Includes bibliographical references / Rheumatic Heart Disease (RHD) is a leading cause of heart disease in children and young adults in the developing world, with significant associated morbidity and mortality. Early secondary prophylaxis may retard the deleterious progression from its antecedent, acute rheumatic fever to permanent heart valve damage, and thus several echocardiographic screening programmes to detect asymptomatic RHD and institute early prophylaxis have been conducted. While effective interventions are available for ameliorating the effects of RHD, research on their use in different settings is scant. Key questions remain regarding the natural history of asymptomatic RHD and the optimal method for early detection. In addition, there is a lack of contemporary estimates of mortality and morbidity among the symptomatic population in the developing world. The primary purpose of the thesis was to determine the outcomes of asymptomatic and symptomatic RHD. More specifically, I sought to quantify the incidence, prevalence and outcomes of RHD in South Africa over the past two decades, determine the natural history of asymptomatic RHD and validate a focused protocol for screening in schoolchildren from Cape Town. In addition, I determined the baseline characteristics, prevalent sequelae and gaps in evidence-based implementation in children and adults from14 developing countries. Finally, I investigated the independent predictors for mortality and morbidity of RHD over a two-year period in patients from Cape Town, South Africa. My thesis has five key findings. Firstly, a systematic review of the literature showed that the incidence and prevalence of RHD over the past two decades in South Africa remains high, although there is evidence of falling cause-specific mortality at a population level. Secondly, asymptomatic RHD has a variable natural history that ranges from regression to a normal state, to persistence of disease, and progression to symptomatic RHD. Thirdly, a focused hand-held echocardiography protocol shows promising levels of sensitivity and specificity for detecting subclinical RHD. Fourthly, the baseline data from the global rheumatic heart disease registry demonstrates significant gaps in the implementation of medical and surgical interventions of proven effectiveness in low- and middle-income countries. Finally, the annual mortality rate for children and adults with RHD in Cape Town over a two-year period is 4.1%with cardiovascular events occurring at a rate of 0.18 events per patient per year. The findings encapsulated in this thesis have important implications for policy, practice and research related to the management of asymptomatic and symptomatic RHD in the world.

The Fecal Fermentation Profile of Twins and Infants with Opioid Exposure Dawson Brown-Ezell Michelle Johnson PhD, RD, LDN W. Andrew Clark PhD, RD Amy Wahlquist, PhD Introduction: The gut microbiome is believed to have a significant impact on health throughout the lifespan, and the influence of infant nutrition and other environmental factors are of particular interest in its development. The aim of this research project was to learn more about the microbiome and short chain fatty acid (SCFA) composition of toddlers of differing weights, considering birth history, environment, and diet. In East Tennessee, opioid misuse is a growing issue, and a number of participants in this study were exposed in utero. We also hoped to identify related effects on infant’s SCFA composition. Finally, it has been concluded that twins share a variety of traits, but much about their microbiome is unknown. With several pairs of twins in the sample, we aimed to identify any associations with SCFAs in this group. Methods: With informed consent, the child’s history was obtained, including age, birth length and weight, delivery type (C-section or vaginal), and feeding method (breast, bottle fed, or both). The child’s current weight, height, and BMI %ile were determined. Caregivers completed the 90-question Block Questionnaire for Ages 2-7 Kids food frequency questionnaire, and results were analyzed by Berkeley Analytics Inc (dba NutritionQuest). Participant-provided stool samples were freeze-dried and ground, and SCFAs were extracted and analyzed by content and concentration. Data analysis was generated using SAS software, Version 9.4 of the SAS System, Copyright © 2013 SAS Institute Inc. Results: Nine SCFAs were measured in duplicate, and the concentrations averaged. Statistical analysis included comparisons of SCFAs related to factors including weight status, infant feeding modality, twin status, and intrauterine drug exposure, and significance determined with a p value < 0.05. Results did not identify significant differences in individual SCFA concentrations between obese and non-obese toddlers, however concentrations of isobutyrate, isovaleric acid, and octanoic acid were greater in toddlers who were formula fed as infants versus toddlers who were breastfed, and those fed a combination of breastmilk, and formula. Analysis further revealed a higher mean concentration of caproic and propionic acid in twin subjects. Of particular interest, toddlers with a history of opioid exposure had higher mean concentrations of isovaleric and octanoic acids, but less isocaproic acid when compared to those who were not drug exposed. Further analysis will help determine if these findings may be related to nutrient intake, in particular dietary fiber intake.

BACKGROUND: In the United States, racial and income disparities in maternity care outcomes are large and persistent. Research demonstrates that community doulas (specialized community health workers for pregnant, birthing and postpartum people) can improve maternal and infant outcomes. Despite this evidence, doulas have not yet been widely adopted in health services for low-income communities. One barrier to scale-up is understanding the costs and benefits of integrating doula services into maternity care payment systems. METHODS: An exploratory, sequential mixed methods study design was used to understand decision-maker perspectives on doulas in maternity care and apply these priorities to an economic evaluation of a randomized trial of enhanced doula support. 16 in-depth, semi-structured interviews with Medicaid, Accountable Care Organization (ACO) and maternity care decision makers in Massachusetts were conducted. Results from the qualitative study informed the design of an economic analysis of a pragmatic trial of doula support. A return on investment analysis, with a focus on areas of high financial impact and organized by segments of health care services was conducted. Program costs were analyzed using a micro-costing approach. Hospital data on health care costs and payments were used to calculate financial outcomes for both intervention and control groups. Sensitivity and sub-group analyses were developed to understand variations in impact for different populations, settings and doula program models. RESULTS: Decision-maker interviews revealed that health care organizations prioritize investments that promote improved population health, patient experience, cost reduction, and elimination of racial disparities in outcomes. Participants universally expressed interest in an analysis approach that provides information on return-on-investment outcomes, as well as the clinical and cost areas with the largest impact. The time frame of interest was primarily in the pregnancy and newborn episodes of care, with some participants expressing interest in longer term outcomes related to fewer first cesarean deliveries or preterm birth. The economic analysis found an 18% return on investment for the Best Beginnings for Babies doula intervention overall. Sensitivity analyses demonstrated the largest impact was for people with medical and social risk factors and for those who received at least 5 hours of prenatal home visits, as well as labor support. CONCLUSION: Medicaid and maternity care decision-makers are supportive of doula programs if they are affordable and can create cost savings. An economic analysis of the Birth Sisters Best Beginnings for Babies program found a positive return on investment, benefiting both health care payers and families. Community doula programs are a high-value innovation that should be reimbursed by Medicaid agencies. / 2021-09-25T00:00:00Z

This study explored the perceptions of parents and staff around the services offered to young children with disabilities in Special schools. Questionnaires were distributed to parents of young children with disabilities attending Special schools and to the professional staff working with these children. Six Special schools, under the auspices of the Western Cape Education Department and situated in the Cape Town Metropole, participated in the study. Questionnaires focused on the following themes: knowledge of disability, the nature and amount of contact enjoyed by staff and parents, the level of participation, consultation and decision making afforded to parents and staff and the extent to which parents and staff perceived that their needs were being met by the school. Findings highlighted a need among staff and parents for more knowledge around all issues of disability. This included information pertaining to disability as well as knowledge of the roles of various staff trained to work with the children. Parents voiced an additional need for information relating to their child's activities during a school day. Results also indicated insufficient contact between parents and staff This impacted on the level of consultation and decision making afforded to parents. It also affected the way in which staff viewed interaction with parents as well as their attitudes towards them. Differences in parents' and staff's perceptions of the extent to which the schools met the needs of parents varied from school to school. It appeared that meeting the emotional needs of parents of young children with disabilities by the schools needed particular attention. Socioeconomic factors appeared to influence responses, especially in areas around knowledge of disability and the amount of contact maintained by parents with the school. Even though many parents wished to participate more in their child's school activities, financial and social constraints were cited as factors preventing this. This study is relevant in a time when changes are being implemented in the Special Education system, particularly when a more meaningful involvement is being demanded of parents in all aspects of school affairs. Recommendations are thus aimed at empowering parents and staff, with a view to strengthening the partnership between parents of young children with disabilities attending Special schools and the staff working at these schools.

Background The World Health Organization's "Coordinated Global Research Roadmap: 2019 Novel Coronavirus"outlined the need for research that focuses on the impact of COVID-19 on pregnant women and children. More than one year after the first reported case significant knowledge gaps remain, highlighting the need for a coordinated approach. To address this need, the Maternal, Newborn and Child Health Working Group (MNCH WG) of the COVID- 19 Clinical Research Coalition conducted an international survey to identify global research priorities for COVID-19 in maternal, reproductive and child health. Method This project was undertaken using a modified Delphi method. An electronic questionnaire was disseminated to clinicians and researchers in three different languages (English, French and Spanish) via MNCH WG affiliated networks. Respondents were asked to select the five most urgent research priorities among a list of 17 identified by the MNCH WG. Analysis of questionnaire data was undertaken to identify key similarities and differences among respondents according to questionnaire language, location and specialty. Following elimination of the seven lowest ranking priorities, the questionnaire was recirculated to the original pool of respondents. Thematic analysis of final questionnaire data was undertaken by the MNCH WG from which four priority research themes emerged. Results Questionnaire 1 was completed by 225 respondents from 29 countries. Questionnaire 2 was returned by 49 respondents. The four priority research themes which emerged from the analysis were 1) access to healthcare during the COVID-19 pandemic, 2) the direct and 3) indirect effects of COVID-19 on pregnant and breastfeeding women and children and 4) the transmission of COVID-19 and protection from infection. Conclusion The results of these questionnaires indicated a high level of concordance among continents and specialties regarding priority research themes. This prioritized list of research uncertainties, developed to specifically highlight the most urgent clinical needs as perceived by healthcare professionals and researchers, could help funding organizations and researchers to answer the most pressing questions for clinicians and public health professionals during the pandemic. It is hoped that these identified priority research themes can help focus the discussion regarding the allocation of limited resources to enhance COVID-19 research in MNCH globally. / Revisión por pares

According to the U.S. Centers for Disease Control and Prevention (CDC), maternal death ratios are severely racially stratified as African American women face the most significant risk. Currently, Black women are four times more likely to die from pregnancy-related death in the United States than white women. Race disparities in maternal health outcomes may be exacerbated by the Covid-19 pandemic as preliminary research suggests that the pandemic's disproportionate impact on Black communities and existing concerns about Black women's medical treatment may indicate an increase in mortality within the next few years. Racial health disparities reflect the nation's flawed maternal healthcare system and highlight a need for alternative healthcare models, including the increased use of doulas, who provide physical, emotional, and educational support during pregnancy, childbirth, and postpartum. Research has shown that doula care effectively mitigates adverse perinatal outcomes for socially disadvantaged women and their infants. Black doulas have distinct knowledge and insights about how race operates in the maternity care system as birth workers who serve Black birthing women, however, there is little research illuminating their perspectives. The current study is a qualitative analysis of the perspectives of Black doulas on their experiences with birth work in the U.S. maternity health care system during the Covid-19 pandemic and beyond using a critical intersectional lens. Data consist of in-depth, semi-structured qualitative interviews with 11 Black doulas throughout the U.S. Interviews were transcribed with the aid of Otter.ai and coded and analyzed thematically using NVivo. The results yielded four overarching themes: Advocacy and Trust are Key Components of Doula Work, Barriers to Accessing Doula Services and a Need for New Hospital Policies, COVID-19 Worsened Restrictions on Doula Work, and Increased Distrust of Hospitals among Black Indigenous and People of Color (BIPOC). The final theme focused on the History of Racism in Reproductive Health affects the Quality of Care Today and included a sub-theme regarding the Prevalence of Dismissive and Abusive Care. This study expands existing knowledge of race inequalities in maternal health by contributing the experiences and perspectives of Black doulas, who are uniquely positioned to observe Black patients' treatment in maternity care. Findings demonstrate a need for medical institutions to address systemic racism within their policies and procedures and highlight actionable solutions proposed by doulas to mitigate existing injustices.

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