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No / Nigerian health professionals are impacted by several global forces bearing down on them, one of which is the positive economic prospects associated with emigrating to work abroad. This emigration is an aspect of increased global mobility which has had an adverse effect on the Nigerian health economy. This is important globally because countries with the smallest healthcare workforce capacities such as Nigeria have the poorest health outcomes. The emigration of health professionals from Nigeria will continue until domestic structures such as improved healthcare infrastructures, job security, and financial rewards change for the better. Thus, it is important that measures aimed at supporting the Nigerian health workforce be implemented with a focus on building and managing for sustainability within the context of international interdependency. Accordingly, this chapter is aimed at creating a theoretical framework for building capacities and managing the challenges of the Nigerian health workforce vis-à-vis the opportunities offered by globalization.

INTRODUCTION: Approximately two-thirds of the U.S. population have had at least one adverse childhood experience (CDC-Kaiser Permanente Adverse Childhood Experiences [ACE] Study, 2009). Some consequences of ACEs are manifested as the child grows into late teenage years and young adulthood. Research suggests that children exposed to traumatic events during childhood subsequently experience negative health outcomes like substance abuse, engagement in risky and harmful sexual behavior, and STD occurrence. AIM: In this thesis I explore the associations of 18 year olds’ described use of alcohol, risky sexual behavior and sexually transmitted diseases (STDs) with childhood exposure to caregiver substance abuse, violence and family circumstances METHODS: Data were obtained from the Longitudinal Studies of Childhood Abuse and Neglect (LONGSCAN) Assessments 0 - 18 from the National Data Archive on Child Abuse and Neglect (NDACAN). Variables on adverse childhood experiences, sex behaviors, STDs and substance use were observed in SAS. Multiple logistic regression models were used to identify odds ratios and strength of associations. RESULTS: Results suggests significant associations among participants who were exposed to parent/caregiver use of illicit drugs during participant’s childhood and subsequent self-reported heavy alcohol use 1.60 (95% CI: 1.18, 2.22), having early sexual initiation (at age 13 or younger) 1.60 (95% CI: 1.18, 2.22), having 6 or more sexual partners 1.36 (95% CI: 1.09, 1.68) and having STDs 1.83 (95% CI: 1.36, 2.46). Eighteen year olds with who were African American, were at a greater odds of having greater than 6 sexual partners, having sexual intercourse at or before age 13 and having (an) STD(s). No significant associations were found between having a parent/caregiver or member of household who was incarcerated, being exposed to violence, being exposed to yelling often or parental often use of alcohol and subsequent alcohol abuse, having greater than 6 sexual partners, having sexual intercourse at or before age 13 and having (an) STD(s) . DISCUSSION: Based on the findings of these analyses, programs for adolescents should focus time and resources on young children who may be currently experiencing, or at risk for experiencing, parental/ caregiver illicit drug use in the home.

Inhalation exposure to semi-volatile polychlorobiphenyls (PCBs) that ubiquitously exist in the environment has the potential to cause adverse health effects. Recently identified sources of airborne PCBs, especially non-legacy sources, stress the importance of risk assessment for inhalation exposure. However, the fate of inhaled airborne PCBs in biological systems and the resultant toxicity remain unexplored. The objective of this thesis research was to investigate the distribution and elimination of semi-volatile PCBs in biological systems after inhalation exposure and evaluate the biologic and toxicologic consequences. This objective was achieved by conducting the following inhalation studies in rats: a short-term exposure study of the body burden and elimination; a subchronic exposure toxicity study; an acute exposure study of PCB11 metabolism; and a mass balance study of [14C]PCB11 following lung exposure. PCBs found in technical Aroclor mixtures and PCB11 were readily absorbed and distributed following nose-only inhalation exposure. PCBs accumulated in adipose tissue, but decayed in other tissues with biological half-lives of several hours. Their elimination was dependent on the structure of the PCB congeners and the metabolic nature of the organ. Lower-chlorinated PCBs exhibited more rapid clearance than higher-chlorinated congeners yet differential rates of elimination were also seen within the homologue. A distinct congener pattern was found in tissues, ranging from tri- to pentachorobiphenyls after subacute and subchronic exposure. Rapid elimination of PCB11 and its metabolite, 4-OH-CB11, were detected in liver following nose-only inhalation exposure by our established methodology. Further investigation revealed that [14C]PCB11 was 99.8% absorbed in lung. Elimination of the [14C]PCB11 and products consisted of an initial fast phase followed by a slow clearance phase. [14C]PCB11 underwent rapid and extensive metabolism in liver. The major products were phase II metabolites which dominated in the non-adipose tissues and were eliminated via the large intestine and urine. Overall, differential congener elimination was found after inhalation of airborne PCBs, with minimal toxicity. Lower-chlorinated congeners were rapidly and extensively metabolized to phase II products and eliminated within hours.

Sleep impairments for caregivers are multifactorial. Assumptions are that caregivers of those with primary malignant brain tumors (PMBT) are similar to caregivers of persons with dementia as cognitive impairments are present at diagnosis. The shorter trajectory of PMBTs and rapid deterioration of recipients’ health may influence sleep in caregivers of persons with a PMBT. The purposes of this study were to use a sleep impairment model to characterize caregiver sleep using objective and subjective measures, and to examine sleep loss effects on psychosocial and physiologic health outcomes. A secondary data analysis using baseline data from a larger study of mind-body interactions in caregivers of family members with PMBTs was used. Caregiver data included standardized questionnaires, serum blood draw, and three-day sleep-wake activity data from an accelerometer. Analyses included descriptive statistics, correlations, t-tests, and hierarchical regression models. Caregivers (N = 133) were White (94%), female (69.2%) spouses (75.2) and on average 52 years old (SD = 11.8). Care recipients were mainly White males of similar age with a highly malignant glioma (57.4%). Sleep latency was longer (35 min, SD = 34.5), with shorter total sleep time (TST) (357 min, SD = 84.6) and more frequent wake after sleep onset (WASO; 15.1%, SD = 9.2) than in the general population. Caregivers reported high anxiety (59.4%). Caregiver comorbidities and care recipient functioning explained higher perceptions of health (R2 = 26, F(2, 84) = 14.94, p < .001). Whereas, longer TST, more WASO and poorer sleep quality explained poorer quality of life (R2 = .27, F(4, 66) = 6.19, p < .001). Sleep loss variables explained little variance in physical health status, interleukin-1ra and interleukin-6 levels, fatigue, depressive symptoms, spiritual health, social support, and work limitations. Nurses need to assist caregivers with anxiety management and ways to improve sleep at time of PMBT diagnosis. Sleep impairments place these caregivers at risk for physical and mental health problems, and compromise their ability to continue in the role.

Aim: The aim of this study was to develop a targeted health information package for women to use specifically as a reference during their return to health following a hysterectomy and to subsequently test its usefulness. Method: A quasi-experimental design measured the effectiveness of this package in improving the health and satisfaction outcomes of women compared to those who received the standard information. Women undergoing a hysterectomy for benign reasons who were between the ages of 20 and 60 years were included. There were 55 participants recruited into the control group and 44 into the intervention group. Participants completed a self-administered questionnaire both prior to and 14-16 weeks post-surgery. Results: The study found that there were no statistically significant differences between the two groups for their self-reported health, the time taken to return to usual activities and the number of symptoms experienced after surgery. Clinical improvements, however, were noted in the intervention group. A statistically significant difference was found between the groups for the amount written information that they would have preferred for their recovery (X2 8.26 df2 p=0.011). Ninety percent (90%) of the women who received the intervention wanted the same amount of written information to take home whilst 40% of the control group would have preferred more written information. This indicated a positive effect from the intervention. An unexpected finding in this study was that almost 40% of both groups wanted more verbal information and discussion prior to discharge. Conclusion: A valuable aspect of this study was its usefulness in identifying the clinical importance of discussion as part of the discharge process. These findings will be important for health professionals to utilise in their clinical practice for women undergoing a hysterectomy.

Australia's population as estimated at 30 June 1997 was 18.5 million of which 23.3 percent were born overseas. People from non-English speaking countries account for 14.2 percent of the Australian population. The 1996 Census shows that 2.6 million in Australia speak a language other than English at home. Therefore, no one can deny that Australia's society is characterised by cultural and linguistic diversity. In this context, migrant health services, and policies and the needs of people from different cultural backgrounds in the area of health have been addressed since the early 1980s. This thesis draws attention to the concept of 'health' as a fundamental dimension embedded in the area of health care and its related policies, services, programs, and health instruments. This current study questions the idea of universality in the concept of 'health' which suggests that a certain meaning and construction of health can be applied to any culture and society. For this purpose, a qualitative study was designed to explore the concept of health within a group of Iranians in Australia and to examine the appropriateness of the aspects and constructs of health identified in the SF-36, a self-report health status questionnaire developed in the United States, for an Iranian population. The methodology used in this research sought to collect qualitative data with a sample of 21 Iranians- 10 females, and 11 males. The NUD.IST program was used to organise and manage the data for the first time in the Persian language. Findings from the research provided evidence of the ways a sample of Iranians understood health and its embedded dimensions. The themes that emerged from the transcripts as significantly reflecting participants' conceptualisation of health included harmony, health as a concept which is both emotional and physical; integrated, spiritual aspect of health; tranquillity, physical and emotional aspects of health; social and familial relationships; and absence of disorder. Using these themes, a framework consisting of the components of health was developed. The components of the framework include holistic, spiritual, dualistic, social, operational, oppositional, and comparative and relative dimensions. Findings provide evidence which supports the assumption that a group of Iranians have certain views of 'concepts of health'. The results from the research provided evidence that some of the items and constructs relating to health included in the SF-36 seem to be problematic when administered to an Iranian population. The findings of the thesis suggest that a qualitative inquiry into Iranians' discourse of health and its dimensions should be made with an Iranian group before administering an instrument such as the SF-36. Analysis of findings suggests a number of recommendations and modifications when the SF-36 is translated from English into Persian and administered to a group of Iranians.

This thesis is comprised of three chapters that empirically examine two important areas in health economics: access to health care and health outcomes. The first chapter explores the impact of health care utilization on unmet health care needs (UHC) using four biennial confidential master files (2001-2010) of the Canadian Community Health Survey and applying an instrumental variables (IV) approach to deal with the endogeneity of health care utilization. The presence of drug insurance and the number of physicians in each health region are used to identify the causal effect. I find a clear and robustly negative relationship between health care use and unmet health care needs; individuals who are more likely to report unmet health care needs are those who use the health care system less frequently. One more visit to a family doctor, specialist or a medical doctor on average, decreases the probability of having unmet health care needs by 7.1, 4.6 and 2.8 percentage points, respectively. Further analysis by sub groups reveals that the impact of health care utilization on UHC is larger for females in comparison to males, rural residents in comparison to urban dwellers and those with low household income rather than high. The second chapter of this thesis examines whether the presence of the unmet health-care (UHC) needs has an adverse effect on health outcomes using the National Population Health Survey, a nationally representative longitudinal data set spanning 18 years. I pay close attention to the potential endogeneity of this problem. Five direct and indirect measures of health-related outcomes are examined. I find clear and robust evidence that the presence of UHC either two-years previously or anytime in the past, affects negatively the current health of the individual – controlling for a host of other influences. For instance, reporting UHC in the previous cycle reduces the probability of being in excellent or very good health and in good mental health, respectively by 8.1 and 1.2 percentage points; it reduces the HUI3 score by 2.9 percentage points and increases the expected number of medications used by 11%. Further analysis by looking at the effect of UHC when it was due to accessibility reasons, reveal that the effect of UHC because of accessibility reasons on health outcomes is larger than the one of the overall UHC, but the difference is small in general. Finally, the third chapter of this thesis examines the link between social networks and access to health care utilization, focusing particularly on the probability of having a regular family doctor. Unlike previous work that uses cross sectional data, I use panel data from the National Population Health survey to control for unobserved heterogeneity. Access to a regular family doctor is modeled using the dynamic random effects probit model, which makes it possible to explore the dynamics of access to a regular family doctor– for instance, the role played by past access status to a family doctor in predicting current access. In particular, I use the dynamic random effects probit model that controls for both unobserved heterogeneity and for initial conditions effects. I find robust evidence of a highly statistically significant relationship between social capital and the probability of having a regular family doctor. Although the marginal effects are modest, the results from all model specifications show that there is clear evidence that individuals with high levels of tangible, affection, emotional, social interaction, who live with spouse only or with spouse and children are more likely to have a regular family doctor, whereas those living alone are less likely to have a regular family doctor. The results also reveal that past access to a family doctor is an important determinant for both current and future access. The predicted probability of having a regular family doctor is about 18 percentage points (or 20%) higher for individuals who had a family doctor in the previous period, relative to those who did not. In addition, I find that unobserved heterogeneity accounts for about 25% of the variation in accessing a regular family doctor and is significantly correlated with the access to a family doctor over my long panel.

Since the advent of antiretroviral therapy (ART), few studies have examined how mother-child relationships relate to physical and mental health in HIV+ and demographically-similar uninfected mothers. The present three studies investigated the relationships of mother-child relationship quality (MCRQ: measured qualitatively with autobiographical narratives) with HIV status, domestic violence, substance use, childcare burden, self-silencing, and mental and physical health outcomes. Health outcomes were measured at two time points, concurrent with the autobiographical narratives (T1) and 11 months later (T2). Participants were recruited from the Chicago Women’s Interagency HIV Study and included 87 HIV+ mothers and 38 demographically matched HIV‒ mothers (M age=43.8, SD=9.4) who were primarily African American (89.6%) and low income. Study 1 used analyses of covariance to examine relationships between MCRQ and concurrent HIV status, self-reported self-silencing, substance use, domestic violence, caregiving (i.e., number of children and time spent caregiving) and childcare burden (i.e., mother’s opinion of parenting, perceived difficulty of parenting, help received from children). Relative to HIV‒ mothers, HIV+ mothers spent fewer hours caregiving and cared for fewer children. Negative mother-child relationships related to higher substance use and self-silencing, and positive mother-child relationships related to more time caregiving and more children cared for. In Study 2, multiple and logistic regressions were used to examine MCRQ as predicting T1 and T2 self-reported depression symptoms and health-related quality of life among HIV+ and HIV‒ mothers, and self-reported ART adherence and viral load and CD4+ counts assessed through blood specimens in HIV+ mothers. Negative MCRQ predicted higher depression symptoms at T1, as well as lower health-related quality of life at T1 and T2. Positive MCRQ predicted lower viral load at T1. Study 3 examined the potential moderation of MCRQ on the relationship between time spent caregiving and health indicators in HIV+ and HIV‒ mothers. At higher levels of positive and negative MCRQ, more hours caring for children related to better odds of being 95% adherent to ART medications at T1. Together these studies suggest that mother-child relationships are integrally related to the health of HIV+ and HIV− mothers and may be important areas to consider in treating this population. / 2020-12-11T00:00:00Z

This study used a twin and triplet sample to investigate the influence of preschoolers’ physical activity levels and internalizing problems on subsequent health outcomes (body-mass index, internalizing behavior problems, household health behaviors) in middle childhood. The potential influence of stressors salient in childhood (household chaos, socioeconomic status, stressful life events) on the hypothesized relationship between physical activity and internalizing on health was also explored. A specific focus was placed on examining the underlying genetic and environmental influences of children’s physical activity levels, as assessed by both temperamental (parent-reported) activity levels and observed (in-lab) motor behavior, using a behavioral genetic approach. By measuring physical activity in these two ways, this project also investigated the validity of the observational coding scheme developed for the current study to assess preschoolers’ overt motor behavior during laboratory testing. Data from 65 families (n = 134 children) included in the Southern Illinois Twins/Triplets and Siblings Study (SITSS) were examined from age 5 (physical activity levels, internalizing problems, and household chaos) to follow-up (body-mass index, internalizing problems, household health behavior, socioeconomic status, and stressful life events) when children were age 7-13 years old. Findings indicated that observed motor behavior and temperamental activity were not significantly correlated, suggesting that these measures assess different aspects of preschoolers’ physical activity levels. Additionally, results supported the reliability and validity of the newly developed observational coding scheme, which underscores the utility of this measure; employing this methodological tool in future studies focused on investigating motor behavior in childhood may be particularly fruitful. Genetic analyses demonstrated that approximately 66% and 34% of the variance in observed motor behavior was accounted for by additive genetic and non-shared environmental influences, respectively, whereas the variance in temperamental activity was attributable to dominant genetic effects (72%) and non-shared environmental influences (28%). These results suggest that differences in age 5 physical activity levels are largely due to genetic differences. Finally, longitudinal analyses showed that health outcomes at follow-up were significantly influenced by 5-year-old temperamental activity and internalizing problems, as well as follow-up socioeconomic status and stressful life events: 1) children who were older, were boys, and lived in a low socioeconomic status household had a higher body-mass index at follow-up; 2) children with higher age 5 internalizing problems and concurrent stressful life events had greater internalizing problems at follow-up; 3) boys and children with higher age 5 temperamental activity had lower scores for household health behaviors. The present project provides greater insight into childhood health (body-mass index, internalizing, household health behaviors) by examining factors relevant to health (physical activity levels, internalizing problems, stress) across development (i.e., from age 5 to ages 7-13 years).