Background. In striving to achieve the UN Millennium Development Goals, Pakistan pledged to focus on eradicating extreme poverty for its population. The association between socio-economic status and health is well established. Micro-finance institutions provide access to credit for poor women where cultural and social constraints limit their opportunities for economic advancement. While involvement in a micro-finance program has been shown to reduce poverty, little is known about how this involvement impacts women’s mental health. Objective. The purpose of this qualitative study was; (a) to gain an understanding of how women conceptualize the meaning of their mental health; (b) to explore the impact of women participation in micro-finance programs on their mental health; (c) to determine how they promote their mental health; and (d) to obtain their recommendations for change to micro-finance institutions. Methods. Using interpretive description methodology, data were collected and analyzed through interviews with 32 urban-dwelling women who have been micro-finance loan recipients for a period of 1 to 5 years. A total of six micro-finance administrative personnel were also interviewed; five institutional documents were reviewed. Data were analyzed in the source language Urdu, following three main phases of content analysis methods, preparation, organization and reporting. Results. Women conceptualize mental health as being the presence of peace and the absence of tension. Participants relate this tension to absence of basic resources in their day-to-day living and lack of safety and security around the city. Women recognized micro-finance programs as being a major inspiration towards their flourishing mental health. Regular practice of religion, being resilient towards adversity and securing family respect through a consistent source of income and repayment of the loans were identified approaches to promoting mental health. In enhancing micro-finance programs further, the women recommended for them to initiate vocational training institutions and to provide opportunities for their children to seek education at affordable cost. Conclusion. The women participants of this study represented “everyday women” of Pakistan, who thrive through their resilience and courage to mitigate poverty and to achieve peace. Combating obstacles to meet the basic needs, including access to education, would be a useful first step towards mental health promotion for Pakistani women. Financial services of micro-finance, along with provision of vocational skills training, “women-to-women” approach and modifications in policy would assist women to utilize their loan productively. Multiple stakeholders should work collaboratively for the promotion of mental health determinants. As nurses are now moving beyond the traditional roles and counteracting complex issues, this study identifies implications for research, education, and practice. / Thesis / Doctor of Philosophy (PhD)

M.A. / In the Western world, anorexia nervosa has long been regarded as an age-old medical syndrome and was conceded to have reached epidemic proportions in white South African females by the 1970s. On the contrary, it has been deemed to be non-existent in indigenous African females, this being attributed to the African socio-cultural preference for the fuller figure. The first clinical case in an indigenous female was reported in Nigeria (Nwaefuna, 1981). In South Africa, the first diagnosis in 1993 and earliest reporting of three cases by Szabo, Berk, Tlou and Allwood (1995) coloured the face of prevailing conceptualisation and was viewed as a nascent indication of global acculturation to a Western lifestyle and value system. This research represents the researcher’s invitation to the reader to embark on an exploratory journey into the biographically situated experience of anorexia nervosa as revealed through the personal experience stories of three black South African female participants. With the researcher’s quest to explore this as a uniquely human, lived experience, it became essential to open up the life of each participant as the arena in which this experience unfolded, so that seminal vicissitudes as well their sense of self in the course of this experience could be gleaned. Further, the researcher shied away from a fait accompli acceptance of the acculturation discourse and sought to interrogate it by giving voice to participants’ lived sense of the relationship between this experience and their cultural identity and affiliation. As its dialectic, the researcher also allowed participants to give voice to the cultural scrutiny of their experience through the lens of their culturally-referent others. Finally, the researcher opened up some of the seminal vicissitudes of her personal experience as the space for introspection and reflection on nuances and resonance between her experience and that of participants, without a concomitant attempt to generalise about either. Through post-modernist interpretive interactionism (Denzin, 1989), the researcher undertook a comprehensive deconstructive review of biopsychosocial discourses on the experience of anorexia nervosa, which sought to uncover and juxtapose various underlying models of human action. This review also included a feminist lens, which allowed that images and conceptions of women that exist within these discourses could be revealed, while simultaneously offering a critique of inherent culturally gendered dynamics. Through metaphoric simultaneity, the crystallised use of personal stories, drawings and naïve sketches sought to provide deepened, complexified and, if it be so, competing accounts of participants’ experience. The researcher drew a number of conclusions pursuant to participants’ experience of anorexia nervosa. First, that although biological factors could not be excluded, especially the role of genetics and hormones in adolescence, the exact nature thereof was beyond the scope of this inquiry and therefore inferential. Second, that although there were varying degrees of resonance in participants’ experience with some of the macro socio-cultural discourses considered, these did not appear to have been pathogenically pre-eminent. Third, that in the exploration of particular vicissitudes of participants’ family relational dynamics, the embryonic seeds and gestalt effect of their susceptibility matrix was vividly exposed. All factors considered, the researcher stands strongly in the opinion that gleaning this as the personal experience of three black female participants and drawing in sediments of her own personal experience, anorexia nervosa is ultimately a uniquely individual experience that stands as a covert and metaphoric language of personal distress. While it may sometimes overlap with some of the dynamics that have coloured the socio-cultural landscape in different epochs, it has its own dynamics and internal logic that is uniquely and inextricably tied to the specific vicissitudes of each person’s biographically constructed self. The specific probing of participants’ cultural identity and affiliation served to confirm that while the evolving cultural identity and affiliation of black females may be undeniable, the prevalent causal attribution of anorexia nervosa to acculturation appears to have been compellingly shown in this case to be an external and cursory one. Finally, the specific probing of participants’ experience through the eye of their culturally-referent others revealed that anorexia nervosa is culturally enigmatic. Its attribution, in participants’ socio-cultural context, to witchcraft, acculturation and especially to HIV and AIDS and attendant stigmatisation and shaming of an already deeply wounded person serves to indicate the degree of distress, isolation and rejection experienced by sufferers. By the same token, it also serves to illumine the felt equivalence of this period in participants’ socio-cultural context with HIV and AIDS. This study represents the researcher’s endeavour to convey participants’ experience of anorexia nervosa in its richness, in an attempt to render it understandable, without any concomitant attempt to foreclose or pretence of being exhaustive. Therefore, it recognises that the understanding presented here inalienably represents the researcher’s hermeneutic circle. The reader is thus invited, if not challenged, to discern their own understanding. Finally, it offers itself as a signpost for future research into what by all accounts, stands starkly as an untapped minefield.

Although the effects of both the menstrual and circadian cycles on mood have been well documented, the question of whether the two interact to influence mood has not yet been addressed, despite evidence for such an interaction on other variables. Blood sugar level is a major contributor to the mediation of mood and is easily regulated by dietary intervention; there is also evidence that it is influenced by both the menstrual and circadian cycles. The present research takes a positive psychological approach to managing mood; the aims were to identify where natural variations in mood occur in relation to its underlying physiology, taking an applied approach to suggest ways of effectively managing positive mood and maintaining psychological well-being. A series of studies was carried out to measure fluctuations in mood in relation to biological rhythms, and in response to cognitively demanding situations and simple interventions. Mood was measured throughout the research using the UWIST Mood Adjective Checklist. The most consistent results were in relation to the Energetic Arousal dimension. This was shown to be influenced by both the menstrual cycle and the time of day, as well as an interaction between these two factors, and was consistently related to changes in blood glucose levels. Energetic Arousal also appeared to be more sensitive to the effectsof the suggested interventions. Diurnal changes in mood throughout the course of a normal day were more evident among women in their premenstrual to menstrual phases, and also become more apparent in response to cognitive tasks. Trait Anxiety was a mediating factor in how individuals reacted to such tasks. Mood was closely related to blood glucose levels, and raising blood glucose to a robust but safe level effectivelyenhanced positive mood in cognitively demanding situations. Oral contraceptives generally tended to eliminate menstrual cycle-related effects on mood and responses to intervention. It was concluded that mood states among healthy women are influenced by a complex interplay between biological rhythms, physiological states, individual differences and the context in which these moods take place. Simple interventions that can easily be incorporated into one’s daily routine may be efficacious in maintaining a positive mood state, which has beneficial implications for psychological well-being.

The perinatal period is increasingly recognized as a vulnerable time for the development and exacerbation of psychopathology symptoms. Research has often focused on perinatal depression, with limited information on perinatal anxiety. This study examined the psychometric structure of all anxiety and depressive disorder symptoms as well as explored the relation between perinatal internalizing symptoms and sociodemographic, obstetric, and psychological risk factors. Obsessive-Compulsive Disorder (OCD) is a common perinatal anxiety disorder that is now classified with the Obsessive-Compulsive Spectrum (OCS) (hoarding, body dysmorphic, trichotillomania, and excoriation disorders). This study also aimed to determine the prevalence of clinically significant OCS symptoms and their association with postpartum adjustment. Participants recruited from the University of Iowa Hospitals and Clinics (N =246) completed an online questionnaire and a structured clinical interview during pregnancy (28-32 weeks gestation) and the postpartum (6-8 weeks). Questionnaires assessed demographics, pregnancy complications, anxiety sensitivity, coping strategies, maternal attitudes and experiential avoidance. Clinical interviews dimensionally assessed all anxiety and depressive symptoms as well as past psychiatric diagnoses. Confirmatory factor analyses identified three factors: Distress (depression, GAD, irritability, and panic); Fear (social anxiety, agoraphobia, specfic phobia, and OCD); and Bipolar (mania and OCD) during pregnancy and the postpartum. During pregnancy, structural equation modeling demonstrated that past psychiatric history predicted Distress and Fear symptoms. Experiential avoidance mediated the relation between negative coping strategies and Fear symptoms. In the postpartum, negative maternal attitudes predicted Distress symptoms. Experiential avoidance mediated the relation between negative coping strategies and Fear symptoms as well as between anxiety sensitivity and Fear symptoms. There were low rates of clinically significant OCS symptoms, except for body dysmorphic disorder symptoms. Elevations in all OCS disorder symptoms were significantly associated with more difficulty adjusting to the postpartum. Past psychiatric history, negative maternal attitudes, and experiential avoidance are particularly important risk factors for perinatal anxiety. Future clinical research should be aimed at identifying at-risk women and modifying experiential avoidance during the perinatal period. Elevated OCS symptoms, particularly body dysmorphic disorder symptoms, affect postpartum adjustment. Future intervention work should focus on assessing and treating perinatal body dysmorphic disorder symptoms.

Obsessive-compulsive disorder (OCD) is heterogeneous. Clinical presentation of OCD differs by sex and age-of-onset and evidence supports classification based on these subtypes. The prevalence of OCD in the general population is 2%. However, it has been established that women tend to experience onset and exacerbation of OCD during reproductive milestones. In particular, the prevalence of postpartum OCD is between 4 to 9%. This study seeks to examine the effects of past childhood maltreatment and S/Lg-allele status of the 5-HTTLPR polymorphism on perinatal obsessive-compulsive symptoms and aberrant resting state functional connectivity in the postpartum period. Forty women participated in the first visit and sixteen women have been followed up with in the postpartum period. 5-HTTLPR genotype was determined from whole blood samples via polymerase chain reaction and a restriction fragment length digest. We used the Yale-Brown Obsessive-Compulsive Scale and Perinatal Obsessive-Compulsive scale to measure symptom severity. Resting state functional connectivity was determined from functional magnetic resonance imaging data. Obsessive-compulsive symptoms during late pregnancy are significantly predicted by 5-HTTLPR genotype, past history of total childhood maltreatment or childhood emotional neglect and trait anxiety symptoms. Whereas obsessive-compulsive symptoms during the postpartum period are predicted by poor sleep quality and childhood emotional maltreatment or 5-HTTLPR genotype, childhood emotional maltreatment and trait anxiety symptoms. Seed to region-of-interest analysis was employed to evaluate resting state functional connectivity differences between OCD patients and healthy controls in the postpartum period. Compared to healthy controls, OCD patients show greater connectivity between the caudate nucleus with the orbitofrontal cortex, the pars triangularis and the cingulate area. The insular cortex shows decreased connectivity between the right and left, the dorsal anterior cingulate area and the pars opercularis. The amygdala has increased connectivity with the cingulate area, the calcarine fissure, the supramarginal gyrus and decreased connectivity with the gyrus rectus. The above clinical and neuroimaging findings are in line with past work. However, this is the first study to show both 5-HTTLPR genotype and history of childhood maltreatment predict obsessive-compulsive symptoms in a perinatal population. Further, the resting state data replicates findings in the OCD literature but the study is the first to show this in postpartum women. This study serves as a platform for future work to further investigate both gene-environment interactions and distinct neuroimaging correlates in perinatal OCD. / Thesis / Master of Science (MSc)