Thesis (doctoral)--Freie Universität Berlin, 1980.

Thesis (Ph.D.)--Aberdeen University, 2009. / With: Health status and health needs of the orphan children of Kathmandu Nepal : the findings of the pilot study / S. Sing, Edwin R. Van Teijlingen, P. Simkhada. Stupa Journal of health services. 2007: 3, 1-2. With: Health status and health needs of orphan children of Kathmandu Nepal / S. Sing, P. Simkhada, Edwin R. Van Teijlingen. Journal of Nepal Heath Research Council. 2007: 5, 2. Includes bibliographical references.

Reducing maternal and child mortality has been a top global health priority for the past two decades. Through this thesis, I underline some of the strategies, barriers and determinants to optimal maternal and child health (MCH) in three specific districts of Jimma Zone in the southwest of Ethiopia. My first paper has a particular focus on the quality of MCH data collected within the health management information system (HMIS), while the second paper focuses on the utilization of antenatal care (ANC) services, assessments of malaria in pregnancy, and women’s access to malaria preventive measures using data from a cross-sectional survey conducted in the three study districts. The quality of MCH data collected within the HMIS from July 2014 to June 2015 for the 26 primary health care units (PHCUs) located within the three districts was evaluated using the World Health Organization’s Data Quality Report Card (DQRC). To complement the methods recommended in the DQRC, Pearson correlation coefficients, intraclass correlation coefficients, and Bland-Altman analysis were used to determine the agreement between MCH indicator coverage estimates derived from the HMIS and a population-based survey conducted with 3,784 women who had a birth outcome within the same time frame. The quality of MCH data collected within the HMIS was determined to be unsatisfactory, with many health facilities located in the three districts not reporting completely, consistently, or accurately MCH key indicators relating specifically to ANC, skilled birth attendance at delivery, and postnatal care. This finding is important since poor data quality can compromise effective decision-making and resource allocation processes aimed at contributing to better health outcomes in mothers and newborns. vi To address the objectives set in the second chapter, analysis of cross-sectional survey data from 3,784 women who had a birth outcome in the year preceding the survey was performed through logistic regression models adjusting for clustering of the participants by PHCU. While close to 85% of the women attended at least one ANC visit, less than 50% of the participants received four or more ANC visits. Lack of necessity, distance to health facility and unavailability of transportation were determined as key reasons for not attending ANC. Women who completed secondary or higher education, were from the richest households, were exposed to different media sources, and were able to make decisions about their healthcare by themselves or jointly with their husband were more likely to attend ANC services. Frequent visits by a health extension worker and pregnancy intendedness also influenced ANC attendance. Bed net ownership and utilization during last pregnancy were also relatively low (52% and 26%, respectively). The results also showed that the odds of owning and always using a mosquito net were higher in participants that attended ANC, with odds ratios of 1.98 (95% CI: 1.55-2.53) and 1.62 (95% CI: 1.23 – 2.13), respectively. The prevalence of malaria infection during pregnancy was low in our recruited sample, with 1.45% of the participants reporting suffering from malaria during their last pregnancy. We determined significant negative relationships between malaria infection and maternal age and education level. This work emphasizes the importance of improving the quality of MCH data within the HMIS in Ethiopia as well as addressing the inequities relating to ANC attendance in Jimma Zone. Given the adverse effects that malaria can have on the progress and outcomes of a pregnancy, the importance of promoting mosquito net ownership and use as part of ANC services is also highlighted.

The development of socio-emotional competence in middle childhood is an essential acquisition that will enable a child to negotiate interaction with peers and others (Robbins & Rutter, 1990). A substantial body of research has arisen concerned with the identification and prevention of risk factors that might impede certain children's ability to thrive socially and emotionally (Doge & Coie, 1987, Parker & Asher, 1993). This expansion in prevention and evidence-based practice has led to changes in national policy. As a consequence of the revised Children's Act (2004) the promotion of emotional health and well-being in schools, through both the curriculum and school-based intervention, has become a recognised priority. The studies in this thesis describe a pragmatic evaluation of a Year 3 intervention, (Pyramid), which is designed to be delivered in school and targeted at children who are quiet, behaviourally inhibited and at risk of social isolation (Pyramid, 2007). Children's socio-emotional health was measured using the teacher-rated version of the Strengths and Difficulties Questionnaire (Goodman, 1997) both pre- and post-intervention and at a twelve-month follow-up. The views of the children who attended were elicited through a series of focus groups. Pyramid attendees showed greater levels of improvement than Comparison group classmates at both post-intervention time-points. Evidence of preservation of gains for Pyramid attendees was also shown at the twelve-month follow-up. Emergent themes from the focus groups supported these results with Pyramid attendee children reporting self-recognised improvements post-intervention and with no personal costs experienced as a result of the intervention. These results augment both the existing evidence base for Pyramid (Davies, 1999, Fitzherbert, 1985, Skinner, 1996) and add to the evidence base regarding the efficacy of school-based preventative interventions. This thesis proposes a novel conceptual model for the monitoring of socio-emotional health and wellbeing in primary schools and highlights the importance of the need to discern how these interventions can influence future policy and practice.

Podoconiosis is a neglected tropical skin disease caused by a fault in skin barrier function (SBF) combined with a genetic predisposition. Irritant minerals and pathogens entering breaches in plantar skin cause an inflammatory reaction and lower leg lymphoedema. This has a considerable negative impact on the quality of life and economic status of some of the poorest people in 20 countries. Podoconiosis is preventable and treatable but not curable. No previous pre/post controlled intervention studies on skin treatment for the disease have been published. The aim of this randomised control trial (RCT) was to evaluate the effectiveness of a low-cost evidence-based skin care intervention to improve the SBF in the legs/feet and enhance disease related quality of life. A pilot study (n=10) indicated that adding 2% glycerine to the existing skin management regime used in Ethiopia could have a positive effect on stratum corneum (SC) hydration levels and trans-epidermal water loss (TEWL). The study recruited participants from two Ethiopian clinics (n=193). The control group used the existing treatment regime: washing legs/feet with soap, soaking in 6 litres of water with disinfectant added and applying Vaseline®. The experimental group added a 2% dilution of glycerine to 1/6 of the amount of soaking water and 0.0045% less disinfectant. After 3 months the experimental intervention had a highly significant positive effect on TEWL (p = < 0.001) and SC hydration (p = < 0.002) compared to the control. The reduction in foot circumference was highly significant (p = < 0.001). There was no significant group difference in Dermatology Life Quality Index (p = 0.907). The study indicates the very positive effect on SBF of adding 2% glycerine and less disinfectant to the current treatment. This finding offers a significant contribution to the body of knowledge on the management of the disease. The addition of 2% glycerine to treatment regimens may also have positive effects on other skin diseases with compromised SBF.

The aim of the study is to explore aspects of child safety in registered day care centres situated in a lower socio-economic area of the Cape Town Metropole. This can be achieved by: a) describing the physical environment in day care centres b) assessing the infrastructure of day care centres to deal with potential injurjes c) reviewing injury reporting systems already in place d) highlighting the issue of child safety in the course of conducting the study.

A cross-sectional, descriptive study combining with open-ended (qualitative) interview questions with quantitative component was conducted to explore disclosure experiences of mothers and caregivers of HIV-infected children. The study was conducted with 102 parents and caregivers at a tertiary hospital in Cape Town delivering care to 303 HIV-infected paediatric patients. The study sample included 102 participants, ranging in age from 16 years to 71 years. The sample included 73 mothers (72%), six fathers (6%), 11 foster-mothers (11%), and 12 caregivers or grandmothers (12%). The median age of participants’ children was 4 (IQR 2-8) years and ranged from five months to 16 years. Only 48 (47%) were old enough for disclosure to be possible. Disclosure or disclosure delay was associated with several factors, including the child’s age or ability to understand, anxiety and guilt about being blamed for infecting the child, fear of exposing the child to stigma, discrimination and social exclusion related to the child disclosing to others, and the hope that the child would be adherent if they understood their illness and the way in which the medication could improve their health outcomes. Only 16 (33%) of 48 participants actually disclosed the child’s HIV status. The results indicate that HIV-disclosure remains a challenging, emotionally-charged experience for mothers and caregivers. The findings of this research, and similar studies, point to the value of integrating disclosure support and planning into routine care for children and adolescents, as well as their parents and caregivers.

Background Each neonatal death counts, as recognised by the Every Newborn Action Plan (ENAP). This is an important aspect in attaining the third Sustainable Development Goal by 2030. Accurate neonatal mortality data as well as an understanding of the causality and context is essential to plan interventions to reduce neonatal deaths and attain the third Sustainable Development Goals (SDG) of a neonatal mortality rate of less than 12 per 1000 livebirths by 2035. Objectives The objectives of this study were: (i) to determine neonatal mortality occurring in and out of health facilities in the Metro West GSA using the three audit programmes; Perinatal Problem Identification Programme (PPIP), Child Healthcare Problem Identification Programme (Child PIP) and Forensic Pathology Services (ii) to ascertain the cause of death specific neonatal mortality (iii) to describe the avoidable factors in each death as coded by the three audit programmes (iv) to make recommendations for the alignment of existing audit databases to obtain accurate neonatal statistics for the Metro West GSA. Methods This was a retrospective descriptive study of neonatal deaths undertaken in the public healthcare setting in the Cape Town Metro West GSA from January 2014 till December 2017. Existing data from PPIP, Child PIP and the CDR/FPS was used. Neonatal deaths were defined as in the first 28 days of life where there had been signs of life at delivery and a birthweight greater than 500g. Neonatal deaths were excluded where birth had occurred outside of the GSA or in the private health care setting. The audit data with regards to cause of death and avoidable or modifiable factors was obtained for each death. Results From a total of 134843 live deliveries, 1243 neonatal deaths were identified: 976(78%) from PPIP, 58(5%) from Child PIP and 209 (17%) from CDR/FPS. Sixteen per cent of the deaths occurred outside of healthcare facilities. The neonatal mortality rate (NMR) for PPIP was 7.2, Child PIP 0.43 and CDR 1,6 per 1000 livebirths. When the audit systems were combined, the annual NMR over the study period varied from 8.05 to 10.1 with a mean of 9.2 per 1000 livebirths over the entire period. Seventy-eight per cent of the deaths occurred in the early neonatal period with a mean early neonatal mortality rate of 7.2 per 1000 livebirths. The mean late NMR was 2 per 1000 livebirths. Where all neonatal deaths were considered for those more than 500g, the main cause of death was immaturity related, then infection related followed by congenital disorders and then hypoxia related. Seventy-four per cent of deaths occurred in those less than 2500g at birth and 41% were less than 1000g and defined as extremely low birthweight. In the group of neonates greater than 1000g, the main cause of death was infection related deaths, closely followed by congenital disorders and then hypoxia, followed by immaturity. Most of infection related deaths were collected by the CDR and Child PIP. A third of Child PIP and PPIP deaths and half of the CDR deaths were coded as avoidable. The prevalence of deaths due to abandonment either by passive or active neonaticide contributed towards the higher proportion of preventable deaths in the CDR group. Conclusions The burden of deaths due to immaturity is high and may be attributed to the finding that 41% of neonatal deaths were in the ELBW group. Current viability criteria that aim at optimum use of resources may improve survival amongst this group. Infection related deaths were shown by this study to have a greater burden than recorded from PPIP data; most of these deaths were derived from Child PIP and CDR data. Also, where 10% of neonatal deaths were sudden unexpected deaths (SUDIs), a better understanding and definition of this group is urgently required as many of these deaths were subsequently found to be secondary to lower respiratory infections. It is further relevant that where 20% of CDR deaths or 3% of all the study deaths were due to active and passive neonaticide, this entity should be monitored and investigated. The study showed that the GSA has achieved the SDG for NMR of less than 12 per 1000 livebirth. However, a mean NMR of 9.2 per 1000 livebirths is not comparable to other upper middle-income countries. As 38% of the deaths were coded as avoidable, appropriate programmes to address these factors could reduce the NMR to 5.7 per 1000 livebirths. A strong recommendation from this study would be to use all three audit systems to calculate the NMR, understand the causes of neonatal deaths and plan programmes to improve neonatal survival in this GSA.

Background: Congenital heart disease (CHD) is the leading non-infectious cause of paediatric morbidity and mortality worldwide and a significant social and healthcare burden. The aetiology of CHD is poorly understood, though heritable genetic factors including copy number variants (CNVs) have been shown to contribute to the risk of CHD in individuals of European ancestry. However, the role of rare CNVs in the development of CHD in African populations including South Africa is unknown. This study aims to identify pathogenic and likely pathogenic CNVs in South African cases of CHD. To our knowledge, this is the first study to investigate the genetic basis of CHD in a South African cohort. Methods: The study cohort included 105 patients presenting to the cardiac clinics at Red Cross War Memorial Children's Hospital and Groote Schuur Hospital with non-syndromic isolated CHD (n = 76), nonsyndromic CHD with additional extra-cardiac anomalies (n = 17), and positive controls with syndromic CHD (n = 12). Genotyping was performed using the Affymetrix CytoScan HD platform. Rare CNVs were filtered using stringent criteria for their size and algorithm-specific quality score and were compared against a gene panel of known CHD-associated genes. Candidate genes were considered based on pLI scores and reported CHD phenotypes in mouse models. The identified CNVs were validated by quantifying the read-coverage of available whole-exome sequencing data of a similar overlapping cohort. Results: Chromosomal microarray analysis was successful for 101 participants (including 89 non-syndromic CHD cases and 12 control cases) and led to the identification of eight CNVs overlapping genes known to be causal for CHD (GATA4, TBX1, FLT4, CRKL, NSD1, and B3GAT3), and four CNVs encompassing candidate genes likely to play a role in the development of CHD (DGCR8, JARID2, KDM2A, and FSTL1). The CNVs were identified in nine unrelated individuals: five of the CNVs were classified as pathogenic or likely pathogenic (5.6% of the cohort) and four were classified as variants of unknown significance (4.6%). CNVs of interest were validated using the available whole-exome sequencing data. Conclusions: In this study, we show that chromosomal microarray analysis is an effective technique for identifying CNVs in patients diagnosed with CHD and that this approach can be performed locally in South Africa, producing results similar to those seen in international CHD studies. The findings of this thesis highlight the wide genetic heterogeneity of CHD and the growing importance of CHD genetic studies for both research and clinical purposes. Advancing our understanding of CHD aetiology will help define disease risk in South Africa and improve the way we care for and assess our cardiac patients.

Background Effective phototherapy reduces neonatal jaundice and its complications. Irradiance increases as the distance of the light source decreases from a single phototherapy light. There are limited studies of the effect of distance and positional changes on different LED light designs on achieving effective phototherapy. Objectives To describe and compare the effect of distance, angle and plastic barriers on three different LED lights of different design. Methods Comparisons were made using a Servolite LED light, a General Electric (GE) Lullaby and a Ningbo David LED phototherapy light. Measurements were done according to methods described by the International Electrotechnical Communission (IEC). The effective irradiated area was measured on a grid measuring 60 x 30 cm subdivided into 5 x 5 cm squares. Measurements were done for the following scenarios: light placed at the manufacturers' recommended distance, 20 cm closer, 20 cm further, at an angle, through clear plastic and through scuffed perspex. Results When the lights were placed closer to the irradiated surface than the manufacturers' recommendations, the maximum irradiance increased, but the median irradiance and uniformity ratio decreased. When the lights were angled at 45 the median irradiance was decreased. A decrease in the median irradiance was also seen when phototherapy lights passed through scuffed plastic and food grade plastic. Conclusion Our study demonstrated that placing LED lights closer than the manufacturers recommendations, the use of transparent barriers and the use of lights at an angle, compromised phototherapy irradiance and distribution. Only the GE light met IEC standards.