<strong>Background and objectives:</strong> The incidence of preterm birth (PTB), and the extent to which it results in perinatal mortality in sub-Saharan Africa (sSA) is unclear, partly because reliable estimates of gestational age (GA) at birth are lacking. This research: 1) Describes how clinical and ultrasound (US) estimates of gestational age (GA) influence PTB rates and perinatal mortality amongst a population in Kilifi, Kenya; 2) Implements a novel PTB classification system as proof of concept that such systems are feasible in low-income settings, and 3) Presents two novel approaches for estimating GA for women presenting >24 weeks’ gestation. <strong>Methods:</strong> Objectives 1) and 2) used a perinatal surveillance platform developed at the KEMRI/Wellcome Trust Research Programme in Kilifi, Kenya. Ultrasound (US) was offered for GA estimation in women ≤24 weeks’ gestation clinically. To achieve objective 3), two candidate US dating equations were derived by combining a machine learning algorithm with polynomial regression analyses. Lastly, an entirely automated model with the capacity to estimate GA using computational image analysis of the fetal cerebral cortex was developed and tested. <strong>Results:</strong> 1) Between November 2011 and July 2013, 3630 women presented for antenatal care, 1107 women had US and data were available for 950 (86%) of these. The PTB rate by US (US-GA) was 10.0% compared to 17.1% by a best clinical estimate of GA (C-GA), although the number of perinatal deaths that were preterm by US and C-GA were similar; 2) Implementation of a novel PTB classification system is feasible, and 3) New dating equations and an automated model provide estimates in the 3rd trimester with a prediction error at 34 weeks of 12.4 and 14.2 days, respectively. <strong>Conclusion:</strong> Clinical estimates of GA significantly overestimate the rate of PTBs. Despite this, the proportion of perinatal deaths in those identified as preterm by clinical and US methods was similar, suggesting that US may be a better predictor of PTB and its associated mortality. Novel dating methods can estimate GA at 34 weeks’ gestation with an error equivalent to that provided by routine clinical methods at 22 weeks’. This has important implications and may extend capacity to provide GA estimates amongst a large group of women whose birth phenotypes remain poorly described.

BACKGROUND: Quality improvement (QI) efforts in which providers from various health facilities, with support from coaches, work together to implement innovations for improving health care are rapidly spreading from high-income settings to resource-poor settings. However, limited research exists regarding the factors which drive teams to succeed or fail, spread, and sustain best practices. The purpose of this study was to understand the factors facilitating or inhibiting the performance of QI teams of maternal and child health (MCH) service delivery in resource-poor settings. METHODS: A qualitative multi-site case study was conducted in northern Ghana to determine the views and beliefs of QI teams, coaches, and beneficiaries of Project Fives Alive (PFA) about the application of QI to MCH service delivery. Using key informant interviews, document review, and group interviews, the study elicited information about: 1) the factors that affect QI team success and failure when implementing QI methods designed to improve MCH service delivery; 2) the interplay of factors that facilitate or inhibit the spread of best practices among QI teams in northern Ghana; and 3) steps being taken by stakeholders to sustain these best practices. Grounded theory processes were used to identify themes from the data. RESULTS: Testing of changes using Plan-Do-Study-Act (PDSA) cycles and adoption of a client-centered model to the delivery of services has helped teams to identify the felt needs of clients, resulting in perceived increased uptake of MCH services. Key contributory factors to successes were: availability and accessibility of midwives, training of QI teams, incentive packages for providers and clients, community support groups, and PFA partners. Key challenges inhibiting success were: staff turnover, inadequate supervision, cultural practices, and inadequate infrastructure. Some of the key factors that shaped successes have dissipated, threatening sustainability of QI efforts two years after PFA ended. CONCLUSION: The presence of a midwife, providing leadership for organizing team members and implementing PDSA cycles, can facilitate success. Project staff support is important, but teams and coaches need space and time to drive the QI process independently and practice QI methods in ways that foster continuity beyond donor support.

<p>The current study aimed to describe the extent and reasons for substituting and switching HAART at the Katutura Intermediate Hospital in Windhoek, Namibia</p>

<p>This thesis interrogates the claim that resource-poor, rural land seekers can acquire land through the land market which constitutes the central mechanism of land redistribution in South Africa&rsquo / s market-based land reform programme. The study explores two key aspects in relation to this claim. Firstly, it provides a critique of the underlying assumptions prevalent in much of the current market-based land reform policy, as advocated by its national and international proponents, and the manner in which the market as a mechanism for land redistribution has been conceptualized and its outcomes envisaged. Secondly, it considers the extent to which this conceptualization - which it is argued, draws on idealized and abstracted notions of land market functioning - is realized and examines the extent to which the espoused outcomes of market-based land reform policy are aligned with or contradicted by the functioning of real markets and the experiences of resource-poor land seeking people in their attempts to engage in the land market with limited state support. The details of the market&rsquo / s operation are analysed, with a distinction made between the operational practice of real markets &ndash / based on direct evidence-based observation <br /> and degrees of policy abstraction and theoretical assumptions regarding how markets should or might operate. The study&rsquo / s methodological framework draws on an agrarian political economy perspective, as used by theorists such as Akram-Lodhi (2007) and Courville (2005), amongst others. This perspective enables a consideration of the various contexts and socially embedded processes involved in land transactions and the extent to which these are shaped and framed by the politics of policy-making. In line with this perspective, the study focuses on the social relations brought to bear on the acquisition of land and the way in which land markets operate. It is suggested that land is not solely viewed as an economic commodity by land-seekers. Furthermore, it was found that markets cannot be understood as neutral institutions in which participants are equal players.</p>

<p>The current study aimed to describe the extent and reasons for substituting and switching HAART at the Katutura Intermediate Hospital in Windhoek, Namibia</p>

<p>This thesis interrogates the claim that resource-poor, rural land seekers can acquire land through the land market which constitutes the central mechanism of land redistribution in South Africa&rsquo / s market-based land reform programme. The study explores two key aspects in relation to this claim. Firstly, it provides a critique of the underlying assumptions prevalent in much of the current market-based land reform policy, as advocated by its national and international proponents, and the manner in which the market as a mechanism for land redistribution has been conceptualized and its outcomes envisaged. Secondly, it considers the extent to which this conceptualization - which it is argued, draws on idealized and abstracted notions of land market functioning - is realized and examines the extent to which the espoused outcomes of market-based land reform policy are aligned with or contradicted by the functioning of real markets and the experiences of resource-poor land seeking people in their attempts to engage in the land market with limited state support. The details of the market&rsquo / s operation are analysed, with a distinction made between the operational practice of real markets &ndash / based on direct evidence-based observation <br /> and degrees of policy abstraction and theoretical assumptions regarding how markets should or might operate. The study&rsquo / s methodological framework draws on an agrarian political economy perspective, as used by theorists such as Akram-Lodhi (2007) and Courville (2005), amongst others. This perspective enables a consideration of the various contexts and socially embedded processes involved in land transactions and the extent to which these are shaped and framed by the politics of policy-making. In line with this perspective, the study focuses on the social relations brought to bear on the acquisition of land and the way in which land markets operate. It is suggested that land is not solely viewed as an economic commodity by land-seekers. Furthermore, it was found that markets cannot be understood as neutral institutions in which participants are equal players.</p>

Magister Philosophiae - MPhil / This thesis interrogates the claim that resource-poor, rural land seekers can acquire land through the land market which constitutes the central mechanism of land redistribution in South Africa's market-based land reform programme. The study explores two key aspects in relation to this claim. Firstly, it provides a critique of the underlying assumptions prevalent in much of the current market-based land reform policy, as advocated by its national and international proponents, and the manner in which the market as a mechanism for land redistribution has been conceptualized and its outcomes envisaged. Secondly, it considers the extent to which this conceptualization - which it is argued, draws on idealized and abstracted notions of land market functioning - is realized and examines the extent to which the espoused outcomes of market-based land reform policy are aligned with or contradicted by the functioning of real markets and the experiences of resource-poor land seeking people in their attempts to engage in the land market with limited state support. The details of the market's operation are analysed, with a distinction made between the operational practice of real markets - based on direct evidence-based observation and degrees of policy abstraction and theoretical assumptions regarding how markets should or might operate. The study's methodological framework draws on an agrarian political economy perspective, as used by theorists such as Akram-Lodhi (2007) and Courville (2005), amongst others. This perspective enables a consideration of the various contexts and socially embedded processes involved in land transactions and the extent to which these are shaped and framed by the politics of policy-making. In line with this perspective, the study focuses on the social relations brought to bear on the acquisition of land and the way in which land markets operate. It is suggested that land is not solely viewed as an economic commodity by land-seekers. Furthermore, it was found that markets cannot be understood as neutral institutions in which participants are equal players. / South Africa

Magister Public Health - MPH / Background: Namibia is one of the Southern African countries hardest hit by the HIV epidemic, with an estimated one out of every five people infected (MoHSS, 2004). Approximately 80,000 of the infected population currently require antiretroviral treatment (ART). In order to prevent the progression of the HIV infection to AIDS, patients are required to take antiretroviral medicines lifelong. This lifelong use exposes patients to toxicities of these medicines and the only available options of managing the toxicities of ARVs are to treat the toxicity or substitute or switch the offending medicines. Aim: The current study aimed to describe the extent and reasons for substituting and switching HAART at the Katutura Intermediate Hospital in Windhoek, Namibia. Methodology: A descriptive retrospective case series study, in which medical records were reviewed to determine the extent and reasons for substituting and switching HAART was conducted. Random sampling was used to draw a sample of 500 from 3477 adult HAART patients who commenced treatment between 1 January 2002 and 31 December 2006. A prepiloted data collection tool was used to collect the data. The following information was collected: baseline CD4 count, weight, initial ARVs, first and second ARV substitutions, ART switch and the reasons for substituting ARVs or switching ART during the indicated period. Epi Info version 6 was used to analyse frequencies, means and medians of all important variables in the data set. Results: The sample was made up of 500 HAART patients; 60% were females. The median age of the sample was 34 years (Inter-quartile range (IQR) 30 – 40) and the median CD4 cell count was 153 cells/mm3 (IQR 96 – 212) at initiation of therapy. The median time on treatment before first substitution was 28 months (IQR 24 – 34), whereas the median time before second substitution was 10 months (IQR 6 – 15) from the time of the first substitution. The median time before switching was 31 months (IQR 24 - 39). A total of 31% of the study subjects underwent a substitution once, whereas 1.8% underwent a second substitution. Only six (1.2%) patients switched to a second line treatment after the modification of the treatment. The most commonly recorded reason for the first substitution was toxicity (19%). As in other studies, stavudine (D4T), nevirapine (NVP) and efavirenz (EFV) were the ARVs associated with most of the recorded toxicities. High viral load (50%) was the most reported reason for switching. In almost half of the substitution cases the reasons for substitution were not stated, and in a third of the switch cases the reasons for switching were not stated. Conclusion: The rate of substitution at 31% was similar to that found in other resource poor settings, however, the rate of switching (1.2%) was much lower than was found in similar settings. The main reason stated for substituting antiretrovirals was “toxicity”. / South Africa

The dire state of Cuban internet connectivity has inspired local informal innovations. One such innovation is El Paquete, a weekly distribution of downloaded content spread through an informal network. Taking a postcolonial approach, I investigate through user experiences how this network operates in a resource-poor environment. This investigation articulates a model of El Paquete centered on social interactions, which inform the system’s function but also shape El Paquete’s design and role in society. Based on this model, a set of speculative design exercises probe possibilities to streamline El Paquete’s compilation, involve consumer preferences in its design directions, or act as a disruption tolerant network. In uncovering the technical possibilities of El Paquete, these designs illuminate how its current design serves Cuban communities by embodying realities and limitations of Cuban society. El Paquete’s embodiment of informal innovation serves as a call to designers to continuously rethink development design processes, centering communities and their knowledge and technical practices. / Det kritiska tillståndet för den kubanska internetanslutningen har inspirerat flertalet informella lokala innovationer. Ett exempel på en sådan innovation är El Paquete, vars lösning går ut på distribution av nedladdat innehåll som sprids veckovis genom ett informellt nätverk. Jag har undersökt hur detta nätverk fungerar i en resursfattig miljö genom att undersöka användarupplevelser ur ett postkolonialt perspektiv. I denna undersökning framförs en modell av El Paquete som inriktas på sociala interaktioner, vilket utgör systemets funktioner men som också formar El Paquete’s design och samhällsroll. Baserat på denna modell undersöks möjligheterna till att effektivisera El Paquete’s sammanställning, genom ett antal olika spekulativa designövningar som inkluderar konsumentpreferenser i designinriktning, eller som ett avbrottstolerant nätverk. Dessa designer belyser hur dagens tekniska möjligheter med El Paquete är till nytta för kubanska samhällen genom förkroppsligandet av deras verklighet och begränsningar. El Paquete’s förkroppsligande av informell innovation fungerar som en uppmaning till designers att kontinuerligt ompröva utvecklingen av designprocesser som fokuserar på samhällets kunskap och tekniska praxis.

This dissertation collects principles and insights from various sources related to design for the developing world. These principles and insights form part of the foundation that can guide other engineers working in this area. The sources are the published literature, practitioners, non-governmental organizations, and our own field studies. From the engineering literature, we identified nine principles to guide engineers as they design poverty alleviating products for developing communities. Each principle is articulated, supporting literature is described, an in-depth example from the literature is given, followed by suggestions for how the principle can be applied to day-to-day engineering activities. Next, the work from engineering practitioners is studied. Information from various field reports was analyzed, a list of seven common pitfalls was derived, and the Design for the Developing World Canvas is introduced. This tool is similar to a Business Model Canvas, but it focuses on the product development process rather than the development of a business model. The Design for the Developing World Canvas can be used by design teams to facilitate discussions and make decisions that will allowthem to avoid the common pitfalls identified. A case study is then shared from a non-governmental organization called WHOlives.org about their experience with the Village Drill, a human-powered machine that digs boreholes for water wells. The case study outlines the development of the drill, a timeline of its implementation in 15 countries across three continents, specific values related to cashflows of the organization, and a conservative estimate of their impact in developing communities. A study of our original research conducting field studies using a technique called ethnography is then shared. This study was conducted in four countries on four continents and shows the impact of various conditions on the ability of the design team to collect information that is useful for making product development decisions. The conditions in this study include cultural familiarity, language fluency, gender and age of the respondent, information source type, use of prototypes, and others. The results can guide design teams as they make decisions about who to include on the design team, which projects to pursue, and how to conduct their own field studies. Lastly, conclusions related to design for the developing world are made based on the work presented and potential areas of future work are outlined.