Background: International agencies such as the World Health Organisation have highlighted the potential of digital information and communications technologies to strengthen health systems, which are underpinned by the 'building blocks' of information, human resources, finances, commodities, leadership and governance, and service delivery. In high income countries, evidence of the positive impacts of 'eHealth' innovations on the cost-effectiveness of healthcare is growing and many governments are now providing incentives for their adoption. In contrast, the use of eHealth in developing countries has remained low and efforts to introduce these new approaches have experienced high failure rates. There is even scepticism regarding the feasibility of eHealth in low-resource settings, which may be hindered by high costs, indeterminate returns on investment, technical problems and socio-organisational barriers. More research is needed to document both the value of eHealth for strengthening resource-limited health systems and the challenges involved in their implementation and adoption, so that insights from such research may be used to inform future initiatives. While many studies of eHealth for patient care in low- and middle-income countries (LMIC) are taking place, evidence of its role in improving administrative processes such as financial management is lacking, despite the importance of 'good governance' (transparency and accountability) for ensuring strong and resilient health systems. The overall objective of this PhD was to elucidate the enablers, inhibitors and outcomes characterising the implementation and adoption of a modular eHealth system in a group of healthcare facilities in rural Malawi. The system included both clinical and billing modules. The specific objectives were (i) to understand the socio-technical, organisational and change management factors facilitating or hindering the implementation and adoption of the eHealth system, (ii) to assess the quality of data captured by the eHealth system compared with conventional paper-based records, and (iii) to understand how information within the eHealth system was used for service delivery, reporting and financial management. A further aim was to contribute to the corpus of mixed-methods case studies exploring eHealth system implementation processes and outcomes (including data quality) in LMIC. As described in the following chapters, the research also gave rise to unanticipated and serendipitous findings, which led to new lines of enquiry and influenced the theoretical perspectives from which the analysis drew.

Background: Maternal common mental disorder (CMD), characterised by depression, anxiety and somatic symptoms of distress, is known to be an important health problem in low-and-middle-income countries, but had not been investigated in Malawi, Africa. In preliminary work, we adapted a CMD screening measure and showed that post-partum CMD was common and associated with child stunting. In the research presented here, we expanded the investigation of CMD in Malawi to include pregnant women and mothers of children with severe acute malnutrition (SAM). Using validated measures, we aimed to estimate the prevalence of antenatal CMD/depression and investigate its relationship to social support and intimate partner violence. Secondly, we sought to explore women’s lived experiences of the perinatal period. Finally, we investigated CMD amongst mothers of children admitted with SAM and other life-threatening illness and, in the former, we tested the hypothesis that maternal CMD would be associated with impaired child recovery. Method: In an antenatal clinic-based study, we validated and compared Chichewa and Chiyao versions of the Self Reporting Questionnaire (SRQ) and Edinburgh Postnatal Depression Scale (EPDS) using major depressive episode (MDE) as the criterion diagnosis. We adapted and validated the Multi-dimensional Scale of Perceived Social Support (MSPSS). We measured the prevalence of antenatal MDE and identified associated factors. We conducted focus group discussions with women and enquired about perinatal stressors and supports. We administered the SRQ to mothers of children with SAM during admission to a nutritional rehabilitation unit (NRU) and at 1-month post-discharge, and investigated whether CMD was a risk factor for lower child weight gain at follow-up. In a subsequent study, we compared levels of CMD symptoms between mothers of children admitted to a NRU, a high dependency unit and an oncology ward. Results: We found that the adapted EPDS and SRQ were both valid screening instruments for antenatal CMD/depression. The weighted prevalence of antenatal MDE was 10.7% (95% CI 6.9% - 14.5%). The adapted MSPSS showed adequate test characteristics and differentiated between sources of social support. MDE was associated with lack of support by a significant other; intimate partner violence moderated this association. We found that women in rural Malawi recognised depressive and anxious states in the perinatal period and identified lack of partner support as a key stressor. During admission with a severely malnourished child to a NRU, mothers had very high SRQ scores that greatly reduced post-discharge. There was no association between SRQ score and child weight gain at follow-up. We found no higher level of CMD symptoms amongst mothers of children admitted for treatment of SAM compared with those admitted to other wards. Conclusions: We demonstrated that measures of antenatal CMD and perceived social support can be adapted for use in Malawi. We found that maternal CMD is common and associated with lack of social support, intimate partner violence and child illness. We did not find evidence for a specific association between maternal CMD and child SAM but further prospective studies are required. Our findings suggest that treatment of CMD in mothers in Malawi will require attention to social support and partner behaviour.

The achievement gap in American schools between middle class students and students from poverty is well documented. This paper outlines the findings of a study designed to explore the experience and conscientization of struggling students from poverty. The argument will be made that poverty can be viewed as a culture and that this view may shed significant light on the dynamics of the achievement gap. Further, using the construct of poverty as a culture provides real life applications that have the potential to impact the achievement gap. The study explored the lived experiences in a public school setting of intermediate students from poverty, hoping to capture their voice and insights. The research utilized a Critical Pedagogical Approach to attempt to understand why American schools struggle with these populations and what could be done to address the achievement gap.

Owning a home is often referred to as the American Dream. However, the reality for low income homeowners is often problematic. Some scholars suggested that homeowners are better off than renters are, while others suggested that the current quest for low-income homeownership interferes with other affordable housing initiatives. Yet, few researchers examined the decision-making process of low-income homeowners. This phenomenological study explores and describes the experiences, attitudes, and perspectives of low-income individuals and their homeownership decisions. This study further delineates the costs and benefits of the Housing Choice Voucher Homeownership Program (HCVH) as perceived by low-income families in a southern U.S. city. Rational choice and social cognitive theories serve as a conceptual framework to explore the decision-making processes of people considering participating in the HCVH. Ten HCV clients responded to 13 semistructured questions. The results of the study generated 5 key themes: the pride of owning a home, weighing the costs and benefits of homeownership, leaving a legacy for children and grandchildren, lack of knowledge of the HCVH and other mortgage assistance programs, and “they did it so can I.” These findings suggest that all 10 participants believed in the benefits of owning a home. Several of the participants noted that there are also substantial costs associated with owning a home. This study has policy and social change implications for policymakers and low-income families considering purchasing a home. The recommendations include requiring all housing authorities establish HCVH programs and requiring housing authorities to provide post follow-up services for HCVH clients who exit the program.

There was growing concern in New Zealand in the 1990�s that Food Security: access by all people at all times to enough food for an active healthy life, was not being achieved, despite an abundant food supply. A study of a convenience sample of 40 families with children (58 adults and 92 children) whose sole income was a government welfare benefit was undertaken. Two-thirds of these households regularly relied on a limited variety of food; one-half did not have a sufficient amount of food because of lack of money and outstanding debts. Over the previous year two-thirds had sourced food from a food bank and one-third had been gifted food from friends or relatives. Women�s intakes were compromised regularly but not children�s. All of the women experienced worry about feeding their household. One-fifth were overweight and over 40% obese despite low reported daily energy intakes (median (SE) 5.7 (0.5) MJ) compared to national data. Six repeated 24-hour diet recalls collected randomly over a two-week period enabled calculation of usual daily intake and the prevalence of inadequate intake for eight micronutrients which were disturbingly high. The children�s growth patterns compared favourably with US population percentiles. The National Nutrition Survey (NNS97) allowed the adaption of eight questions--developed by Reid using qualitative methods--to eight indicator statements about food security to be addressed by each participant on behalf of them or their household. Prevalence was significantly higher (p<0.05) for females compared to males for the majority of indicator statements among New Zealand European and Others (NZEO) and Maori. NZEO reported the most food security; Pacific people reported the least and Maori fell between the two. There was a significant increasing linear trend of food security with age (p<0.001) after adjusting for gender. Rasch analysis was performed on 1868 households where participants reported some food insecurity. The responses were ranked according to the proportion and ordering of their positive responses to eight indices of food security, achieving reliability (Cronbach�s Alpha) close to the conventionally accepted level of 0.7. The eight indices were ranked on the same scale; the minimum score -1.66 was achieved by the index �use special food grants/banks� (the index least reported and most severe) and the maximum score 1.86 was achieved by the index �variety of foods eaten limited� (the index most reported and least severe). Categories of food security were assigned using scale cut points: �fully/almost fully food secure�; �moderate food security�; �low food security�. Category status was associated with consumption of recommended number of daily serves of fruit, vegetables, fruits and vegetables, consumption of leaner meats, fatty meats and daily serves of bread. By ANOVA and controlling for sex, ethnicity, Index of Deprivation, urban/rural location, age, level of education, income, and household size, category of household food security was associated with the level of daily intake of total fat, saturated, monounsaturated and polyunsaturated fat, cholesterol, glucose, fructose, lactose, vitamin B6, vitamin B12, and vitamin C. Dietary data were from the primary 24-hour diet recall of respondents. Participants in the fully/almost fully food secure category of households had a mean BMI of 28.7 compared to those moderately secure (29.2) and of low food security (29.5) (p=0.015 for difference among categories). In the Children�s Nutrition Survey 2002 (CNS02) data set, the same eight indices were used and food insecurity was experienced significantly more often by children in the largest households, those in the most deprived areas of residence (NZDep01 Quintile) and those of Pacific and Maori ethnicity compared to NZEO children. Rasch analysis was performed on responses for 1561 households with children which reported some food insecurity. Subject reliability was close to 0.7 (the conventionally acceptable level). The distribution of the eight indices on the Rasch scale was similar to that observed among the NNS97 households and almost identical to the sub-set of households with children, from that dataset. Categories of food security status were assigned as in the NN5S97 and they predicted daily nutrient intake levels of children: total sugars, lactose, vitamm A, β-carotene, vitamin B12 and calcium. A more rigorous assigning of categories at the low/moderate scale cut-off, resulted in a further association with level of intake of glucose, fructose and folate. Mean BMI across categories of food security did not differ. Collectively these data provide unequivocal evidence that food insecurity exists in New Zealand, that it can be quantified and associated with nutrition outcomes. It has a negative impact on the nutrient intakes of both adults and children and a negative impact on the body weight status of adults. These data have implications for nutrition and health professionals and policy makers in New Zealand. They also add to the world-wide body of knowledge of the experience of, and the measurement and predictive potential of food security in populations where the food supply appears plentiful.

Miami is no longer just known as the playground for Latin America's wealthy, rather, it has become increasingly identified as the business, commercial and cultural center of South Florida and the Americas. This increasing importance and global scope has led to the idea of making Miami into a "new" world city a development priority. The city's geographical proximity to Latin America and the Caribbean makes it an ideal city within the United States to form transnational ties and to attract more business from the region and hopefully the rest of the world. How does the idea of being a "world city" affect the types of projects that have taken place or will be taking place in recent years? Does this idea cater only to Latin American elites and the global sphere while ignoring the needs of local residents in adjacent areas? Megaprojects such as Museum Park and the Miami World Center are set to solidify MiamiÕs position as a global node and a greater regional hub. These projects will be built in the two areas of Downtown that do not enjoy the same cosmopolitan lifestyle as the Central Business District and the Brickell areas, in hopes of creating a different identity or a brand for these generally lower-income areas. Adjacent Overtown does not receive this kind of attention. This paper will examine how Downtown Miami is aiming at "world city" status, attempting to attract foreign capital--both economic and social--while neglecting to place a greater importance on homegrown talent and low-income locals living in neighborhoods adjacent to "developing" areas.

Thesis (M.A.)--University of Delaware, 2006. / Principal faculty advisor: Peter Rees, Dept. of Geography. Includes bibliographical references.

Thesis (Ph. D.)--University of Oregon, 2006. / Typescript. Includes vita and abstract. Includes bibliographical references (leaves 502-527). Also available for download via the World Wide Web; free to University of Oregon users.

<p>For close to a decade, Zimbabwe has experienced a protracted socio-economic crisis. Although it is affecting both rural and urban areas, major forms of formal safety nets by the Government and Non-Governmental Organisations have been confined to rural areas. On the other hand the virtual collapse of the formal food marketing system in urban areas and the high formal unemployment rates have contributed to increased vulnerability of low income urban households to food insecurity. Using qualitative research methods, the study set out to understand livelihoods of low income urban households in Dzivaresekwa. In particular strategies low income households employ to cope with the negative macro-economic environment prevailing in Zimbabwe.</p>

The goal of nursing is to promote health and alleviate suffering. Using Appreciative Inquiry, this study explored the possibilities for the nursing profession to reduce the health implications of poverty. Select Saskatchewan registered nurses (RNs) engaged in appreciative interviews that identified positive experiences working with low income clients. The participants were activists challenging the status quo through their practice. Analysis illuminated the best practices of these RNs, constructing a vision for change rooted in their understanding clients realities and communicating those realities through advocacy. By bringing their personal passions to client interactions, and connecting with a broader social justice context, RNs create an opportunity to respond to the effects of income inequities on health.