Background: The use of evidence-based medications for the management of cardiovascular disease (CVD) is low worldwide. A key strategy to improving use of medications is to understand the barriers to their use. This thesis aims to identify barriers that may influence use of these medications in high, middle, and low income countries. Data on barriers in low and middle income countries are especially lacking. We postulate that in those settings lack of availability and affordability of proven medications are key barriers to medication use. Methods: We initially systematically reviewed the literature on barriers to medication use. Since data on these barriers for the management of CVD are sparse, the review included studies focused on hypertension, because it is the leading risk factor for CVD. Baseline data from the PURE study were then used to investigate whether availability and affordability of medications influence their use for secondary prevention of CVD. PURE is a prospective study that recruited adults between the ages of 35 to 70 years from 17 high, middle, and low income countries. Availability and affordability of medications were documented for each country income group, and the associations between these two potential barriers and medication use was explored after accounting for other factors that may influence medication use. Results: The review showed that in high income countries, non-healthcare system related factors, such as lack of knowledge and motivation, were more commonly reported as barriers, whereas in low and middle income countries healthcare system factors were most commonly reported as barriers to hypertension management. However, very few studies were conducted in low and middle income countries and so there is limited information on whether availability and affordability of medications affect their use. Results from the PURE study indicate that medications recommended for the secondary prevention of CVD were often not available and when available, they were not affordable for a high proportion of individuals in low and middle income countries. Lack of availability and low affordability were strongly associated with medication use in these settings. Conclusions: Barriers to medication use are context specific and interventions to improve use should be tailored to barriers depending on the setting. In high income countries where the medications are usually available and affordable interventions should target knowledge and motivation barriers. In low and middle income countries, the focus should be on healthcare system interventions to improve the availability and affordability of medications. / Dissertation / Doctor of Philosophy (PhD)

Introduction: The frailty phenotype is a commonly used tool to study frailty. Two characteristics evaluated as part of the frailty phenotype are “low” grip strength and “low” physical activity, defined by the lowest quintile thresholds for age and sex. In studies of frailty in different geographic regions of the world, it is not established whether these thresholds should be applied universally or whether region-specific thresholds of grip strength and physical activity should be applied. This study aims to determine which way of defining frailty is more appropriate. Methods: Using data from the Prospective Urban Rural Epidemiology study, two variations of the frailty phenotype were defined: universal frailty in which thresholds for low grip strength and physical activity were taken to be the lowest quintile of the entire study population and region-specific frailty, in which these thresholds were calculated separately for each region. Frailty prevalence was calculated for each definition and Cox proportional hazards modelling was used to determine which definitions predicted mortality. Likelihood ratio tests statistics, area under the receiver operating characteristics curve, and the net reclassification improvement index were also calculated. Results: Overall frailty prevalence was 5.6% using universal definitions of frailty and 5.8% for region-specific definitions of frailty. Across regions, universal frailty prevalence ranged from 2.4% (North America/Europe) to 20.1% (Africa), while region-specific frailty ranged from 4.1% (Russia and Central Asia) to 8.8% (Middle East). The hazards ratios for all-cause mortality were 2.66 (95% CI: 2.47-2.86) and 2.09 (95% CI: 1.94-2.26) for universal frailty and region-specific frailty respectively (adjusted for age, sex, education, smoking status and alcohol consumption); statistical tests indicated that universal frailty better fit survival data and predicted mortality slightly better. Conclusions: Frailty prevalence varies greatly across regions depending on how the thresholds for low physical activity and grip strength are calculated. Using region-specific thresholds does not help improve the predictive value of frailty when measuring frailty in heterogenous populations using the frailty phenotype. / Thesis / Master of Science (MSc)

No description available.

BACKGROUND: Problem Solving for Better Health (PSBH) aims to strengthen healthcare systems through a ‘bottom up’ approach, optimizing use of existing resources to solve problems in low-resource contexts. Between November 2021 and June 2022, the Government of Lesotho sought to train about 900 nurses in PSBH (PSBHN), collaborating with the Lesotho-Boston Health Alliance. This dissertation evaluated PSBHN implementation. METHODS: A mixed-methods single group pre-test, post-test design guided by the RE-AIM framework was employed. Change in problem-solving efficacy among nurses was assessed with Problem-Solving Inventory at baseline and 3–6 months post-training. We assigned quality scores for nurses’ planned quality improvement projects at training and assessed extent of project implementation 3–6-months later. We conducted in-depth interviews with the PSBHN implementers and nurses to understand experiences with PSBHN. Costs of implementation from a limited societal perspective and scenarios for future scale-up were estimated. We used Stata17, NVivo12 and Excel16 for data analyses. RESULTS: A total of 89 of the planned 900 nurses were trained (10%). Approximately 66% of nurses achieved a medium quality score for the project designed at training; 31% scored high. At follow up, no significant change in problem solving efficacy was observed (p=0.658), but nearly 50% of nurses had initiated their projects, with a 35% increase in project initiation odds for every one-unit increase in project quality score (p<0.014). Qualitatively, coworker and manager support, along with personal drive enabled nurses. Both trainees and the implementation team reported challenges related to funding and resources, competing interests, and lack of stakeholder support. The total financial and economic implementation costs were US$36,413 and US$41,784, respectively. A four-year scale-up was estimated at US$665,142 in 2023 present value, representing 0.4% of the 2023 government’s health sector budget. Two scale-up alternatives were considered: a minimal case scenario at US$222,428 and an ambitious case scenario, US$987,897, both in 2023 present value. CONCLUSION: Implementing costs are a modest proportion of the health budget, but challenges should be addressed to improve reach, adoption, and implementation effectiveness. Efforts to improve the quality of trainees’ planned projects and address barriers faced in the workplace could strengthen PSBHN implementation in Lesotho.

Introduction: A population especially overlooked in early childhood development research is the ‘missing-middle’, predominantly represented by middle-income, urban populations. Research typically focuses on populations that are either from lower- or upper socioeconomic classes. Insight into the risks, protective factors, and developmental outcomes of children from middle-income populations is needed to guide the implementation and customisation of early intervention policies and services. Aim: The study aimed to describe the developmental outcomes of young children aged six to 24 months from an urban, middle-income setting in South Africa using a descriptive correlational research design. Method: The Vineland-3 was used to describe the developmental outcomes of 55 children between six to 24 months, from an urban, middle-income setting in South Africa. The mHealth PEDS was used to identify caregivers’ concerns regarding their children’s development. Results: Caregivers’ concerns were positively associated (φ = 0.355; p = .024) with their children’s overall developmental outcomes, emphasising their valuable contribution in early identification of developmental delays. Fifteen percent (n = 8) of participants’ children presented with developmental delays, with low birth weight identified as a significant developmental risk (p = .011). Within this sample population, higher maternal education was identified as a significant protective factor (p = 0.16). Conclusion: Developmental delays, risks, strengths and protective factors exist within an urban, middle-income South African setting. Early childhood development can be promoted in all income settings by using baby wellness clinics as a point of access to identify children at risk for developmental delays through caregiver-led developmental screening. Prioritising early childhood development across different socioeconomic classes will help ensure that all children reach their full developmental potential. / Dissertation (MA (Speech-Language Pathology))--University of Pretoria, 2021. / National Research Foundation (NRF) / Speech-Language Pathology and Audiology / MA (Speech-Language Pathology) / Unrestricted

This study aims at understanding the role of education in promoting disaster preparedness. Strengthening resilience to climate-related hazards is an urgent target of Goal 13 of the Sustainable Development Goals. Preparing for a disaster such as stockpiling of emergency supplies or having a family evacuation plan can substantially minimize loss and damages from natural hazards. However, the levels of household disaster preparedness are often low even in disaster-prone areas. Focusing on determinants of personal disaster preparedness, this paper investigates: (1) pathways through which education enhances preparedness; and (2) the interplay between education and experience in shaping preparedness actions. Data analysis is based on face-to-face surveys of adults aged 15 years [or older] in Thailand (N = 1,310) and the Philippines (N = 889, female only). Controlling for socio-demographic and contextual characteristics, we find that formal education raises the propensity to prepare against disasters. Using the KHB method to further decompose the education effects, we find that the effect of education on disaster preparedness is mainly mediated through social capital and disaster risk perception in Thailand whereas there is no evidence that education is mediated through observable channels in the Philippines. This suggests that the underlying mechanisms explaining the education effects are highly context-specific. Controlling for the interplay between education and disaster experience, we show that education raises disaster preparedness only for those households that have not been affected by a disaster in the past. Education improves abstract reasoning and anticipation skills such that the better educated undertake preventive measures without needing to first experience the harmful event and then learn later. In line with recent efforts of various UN agencies in promoting education for sustainable development, this study provides a solid empirical evidence showing positive externalities of education in disaster risk reduction.

Children around the world need care outside their families for a variety of reasons including poverty, war and epidemics such as HIV/AIDS. The majority of these children live in developing countries where there are limited resources to care for them. As a result of concerns about the effects of institutional care on children, and following trends in the developed world, there is a movement in developing countries to replace large residential institutions with a system of adoption, foster care and small group homes. The aim of this study is to examine the experience of orphan, abandoned, and neglected or abused children who grew up in residential institutions in the Caribbean nation of Trinidad and Tobago, to learn the positives and negatives of residential care in order to contribute to developing a model of care suited for high need, low resource countries. Oral history methodology was used to collect the stories of 24 alumni (12 men and 12 women) from seven homes in Trinidad and Tobago. The homes were categorized as 1) state— partially funded by the state but managed by the Anglican and Catholic dioceses, 2) faith-based— run by religious communities, and 3) community homes run by individuals in the community. The findings of the study show that overall experiences were positive. For poor and working-class children, life in the home was better than their life would have been if they had remained with their families. However, discharge and transition from the homes were less favourable. Alumni from the state-funded homes experienced more difficulties than the faith-based and community homes as a result of poor planning and a lack of post-departure supports. Women suffered more hardships than men, often leading to sexual exploitation. The findings also show that being admitted with siblings and staying at the same home over the duration of care—as was the norm—correlated positively with educational outcomes for the majority of alumni. Some life-long relationships were maintained with volunteers and with friends made among peers at the homes. The study concludes that large group care is not necessarily harmful for children. It may be even beneficial and may be cost effective—a factor that is very important for low resource countries. An aftercare plan, with planning beginning at admission might ease the transition process and gender must be considered in discharge and transition policies. / October 2016

Thesis advisor: Ce Shen / Civic engagement, involving people in public processes to achieve common goals, has received increased attention in the past several decades. This renewed interest was triggered by the seeming decline in civic engagement, particularly in the context of Western societies including the U.S. In addition, its potentially positive effects, such as psychological well-being at the individual level, have recently received much attention. Low-income people in developing countries suffer from double discrimination: first, the lack of opportunities to participate in civic matters due to their low socio-economic status (SES) and second, the lack of civil society culture in developing countries. However, less attention has been paid to civic engagement in the context of developing countries and low-income people, in spite of the importance of civic engagement to them. Given the significance of civic engagement for low-income populations in developing countries, this dissertation intends to fill the gaps left by previous scholarship. The following are specific objectives for the study: 1) Paper 1 aims to investigate the construct validity of an instrument to measure civic engagement among low-income populations in developing countries; 2) Paper 2 aims to examine the associations between country-level political and economic determinants and civic engagement among low-income people in developing countries; and 3) Paper 3 aims to examine the effect of civic engagement on subjective well-being through the mediating effect of sense of agency. Using the cross-national data set, the World Values Survey Wave 6 (2010-2014), this study first found that civic engagement among low-income individuals in low- and middle-income countries is defined in three dimensions: electoral behaviors, membership in civic organizations, and cognitive engagement. This result contributes to measurement development of civic engagement, especially among the low-income individuals in the context of developing countries, who have been neglected in policy-making processes. In Paper 2, I found that civic engagement increases in economically disadvantaged environments (low GNI per capita and high Gini coefficient). This finding may reveal the strength that low-income populations have. Lastly, the results of Paper 3 showed that electoral engagement and membership in civic organizations were directly related to well-being, but cognitive engagement had an indirect effect on well-being through a sense of agency. Also, the result of a non-recursive model showed that engagement in electoral behaviors leads to a sense of well-being, not in the reverse direction. The results from Paper 3 may demonstrate the mechanism by which civic engagement is related to well-being. / Thesis (PhD) — Boston College, 2018. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social Work.

The emergency of malnutrition, in all of its forms, and physical inactivity among children and adolescents as serious public health challenges, especially in resource-limited low- and middle-income countries is concerning and requires attention. Data on the prevalence of unhealthy weight status and levels of physical inactivity among children and adolescents in these low- and middle-income countries are limited, not systematically collected nor are they well documented. Accurate prevalence estimates, and an informed understanding of the relationships among movement behaviours and weight status of children and adolescents, are required to facilitate evidence-informed interventions and public health policies in these countries. The main purposes of this dissertation were to examine relationships between lifestyle behaviours and weight status among primary schoolchildren in Mozambique; compare body mass indices and movement behaviours of Mozambican schoolchildren to those of children from other countries; and use these findings to highlight important data gaps that exist in low- and middle-income countries. First, the Active Healthy Kids Global Alliance’s Report Card development methodology was used to conduct thorough narrative literature searches, identify data gaps and research needs which subsequently informed research questions and primary data collection. A published protocol that was developed for the multinational cross-sectional International Study of Childhood Obesity, Lifestyle and the Environment was adopted and used for primary data collection among urban and rural schoolchildren in Mozambique (n=683), to facilitate data comparability. Anthropometric (weight, height, percent body fat, bioelectric impedance, mid-upper-arm circumference, waist-circumference) and accelerometry (nocturnal sleep, sedentary time, various intensities of physical activity) data were objectively measured by trained personnel. Data about lifestyle behaviours (diet and movement behaviours), demographics and environmental (home, neighbourhood, school) factors associated with child weight status were collected using context-adapted questionnaires. As part of this dissertation, six manuscripts were developed and submitted for publication in peer-reviewed scientific journals. Overall, the narrative literature searches revealed a dearth of information about prevalences of unhealthy weight status, and key lifestyle behaviours among children and adolescents in low- and middle-income countries. Results from data collected in Mozambique showed overweight/obesity to be an emerging public health concern, especially among urban children (11.4%), while thinness still persists and is more prevalent among rural schoolchildren (6.3%). Moderate- to vigorous-intensity physical activity, active transport and mother’s body mass index were found to be important modifiable correlates of weight status for Mozambican children. Distinct differences in the prevalences and correlates of lifestyle behaviours (sleep and physical activity) were observed between urban and rural children in Mozambique. The findings showed that mean moderate- to vigorous-intensity physical activity was lower (82.9±29.5 minutes/day) among urban compared to rural Mozambican children (96.7±31.8 minutes/day). Compared to children from 12 other countries, on average, children from Mozambique had lower body mass indices, higher daily moderate- to vigorous-intensity physical activity, lower daily sedentary time and comparable sleep duration. For example, rural Mozambican children had lower mean BMI z-scores (-0.5±0.9) than the rest of the sample (0.4±1.3), 46 more minutes of daily moderate- to vigorous-intensity physical activity, and 99 less minutes of daily sedentary time than the other children. Furthermore, linear distributions of study site-specific body mass index (positive), minutes of daily moderate- to vigorous-intensity physical activity (negative), and daily sedentary time (positive) by country human development index were observed. Compared to others, children from the urban Mozambican site closely resembled those from Nairobi Kenya on body mass index and movement behaviours, whereas those from rural Mozambique were distinctly different from the rest of the sample on many indicators. Findings from this dissertation highlight the importance of including participants from low, medium, high, and very high-income countries in multinational studies investigating contextual and environmental factors related to childhood weight status. The findings revealed important differences between urban and rural children supporting the need to include both in study samples and especially in low- and middle-income countries where the majority of people live in rural areas. Finally, findings from this dissertation have demonstrated that despite the reported global progress in the availability of data about obesity and related factors among children and adolescents, gaps still exist and need to be filled in low- and middle-income countries.

The black middle–class market segment also known as the black diamond market segment has shown immense growth in SA. It currently consists of approximately 3 million black middle–class South Africans with a buying power of approximately R200 billion. Despite the immense size and spending power of black diamonds, combined with its rapid growth over the past 15 years and expected future growth, little research has been conducted on this market segment. The rapid market growth of the black diamond market segment has lead to an immense rise in the demand for middle–income houses. This has caused a shortage of middleincome houses, and government and real estate developers have been unable to supply housing in this bracket to meet this ever increasing demand. The study examines this missing middle between supply and demand for the black diamond market in Tlokwe municipal region in order to provide the Tlokwe Municipality, real estate developers, construction companies, town planners, real estate agencies and the Tlokwe Department of Housing with sufficient information to address this challenge in Tlokwe municipal region. The study was conducted by way of a literature review and empirical study. For the empirical study, the information was obtained through two questionnaires. One questionnaire was compiled for black diamond respondents and one for real estate developers and estate agents in the Tlokwe municipal region. The study found that there is a gap between the supply side and demand side of middleincome housing (houses within the R50 000 to R550 000 price range) in the Tlokwe municipal region, and that there is a high demand for such houses. It was also found that there is a tendency for black diamonds to relocate from the townships to the suburbs. The major reasons for this movement were identified as family and the lack of availability of middle–income houses in the townships. It was also found that the black diamond respondents have a tendency to spend their money on bad debt (debt on expenses) instead of good debt (debt on assets), and are inclined to save rather than spend. Furthermore, as evident from the number of respondents with clothing accounts and cellphone contracts, it was confirmed that black diamonds are status driven, as suggested in the literature. / Thesis (M.B.A.)--North-West University, Potchefstroom Campus, 2011.