Thesis (M. Arch)--Montana State University--Bozeman, 2007. / Typescript. Chairperson, Graduate Committee: Ralph Johnson. Includes bibliographical references (leaves [83]-87).

abstract: Children with dis/abilities the world over are widely required to sacrifice their human rights to education, equity, community, and inclusion. Fewer than 10% of children with dis/abilities in developing countries attend school. Namibia, Africa, where this study took place, is no different. Despite Namibia's adoption of international covenants and educational policy initiatives, children with dis/abilities continue to be overwhelmingly excluded from school. The body of literature on exclusion in sub-Saharan Africa is laden with the voices of teachers, principals, government education officials, development organizations, and scholars. This study attempted to foreground the voices of rural Namibian families of children with dis/abilities as they described their lived experiences via phenomenological interviews. Their stories uncovered deeply held assumptions, or cultural models, about dis/abilities. Furthermore, the study examined how policy was appropriated by local actors as mediated by their shared cultural models. Ideas that had been so deeply internalized about dis/abilities emerged from the data that served to illustrate how othering, familial obligation, child protection, supernatural forces, and notions of dis/ability intersect to continue to deny children with dis/abilities full access to educational opportunities. Additionally, the study describes how these cultural models influenced cognition and actions of parents as they appropriated local educational policy vis-à-vis creation and implementation; thereby, leaving authorized education policy for children with dis/abilities essentially obsolete. The top down ways of researching by international organizations and local agencies plus the authorized policy implementation continued to contribute to the perpetuation of exclusion. This study uncovered a need to apply bottom up methods of understanding what parents and children with dis/abilities desire and find reasonable for education, as well as understanding the power parents wield in local policy appropriation. / Dissertation/Thesis / Ph.D. Educational Leadership and Policy Studies 2010

OBJECTIVE: It is already known from earlier research studies that block grant support can provide educational benefit to students that are orphaned and vulnerable in secondary schools in East Africa. This thesis examines the impact of block grant support given to secondary schools in Southwest Uganda to see whether or not block grant support benefits the entire student population. STUDY POPULATION: The Republic of Uganda is located in East Africa. Block grant support was given to secondary schools starting in 2006 in the districts of Isingiro, Mbarara, and Ntungamo, all located in Southwest Uganda. The NGOs that provided block grants were Africare and Integrated Community Based Initiatives (ICOBI). MEASUREMENT: School-wide indicators, such as the number of secondary schools, the number of students who took the Year IV National Exam, and the proportion of students that failed the exam, were analyzed retrospectively. The main variable of interest was the percent failure rate of students who took the national exam in schools with and without block grant support (intervention vs control schools). The average failure rates for all students who took the exams, male students, and female students were also calculated. Graphs showing the exam failure rate for each year from 2001 to 2010, excluding 2009, for both intervention and control schools were produced to assess patterns and trends. Data for 2009 was unavailable. STATISTICAL ANALYSIS: Excel Data Analysis RESULTS: No statistically significant difference was found in the percent failure rates between control and intervention schools before and after implementation of the block grant support in 2006. However, for male students in 2001 and 2010, there was a statistically significant difference between the percent failure rates at control (6.9% in 2001; 3.3% in 2010) and intervention (11.2% in 2001; 2.2% in 2010) schools. Between genders in intervention schools, a statistically significant difference was found from 2002 to 2006, and 2010. In other words, the percent failure rates of female students were significantly higher than those of male students for those years. Unlike the quantitative analysis, qualitative analysis shows that the majority of stakeholders believe that the block grants benefited the school as a whole. CONCLUSION: As there was no statistically significant difference in percent failure rates between control and intervention schools prior to when block grant support began in 2006, schools targeted by NGOs in 2006 seem to not have been “poor performing” schools. As there was no statistically significant difference in percent failure rates between control and intervention schools after 2006, block grant support seems to have made no significant impact at the school level. According to the qualitative data, the majority of stakeholders interviewed expressed approval of block grants and believed that they benefited the school as a whole.

The success of scale up of antiretroviral therapy (ART) in low- and middle-income countries (LMICs) is in large part due to the introduction of a “public health approach” to access advocated by the World Health Organization (WHO) which emphasized standardized treatment regimens that could be purchased in large quantities and delivered at scale. In 2010 the WHO updated their global HIV treatment guidelines recommending the substitution of stavudine with tenofovir (both of which are members of the non-nucleoside reverse transcriptase inhibitor (NRTI) class of drugs) in first-line antiretroviral therapy (ART). Given the size of treatment programs in sub-Saharan Africa, changing the NRTI used in first-line therapy for HIV could have a substantial impact on treatment outcomes. We conducted three prospective cohort studies using clinical datasets from several sub-Saharan African countries to answer questions surrounding the impacts of exposure to tenofovir in first-line therapy. The first study examines the frequency of stavudine use and single-drug substitutions (substituting the NRTI in first-line ART) in three regions in sub-Saharan Africa by calendar year, 2004–2014. We found a total of 33,441 (8.9%; 95% CI: 8.7–8.9%) single-drug substitutions occurred among 377,656 patients in the first 24 months on ART, close to 40% of which were amongst patients on stavudine. The decrease in single-drug substitutions corresponded with the phasing out of stavudine. We saw an 80% reduction in the risk of single-drug substitutions when comparing tenofovir to stavudine and close to a 70% reduction in the risk when comparing zidovudine to stavudine. The second study uses a regression discontinuity design to evaluate the impact of national HIV treatment guideline changes in South Africa and Zambia recommending tenofovir in first-line ART on treatment outcomes. We found that updated WHO guidelines increased the proportion of patients initiating tenofovir (risk difference (RD) (South Africa): 81%; 95% CI: 73%, 89%; RD (Zambia): 42%; 95% CI: 38%, 45%). Intent to treat estimates showed a decrease in single-drug substitutions in South Africa (RD: -15%; 95% CI: -18%, -12%) and Zambia (RD: -2.0%; 95% CI: -3.6%, -0.3%). In both countries, there was no effect on mortality, attrition or viral load failure (South Africa only). The third study investigates the effect of the 2012 tenofovir stock shortage in South Africa on provider and patient level outcomes, using data from four public-sector Right to Care clinics, two of which experienced a tenofovir stock shortage and two that did not. While imprecise, our results suggest a potential shift in how providers managed patients during the period of the shortage, mainly, a noticeable decrease in the average number of days between visits during the shortage compare to before or after at all four clinics and a significant difference in the proportion of patients missing visits. Difference-in-difference regression results showed a small, but significant, increase in the risk of missed visits during the shortage compared to after (RD: 1.2%; 95% CI: 0.5%, 2.0%), mainly driven by ACTs clinic. No significant difference was seen in other outcomes. Great strides have been made to extend access to ART as well as increase the quality of the services provided to patients in sub-Saharan Africa. Continued access to and a consistent supply of tenofovir in this setting is necessary for patients to receive drugs that are comparable to those used for HIV treatment in high-income countries, as we show that phasing out of stavudine and for either zidovudine or tenofovir potentially reduced toxicities and potentially improved quality of life in multiple regions throughout sub-Saharan Africa. While we show little effect on treatment outcomes when comparing patients accessing care and treatment during the shortage of tenofovir compared to those that did not, this most likely reflects the clinics’ ability to offset the crisis by continuing to initiate newly diagnosed and eligible patients on treatment and keep treatment experienced patients on their current regimen.

Philosophiae Doctor - PhD / This study is based on the assumption that the under-five mortality rate, in recent decades, has declined, particularly in developing countries. However, all the social strata across many countries do not seem to benefit from this reduction of mortality - and mortality remains abnormally high among children especially those from underprivileged social strata. This research is, therefore, a holistic approach to analyse and quantify the inequalities of health among children under five in sub-Saharan Africa over the last two decades (1990-2010). The research sought to investigate the trend and determinants of health inequalities of under-five years (mortality and morbidity) in sub-Saharan Africa (SSA) from 1990 to 2010. An essential point has been devoted to the decomposition of effects and analysis of the contribution of the factors explaining these inequalities. The data used in the study come from Demographic and Heath Surveys (DHS) done between 1990 and 2015 in sub-Saharan Africa countries. In order to analyse the inequalities in trends of mortality and morbidity of children, different selected countries that have conducted at least three DHS during the 1990-2010 period. Several statistical methods were used for data analysis. There were four chapters which is prepared with an article style. For the first paper titled "Decomposing Inequalities in Under- Five Mortality in Selected African Countries", concentration index (CI) and Generalised Linear Model (GLM) with a logit link were used to analyse and measure under 5 mortality inequalities and the associated factors. This paper has been published in the Iranian Journal of Public Health. For the second paper titled "Determinants of Under-Five Mortality in Burkina Faso: A Concentration Dimension". The study used logistics regression and Oaxaca-Blinder decomposition method for the binary outcome to analyse data was involved. For data analysis of the third paper titled "Women Education, Health Inequalities in Under-Five Mortality in sub-Saharan Africa, 1990 – 2013", logistic regression and Bius's decomposition method were used to examine the effect of mother's education level on childhood mortality. In the fourth paper titled "Trends and Risk Factors for Childhood Diarrheal in sub-Saharan Countries (1990-2010): Assessing the Neighbourhood Inequalities", a multilevel logistic regression modelling was used to determine the fixed and random effects of the risk factors associated with the diarrheal morbidity. The work carried out during this on-going thesis helps to understand the magnitude of inequalities in under-five mortality in sub-Saharan countries. The findings showed that the contributing factors of inequalities of child mortality were birth order, maternal age, parity and household size. With regards to the relationship between mother's education level and inequalities in mortality of children under-five in sub-Saharan Africa, findings showed that children of mothers who did not attend school have a higher rate of death compared to those who had been to school. However, we have observed that the inequalities have narrowed over time. The results showed the risk factors of diarrheal morbidity varied from one country to another, but the main factors included: child's age, the size of the child at birth, the quality of the main floor material, mother's education and her occupation, type of toilet, and place of residence. In conclusion, the results of this study show that inequalities in under-five mortality are still important among different social strata in sub-Saharan Africa countries. It is then urgent to take actions to save the lives of children in disadvantaged social strata. / National Research Foundation

In this study, I argue that theorizing about the lived experiences of Black diasporic subjects, specifically, Sub-Saharan African women living in the U.S., must simultaneously take into account cultural parameters of their home country and host culture. I use the term “Black feminisms” as an umbrella term to advocate for an interdisciplinary approach to Black feminist thought and African feminism as tools for analyzing the lived experiences of Sub-Saharan women in diaspora. Specifically, this dissertation investigates how Sub-Saharan women living in the U.S. define, understand and orient to feminist practices in everyday life and how such processes shape their identities as diasporic subjects. By doing so, it seeks to examine how Black feminisms can operate as a tool for promoting social justice through the analysis of Sub-Saharan women’s identity politics in diasporic contexts. To gain insights on Sub-Saharan women’s understanding and performance of feminisms across cultures, I relied on a combination of ethnographic methods. First, I used a critical-performance ethnographic framework to explore how feminism is understood and deployed by Sub-Saharan women in diasporic contexts. My data were collected via a combination of in-depth qualitative interviews, co-performative fieldwork, and every day interactions. Second, I used autoethnographic narrative to explore my own everyday performances of feminisms as a diasporic Congolese woman moving between Congolese and American cultures. Participants’ lived experiences reveal that diaspora operates as a liminal/third/”in-between” space where Sub-Saharan women have to constantly negotiate gendered practices in everyday life at the borderland of two cultural worldviews: African and American. By immigrating to the U.S., these women are expected to integrate the cultural and social values of their host culture while maintaining the customs, traditions, and beliefs that constitute their African cultural legacy and which continue to shape their identities in their daily life. Consequently, while participants unanimously agreed on the relevance of feminism for improving the living conditions of African women on the continent and elsewhere, they insisted on a feminist agenda resonant with the peculiarities of African culture, yet promoting cultural exchange between African and American cultures. In light of these findings, this dissertation advocates for a hybrid feminist agenda - which I refer to as “Black diasporic feminism”- applicable to the lived experiences of Sub-Saharan women in diasporic contexts.

<p> This praxis develops a comprehensive performance measuring model to help government policy makers in Sub-Saharan African (SSA) countries identify and evaluate their performance in online outsourcing (OO). After assessing different efficiency measurement methods, data envelopment analysis (DEA) was selected for this study. </p><p> Metrics from the World Bank&rsquo;s proposed framework for assessing countries&rsquo; competitiveness in OO are used to develop the DEA model in this research. Due to the presence of missing values in some of the variables in the dataset, a technique called multiple imputation by chained equations (MICE) is used to estimate these missing values. The DEA model is applied to 23 OO input variables and a single output variable called Information and Communication Technology (ICT) service exports. ICT service exports revenues are used by the World Bank to measure a country&rsquo;s performance in OO. </p><p> Empirical results from the eight SSA countries studied validate that there is a meaningful relationship between ICT service exports revenue and DEA technical efficiency scores. Further analysis indicates that six out of the eight SSA countries are efficient in OO, while two are inefficient in OO. In addition to the efficiency scores, the DEA model produces benchmark information in the form of an efficiency reference set (ERS). The ERS for an inefficient country consists of an efficient country with which it shares similar levels of input and output factors. Thus, through peer comparison, policy makers in inefficient countries will be able to identify factors that may contribute to improving their performance. </p><p> The results from the proposed DEA model demonstrate the actual possibilities of determining the technical efficiencies of countries participating in OO; the use of this model is therefore not limited to SSA countries but can be applied to various world regions identified by the World Bank.</p><p>

<p> Protracted conflict and development in South Sudan: A feminist analysis of women&rsquo;s subjugation in the making of a nation argues that international interventions in South Sudan from the period of British colonization to present day South Sudan perpetuate and [re]inscribe formations of women&rsquo;s oppression and agency. Foreign presence affects identity constructions, conflict, and governance. I demonstrate how international interventions, militarization, and protracted conflict, compromise women&rsquo;s rights, health, and self-determination as they permeate understandings of gender, sex, reproduction, and security. I integrate an analysis of customary and civil law to establish how the expression and implementation of law and rights inform relationships to women&rsquo;s freedom and justice. Further, I investigate techniques the United Nations and NGOs used to influence cultural shifts that reproduce structural inequities based on gender, body, class, and nation. Foregrounding power, politics, and local knowledges, my ethnography is a practice of emancipatory anthropology to excavate techniques and procedures of normalizing gender, reproductive and sexual health, and biopolitical governance (Foucault 2008, 4). Informed by an ethnography of United Nations and NGO staff, I argue that international interventions in South Sudan introduce formations of biopolitical governance mediated by donor-driven, development agendas, by superimposing relationships to sex, gender, reproduction, and health, which are both culturally contested and unsustainable.</p><p>

Background: Recent stalls in fertility decline have been observed in a few countries in sub-Saharan Africa, and so far no plausible common reason has been identified in the literature. This paper develops the hypothesis that these fertility stalls could be associated with stalls in the progress of education among the women of the relevant cohorts, possibly resulting partly from the Structural Adjustment Programs (SAPs) of the 1980s. Methods: We descriptively link the change in the education composition of successive cohorts of young women in sub-Saharan Africa and the recent fertility stalls. We use reconstructed data on population by age, gender, and level of education from www.wittgenstein centre.org/dataexplorer, and fertility rates from the United Nations. Results: In most sub-Saharan African countries, we observe that the same countries that had fertility stalls had a stall in the progress of education, particularly for young women who were of primary school age during the 1980s, when most of the countries were under structural adjustment. Conversely, stalls in fertility are less common in countries that did not have an education stall, possibly in relation to SAPs. Conclusions: The results point to the possibility of a link between the recent fertility stalls and discontinuities in the improvement of the education of the relevant cohorts, which in turn could be related to the SAPs in the 1980s. This descriptive finding now needs to be corroborated through more detailed cohort-specific fertility analysis. If the education-fertility link can be further established, it will have important implications for the projections of population growth in affected countries.

Magister Chirurgiae Dentium (MChD) / The World Health Organisation estimated that in 2002 more than 13,772 000 deaths in developing countries were caused by infections. This accounted for more than 45% of all deaths, making up 7 of the top 10 causes of death (World Health Organisation, 2004). Sub-Saharan Africa is the epicentre of the devastating HIV pandemic. The country leading with the highest HIV rate in the world is South Africa, with approximately 5.5 million people infected(UNAIDS, 2008; South Africa Country Progress Report, 2008).The development from HIV to AIDS progressively weakens the immune system, making the individual more susceptible to numerous infections, e.g.various forms of orofacial sepsis (Mindel, and Tenant-Flowers, 2001). HIVpositive individuals are eighteen times more likely to become infected with community-acquired methicillin-resistant Staphylococcus aureus than the general population. (Crum-Cianflone et al., 2006). The management of sepsis is of great concern with regard to human morbidity and mortality, as well as its financial implications, especially in cases of antibiotic resistance (Kimleck et al., 1976; Panlilo et al., 1992; Kirkland et al., 1999). Currently, there is no published peer-reviewed literature assessing the impact of HIV on orofacial sepsis. This study aimed to assess the impact of HIV on orofacial sepsis, investigating the clinical and microbiological profiles of the population. These results were used as a guide in the adaptation of current treatment protocols.The study population consisted of patients with orofacial sepsis (requiring incision and drainage or admission) who were referred to the Maxillo-Facial and Oral Surgery Units at either Groote Schuur or Tygerberg Hospitals. These patients were examined, diagnosed and treated as per standard protocol. The empiric antibiotic treatment was tailored according to microscopy and sensitivity results when it became available. The exclusion criteria of the study were refusal of HIV testing or unwillingness of patients to participate in the study.The ratio of HIV positive patients treated was much higher than the population prevalence (2.4:1.1). Odontogenic infections (71.11%), followed by septic jaw fractures (15.56%) were the most common causes of sepsis. The most common causative teeth were the mandibular posterior teeth (43.75%)(excluding the mandibular 3rd molars). The most common fascial spaces involved in the HIV positive group were the submandibular spaces (36%),followed by the submasseteric and canine spaces (27% each). In the HIV negative group, the buccal (41%) and submandibular spaces (33%) were the most common fascial spaces infected.The HIV negative group had the most multi-fascial space involvement, with 35% having more than one fascial space involved. In comparison, the HIV positive group had only 18% involvement of more than one fascial space. This was also reflected by the HIV negative group, which included five cases of Ludwig’s Angina as compared to one case in the HIV positive group. The Gram Stain showed a predominance of Gram positive cocci for both the HIV positive and negative groups. Gram positive bacilli were significantly more prevalent in the HIV negative group (p = 0.0409). Pre-treatment antibiotics were associated with sterile abscesses in 20% of the cases. No growth on culture occurred only in the HIV negative group (statistically significant with p = 0.00488).A statistically significant increased length of admission was found for the cases with penicillin-resistant bacteria (Wicoxin Rank Sum Test p =0.0072). Penicillin resistance was found in 17.78% (8 cases) with ten strains of five types of bacteria (S. aureus, K. pneumonia, Enterobacter, E. coli,Alpha-haemolytic Streptococcus). Eight percent (5) of these cases were also resistant to co-amoxiclav®.In the HIV positive group the following trends (p>0.005) were found:• The average platelet counts of this group was 112.34 x108/L (lower than the HIV negative group);• The length of admission for the HIV positive group was slightly longer by 0.25 days even though this group had fewer fascial spaces infected;• A larger number of bacteria with penicillin-resistance was more prevalent in the HIV positive group (six resistant bacteria in four cases compared to four resistant bacteria in four cases).Greater numbers of orofacial infections were seen in HIV positive subjects relative to their population prevalence rates. Added to this, was the higher rate of antibiotic resistance and longer hospital admissions.These findings may warrant further investigation of the relationship between HIV positive and negative groups with regard to orofacial sepsis.