy (CHP) was undertaken. Costs analyses of PHC services provided at Manguzi clinics with similar facilities compared to other sites. namely Agincourt (a rural setting), and Alexandra Health Centre (AHC) (an urban setting), were undertaken. Manguzi and Agincourt have similar costs of PHC services. However, AHC has relatively higher costs compared to the other two sites. This is probably because Manguzi and Agincourt are both rural. Finally, analysis on scaling-up PHC services in Manguzi to the essential package target of 3.5 utilisations per person per year shows that there would be no additional staff costs required. The current staffing levels in Manguzi seem to be sufficient to provide a comprehensive PHC package of 3.5 visits per person per year.

Includes bibliographical references. / The overall aim of this study was to understand how diabetic and hypertensive patients experience PHC in Cape Town, as well as their capacity for self- management of their condition. The specific objectives were: to explore how patients react to existing health care materials/interventions at the health care facility; to identify the needs these patients have for information and behavioural change counselling; to investigate the perceived barriers to lifestyle modification in relation to the patients and to the broader social and economic environment and to investigate the sources of personal motivation to control their illness through lifestyle modification.

Includes abstract. / Includes bibliographical references (leaves 83-94). / Home-based HIV counselling and testing (HBCT) is a wayt to provide confidential HIV testing in a person's home. As home-based testing has not yet been evaluated on a wide scale in Kenya among adult individuals [over age 15], this project is designed to assess in rural Kenya 1) overall acceptance rates and variables that predict differential acceptance rates of home-based HIV testing, 2) reasons for refusal of home-based testing, and 3) barriers to seeking treatment for people who are HIV positive.

Incorrect classification of silent transfer (STF) patients as lost to follow-up (LTF) negatively impacts accurate assessment of retention in care for antiretroviral (ART) programmes. Understanding reasons why patients STF and what proportion of LTF patients constitute this silent transfer phenomenon is necessary to ensure patient continuity of care. We attempted to identify STF patients using the routine government electronic monitoring systems. Furthermore, we sought to identify potential reasons for the STF phenomenon through patient surveys and healthcare provider interviews, in order to guide policy and improve programmatic outcomes. In this mixed methods approach, we selected patients identified as LTF between 2008-2012 in three health facilities from Khayelitsha, Western Cape. Identified patients were subsequently searched for using a combined provincial patient data set. Once consent was obtained, sampling of patients and healthcare providers, using convenience and snowballing methods respectively, were selected for participation. Ninety percent of patients believe it necessary to inform facility staff of the intent to transfer, 56% of patients interviewed cited fear of negative attitudes from staff regarding transfer request (65%), family situations (30%), and long waiting times (11%) as contributing factors to silently transferring care between facilities. Healthcare providers cited stigma, family obligations and/or support, and migration to the Eastern Cape as main reasons for patients transferring. Healthcare providers cited incomplete or lack of transfer documentation as the biggest barrier to timeous treatment of the transfer patient. Incorrect reporting of patients as lost to follow-up negatively affects the treatment programmes retention in care. Negative staff attitudes and poor operational services prevent patients informing staff of transfer intent. The treatment programme must adapt current transfer policies in order to facilitate the transfer process for all patients, including those experiencing emergencies and life events. Linked electronic patient monitoring systems will improve accurate retention in care reporting and improve fluidity of transferring of patients between health services.

Includes bibliographical references. / This study considers the human rights implications of adopting male circumcision as an HIV prevention strategy in South Africa. Consistent findings from three randomised controlled trials in sub-Saharan Africa reflect a protective effect of male circumcision on HIV infection. Given the attention bestowed on the topic by popular media and the international HIV / AIDS community alike, it is justifiable for countries with high HIV prevalence to consider adopting a policy for male circumcision in HIV prevention. However, male circumcision involves many human rights challenges and therefore it is justifiable to consider the human rights issues at stake during policy development.

South Africa has one of the highest rates of alcohol consumption in the world. It is important to study public opinion of alcohol regulatory policies as it plays a crucial role in the success of policy measures. There is a dearth of research on public opinion of alcohol policies in developing countries. This study is the first to explore public opinion of older and young adults on alcohol policy in South Africa. In addition, the drinking behavior of young adults was also investigated along with its relationship with policy support. Methods: The study sample consisted of 1728 young (n=513) and older adults (n=1215). Demographic details and opinion on 15 policy measures (Yes/No) were recorded for both groups. The survey of young adults included additional questions on drinking patterns. Univariate analysis of opinion on policy measures was performed for each group and compared using chi-square tests. Logistic regression was used to find the relationship between policy support levels and demographic factors and drinking behavior of young adults. Results: Complete data were recorded for 567 older adults and 402 younger adults. The majority of the participants (75-80 percent) agreed on restricted availability, increased pricing and greater enforcement measures. In contrast, only 65% of the participants were in favor of increased restrictions on alcohol marketing. Older adults were more supportive of earlier closing times of bars, a raise in minimum purchasing age, as well as an increase in pricing and taxes of alcohol (p<0.001). Females and employed participants were found to be more likely to support alcohol policy measures. Drinking patterns and behavior of young adults significantly predicted most policy measures after controlling for demographic factors. For example, policies on restricted alcohol availability, increase in taxes, and raids were supported by participants who reported that they mostly drank at big events. In contrast, these policies were opposed by those who drink alcohol every day and almost every day along with those who drink during street bashes Support for restrictions on the purchase age of alcohol was not predicted by drinking patterns of young adults Conclusion: It is important to increase the understanding and support of vulnerable groups, especially males and young adults, for policy measures. The relationship between drinking patterns and policy support levels indicates that regular tracking of drinking behavior is necessary for the success of these policies. The results support previous findings indicating that young people are more likely to resist alcohol regulations.

Includes bibliographical references (leaves 118-127). / Zimbabwe is facing very serious economic challenges including hyperinflation, poor international relations, scarce foreign currency and a crumbling infrastructure. This situation has adversely affected all sectors of the economy, including health care. Resources for health care have significantly dwindled and the population's disposable incomes are very low. However, the burden of disease due to HIV/AIDS, TB, Malaria and Diabetes is increasing unabated. Thus, the current study seeks to determine whether public sector diabetes care services are available, affordable, acceptable and also whether access to care is equitable or not. A cross sectional design was adopted for this study. Questionnaires were administered to 179 patients who presented at public health facilities in Harare, 15 provider interviews were done, 15 health facility checklists were completed, one Provincial Medical Director completed a questionnaire and three focus group discussions (FGDs) were conducted. Purposive sampling was used for key informant interviews (PMDs) and also, in the selection of FGD participants. For provider interviews, nurses who attended to Diabetics were selected as respondents. All Diabetic patients who presented for care at selected health facilities were interviewed. The study also conveniently selected 10 facilities from high density areas, three from the medium and two from the low density areas for checklists. Study findings show that the major challenges lie with availability and affordability of care. In summary, there is a shortage of resources such as staff, drugs, equipment and supplies. Patients also face high direct and indirect costs of care due to high drug, food and transport costs. Membership of medical aid seems to be restricted to the richest patients. Moreover, poorest the patients do not belong to any support groups. However, the interaction between patients and their providers is reported to be good. There is a high level of trust between patients and their providers and in addition, patients affirm that providers respect the principle of confidentiality.