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.

Background: While specific taxation has been found to be effective in reducing alcohol consumption and its related harms in High-Income Countries, it theoretically encourages drinking initiation in Low- and Middle-Income Countries (LMIC) with a high prevalence of lifetime abstainers. This dissertation aims to systematically review the existing evidence of the effects of taxation in LMIC on alcohol consumption, alcohol-related harms, and the rate of drinker initiation, and to examine how changes in Thailand’s Two Chosen One (2C1) taxation rates affect alcohol consumption, related harms and drinking initiation. Method: (1) A systematic review and meta-analysis that examines the effects of taxation policy on alcohol consumption, alcohol-related harms and the rate of drinker initiation in LMIC. (2) A quasi-experimental study using interrupted time-series analysis that examines the effects of alcohol taxation increases in Thailand on alcohol consumption and traffic fatalities. (3) An analysis of four consecutive national surveys on alcohol consumption behaviours to examine the effect of alcohol tax increases on drinking initiation prevalence in Thailand. Result: There were only 10 published studies that quantitatively examined the effect of alcohol taxation policy on consumption in LMIC. In LMIC the price elasticity of demand was -0.64 for all alcohol consumption, -0.50 for beer consumption, and -0.79 for consumption of other alcohol. No studies were found that examined the effects of taxation policy on alcohol-related harms and drinking initiation in LMIC. Thailand’s alcohol taxation increase in 2009 was associated with a reduction in alcohol consumption (tax elasticity of -1.95) and in traffic fatalities (tax elasticity of -1.90). Increased taxation prevented drinking initiation among young people 15 – 24 years of age during 2001-2011 in Thailand (tax elasticity of -0.40). Conclusion: Increases in taxation under the 2C1 taxation method were associated with decreases in alcohol consumption, alcohol-related harms and drinking initiation.

Background: While specific taxation has been found to be effective in reducing alcohol consumption and its related harms in High-Income Countries, it theoretically encourages drinking initiation in Low- and Middle-Income Countries (LMIC) with a high prevalence of lifetime abstainers. This dissertation aims to systematically review the existing evidence of the effects of taxation in LMIC on alcohol consumption, alcohol-related harms, and the rate of drinker initiation, and to examine how changes in Thailand’s Two Chosen One (2C1) taxation rates affect alcohol consumption, related harms and drinking initiation. Method: (1) A systematic review and meta-analysis that examines the effects of taxation policy on alcohol consumption, alcohol-related harms and the rate of drinker initiation in LMIC. (2) A quasi-experimental study using interrupted time-series analysis that examines the effects of alcohol taxation increases in Thailand on alcohol consumption and traffic fatalities. (3) An analysis of four consecutive national surveys on alcohol consumption behaviours to examine the effect of alcohol tax increases on drinking initiation prevalence in Thailand. Result: There were only 10 published studies that quantitatively examined the effect of alcohol taxation policy on consumption in LMIC. In LMIC the price elasticity of demand was -0.64 for all alcohol consumption, -0.50 for beer consumption, and -0.79 for consumption of other alcohol. No studies were found that examined the effects of taxation policy on alcohol-related harms and drinking initiation in LMIC. Thailand’s alcohol taxation increase in 2009 was associated with a reduction in alcohol consumption (tax elasticity of -1.95) and in traffic fatalities (tax elasticity of -1.90). Increased taxation prevented drinking initiation among young people 15 – 24 years of age during 2001-2011 in Thailand (tax elasticity of -0.40). Conclusion: Increases in taxation under the 2C1 taxation method were associated with decreases in alcohol consumption, alcohol-related harms and drinking initiation.

This study seeks to investigate the attitudes towards mental illness in Sweden in comparison with India. To measure attitudes towards people with mental illness the questionnaire Community Attitudes Towards Mental Illness (CAMI) was used containing positive and negative statements regarding mental illness. These statements are divided into the four attitude categories of Authoritarianism, Benevolence, Social Restrictiveness and Community Mental Health Ideology. The questionnaire study consisted of a total of 410 students; 272 from Sweden and 138 from India. Sweden and India were chosen because of their differences based on factors that recent studies have shown affect a community’s attitudes towards mental illness; socio-economic, religion and culture. The results show that there is a difference in attitudes between the two countries in three out of the four attitude categories, where India showed a more positive attitude than Sweden towards mental illness meaning they have a greater sense of authoritative approach, goodwill, and social inclusion. This result was expected in the sense that there was a significant difference between the countries but not in the sense that India was to be the country to have a more positive attitude than Sweden since it goes against what previous research indicated. / Följande studie söker att undersöka attityderna gentemot psykisk ohälsa i Sverige i jämförelse med Indien. För att mäta attityderna gentemot personer med psykisk ohälsa användes frågeformuläret Community Attitudes Towards Mental Illness (CAMI) innehållandes positiva samt negativa påståenden inom ämnet mental ohälsa. Dessa uttalanden är uppdelade i de fyra attityd-kategorierna: Authoritarianism, Benevolence, Social Restrictiveness and Community Mental Health Ideology. Studien bestod av totalt 410 studenter; 272 från Sverige och 138 från Indien. Sverige och Indien blev valda som länder genom deras skillnader baserade på faktorer som tidigare studier har visat ha effekt på ett samhälles attityder gentemot psykisk ohälsa; socioekonomi, religion samt kultur. Resultaten visar att det finns en skillnad i attityd mellan de två länderna i tre utav de fyra attityd-kategorierna där Indien visade på en mer positiv attityd gentemot psykisk ohälsa än vad Sverige gjorde vilket innebär att Indien har ett mer auktoritärt förhållningssätt, social inkludering samt känsla för välvilja. Detta resultat var delvis förväntat då vi förutspådde en skillnad mellan länderna men då tidigare forskning indikerat, genom faktorerna nämnda tidigare, att Sverige borde ha en mer positiv attityd än Indien var den delen av resultaten inte förväntad.

Background: Children with disabilities living in low and middle income countries’ perceptions of participation are not shown in research. These perceptions are important for providing appropriate interventions. Aim: To describe how children aged 8-12 with an intellectual disability living in Ethiopia perceive their situation regarding participation in activities in everyday life. Method: A descriptive design with a quantitative approach was used. The sample was gathered using consecutive sampling. Fifteen structured interviews were conducted, using “Picture my participation,” an instrument under development. Analyses were made using SPSS Statistics and Microsoft Excel. Results: The children perceived that they participated in activities in everyday life. There was a broad variation in the activities the children prioritized as most important. On a group level, they were very involved in these activities. The majority did not experience any barriers to perform these activities. Conclusions: The perceptions of the majority of the children were that they were involved in daily activities. They did not experience any barriers to participation. The results should be read with caution and generalization is not possible, due to the sample characteristics and that the instrument is under development. / Bakgrund: Barn med funktionsnedsättningar som bor i låg- och medelinkomstländers uppfattningar om delaktighet är inte påvisade i forskning. Dessa uppfattningar är viktiga för att tillhandahålla lämpliga interventioner. Syfte: Att beskriva hur barn i åldrarna 8-12 år med en intellektuell funktionsnedsättning som bor i Etiopien uppfattar sin situation gällande delaktighet i vardagliga aktiviteter. Metod: En deskriptiv design med kvantitativ ansats har använts. Urvalet har samlats in genom konsekutivt urval. Femton strukturerade intervjuer genomfördes med användning av ”Picture my participation”, ett datainsamlingsinstrument under utveckling. Dataanalysen gjordes i SPSS Statistics och Microsoft Excel. Resultat: Barnen uppfattade att de deltog i vardagliga aktiviteter. Det var en stor variation i vilka aktiviteter barnen prioriterade som viktigast och på gruppnivå var de mycket delaktiga i dessa aktiviteter. Majoriteten av barnen uppgav att de inte upplevde några hinder för att utföra dessa aktiviteter. Slutsatser: Majoriteten av barnens uppfattning var att de är delaktiga i dagliga aktiviteter i hög grad och att de inte upplever några hinder för att delta. Resultatet bör tolkas med försiktighet och det är inte möjligt att generalisera resultatet, eftersom urvalet är litet och instrumentet är under utveckling.

The failure to translate evidence into clinical practice has been repeatedly highlighted. This failure is partly attributed to disregarding the context within which healthcare is delivered. The aim of this thesis was to develop and psychometrically evaluate the Context Assessment for Community Health (COACH) tool, and, through that process, provide opportunities to measure aspects of context perceived to be important for Knowledge Translation (KT) interventions in low- and middle-income countries (LMIC). All four studies in this thesis were mainly undertaken in Quang Ninh province, Vietnam during 2008–2014. Study II, however, was also conducted in four other LMICs (Bangladesh, Nicaragua, South Africa, and Uganda). Study I employed inductive content analysis of 16 focus group discussions to explore the influence of context in a community-based facilitation intervention in Vietnam. Studies II and III reported on the development of the COACH tool and assessment of its psychometric properties. Study IV used the COACH tool in a survey among health workers in Vietnam. To date, three sources of evidence regarding validity of the COACH tool have been provided, that is, test content, response processes, and internal instrument structure, with promising psychometric characteristics. The COACH tool could be used as means of characterizing aspects of context ahead of KT interventions, for tailoring KT strategies, and for further understanding of the results of KT interventions. / Context Assessment for Community Health