Dissertations / Theses on the topic 'Public health|Sub Saharan Africa Studies|Health education'

While most of the world has been able to dramatically reduce extreme poverty rates, Sub-Saharan Africa has failed to do so and is the only region in the world with more people living in extreme poverty than thirty years ago. This thesis will develop a policy framework for alleviating poverty by drawing from countries that are performing surprisingly well and poorly in the region. The thesis concludes with an analysis of whether education, health, or agricultural sectors should be receiving more or less funding based on expected rates of return and the feasibility of policy successes.

Gender inequalities are still widely pervasive and deeply institutionalised, particularly in Africa, where the burden of disease is highly gendered. The public health sector has been slow in responding to and addressing gender as a determinant of health. The purpose of this inquiry was to gain a deeper insight into the different ways in which gender was represented in the public health curriculum in sub-Saharan Africa. A qualitative inquiry was undertaken on gender in the curriculum in nine autonomous schools of public health in sub-Saharan Africa. Official curriculum documents were analysed and in-depth interviews were held with fourteen staff members of two schools that served as case studies. A content analysis of the data was carried out, followed by discourse analysis. A poststructuralist theoretical framework was used as the ‘lens’ for interpreting the findings. Most of the official curricula were ‘layered’, with gender not appearing on the surface. Gender was represented mainly as an implicit discourse and appeared explicitly in only one core course and a few elective modules. The overwhelmingly dominant discourse in the official curricula was the ‘woman’ discourse, with a strong emphasis on the reproductive and maternal roles of women, while discourses on men, sexuality and power relations seemed to be marginalised. Gender discourses that emerged from the in-depth interviews with participants were lodged in biological, social and academic discourses on gender. The dominant discourses revolved around sexual difference and role differences based on sex. Participants drew on societal discourses (family, culture and religion), academic discourses and their lived experiences to explain their understandings of gender. Their narratives on the teaching of gender showed that gender was not taught or received a low priority and that it was insufficiently addressed in the public health curriculum. Barriers to teaching gender were: lack of knowledge, resources and commitment; resistance; and competing priorities. From this study it emerged that curriculum and the production of gender knowledge are sites of struggle that result in multiple understandings of gender that are manifest in dominant and marginalised discourses. Prevailing institutional power relations mirror dominant societal and political discourses that have a fundamental effect on curriculum decisions and resource allocations. This interplay between dominant discourses and power relations, underpinned by a strong biomedical paradigm, could explain the positioning of gender as an implicit representation in the curriculum, with a more explicit focus on gender in the elective modules than in the compulsory or core courses. Being implicitly represented, gender does not compete with other priorities for additional resources. It is recommended that the public health curriculum be reconceptualised by: accommodating multiple understandings of gender; questioning constructed dominant gender discourses; considering broader, varied and complex social, cultural, economic, historical and political contexts in which gender is constructed and experienced; and moving from curriculum technicalities to understanding the curriculum as a process and not a product.
Thesis (PhD)--University of Pretoria, 2011.
School of Health Systems and Public Health (SHSPH)
Unrestricted

African-born residents of the United States have a higher incidence of HIV than African Americans. Factors such as lifestyle, habits, behavior practices, and activities may predispose African-born residents to behave sexually in ways that place them at risk of becoming infected with HIV. This study used a qualitative narrative approach to understand the lived experiences first generation Sub-Saharan African-born men who are U.S. residents to analyze the behaviors that expose them to HIV. To analyze data, the study used the health-belief model as the conceptual framework and NVivo for data analysis to assist in identifying, categorizing, and analyzing common themes and grouping unstructured data. The study used a purposive convenience sampling of 14 first generation Sub-Saharan African-born men who are U.S. residents residing in the states of Delaware, New Jersey, and Pennsylvania and discovered that they engage in sexual risk taking behaviors which include: having multiple sexual partners, preferring heterosexual relationships without a condom, have limited knowledge of HIV prevalence in the United States, and preferring to have sex with both African born females and American born women who are thought to be healthy. Their tendency to visit strip clubs, visit sex houses, and to abuse alcohol was also apparent in the study. Social change implications include adding new relevant knowledge in the understanding of how HIV spreads among Sub-Saharan African-born male U.S. residents by discovering the risk behaviors in which Sub-Saharan African men engage to expose themselves to contracting HIV disease. This knowledge can influence future health education efforts and target culture specific behaviors.

Human trafficking is an ever-growing crime in this century. It is estimated that there are 29.8 million slaves around the world today - 16.36% of which are located in sub-Saharan Africa. The sub-Saharan region is a region in which human trafficking is combatted ineffectively due to a lack of food, lack of access to education, lack of post-education opportunities and lack of proper legislation. This thesis explores the environment in which human trafficking is taking place in sub-Saharan Africa, and proposes potential changes that will theoretically disallow human trafficking to take place in the region. The only way in which an environment conducive to trafficking in persons will ever change is through establishing partnerships amongst governments, non-governmental organizations (NGOs), and other international organizations. Through the analysis of case law from the United Nations Human Trafficking Case Law Database, data from the World Bank, the United States State Department Trafficking in Persons Reports, the United Nations Global Reports on Human Trafficking, and various reports from NGOs, this thesis evaluates the approaches taken by various governments in sub-Saharan Africa to change the environment in which human trafficking thrives. Through raising awareness of the environment of sub-Saharan Africa, and by describing three ways in which human trafficking can be combatted effectively, such as the use of food, education, and the law, this thesis contributes not only to the legal discipline, but also to helping combat trafficking in persons effectively throughout the world.
B.A.
Bachelors
Legal Studies
Health and Public Affairs

HIV infection persists in Swaziland with the highest prevalence of the disease globally – 1 in 4 Swazis aged 15-49 are HIV-positive. Women have a higher rate of infection than men (31.1% of women are HIV-positive, whereas 19.7% of men are HIV-positive). The difference in prevalence between the sexes raises some concerns, particularly due to the possibility of vertical transmission from mothers to infants because the average number of children ever born per woman is 2.28 for all women and 3.58 children for married women. This research aimed to determine if there was a significant difference regarding the knowledge and personal beliefs about HIV transmission between men and women. Obtaining correct knowledge regarding the transmission of HIV and where to get tested for HIV is vital to preventing further transmission of the disease. The Demographic and Health Surveys Program (DHS) gathered data in 2006-2007 to determine the baseline knowledge of individuals about the transmission of HIV. Comparisons of data collected from Swazi men (n = 4,156) and women (n = 4,987) concerning their knowledge and beliefs about HIV were made in order to obtain descriptive statistics, including chi-square to determine the presence or absence of significance (p-values) and percent differences between the sexes. Statistical Package for the Social Sciences (SPSS) software was utilized to perform all statistical analyses using both the chi-square and percent difference functions. Data was weighted accordingly prior to analyses being run in SPSS. Questions regarding the individuals’ personal beliefs about the transmission of HIV were included on surveys for both sexes, specifically addressing the following: 1) the outward appearance of those who are HIV-positive (96.1% of women and 95.7% of men believed healthy-looking individuals can be infected with HIV; p = 0.336, % difference = 0.3999, χ2 = 0.926), 2) the role (or lack thereof) of mosquitoes in transmitting HIV (65.7% of women and 66.1% of men believed mosquitoes cannot transmit HIV; p = 0.688, % difference = 0.3999, χ2 = 0.161), 3) supernatural involvement in the transmission of HIV (92.3% of women and 91.7% of men believed supernatural means do not contribute to the spread of HIV; p = 0.292, % difference = 0.5999, χ2 = 1.112), 4) and the ability of HIV to be spread via food intake (82.2% of women and 82.3% of men believe they cannot becoming infected with HIV by sharing food with an HIV-positive individual; p = 0.901, % difference = 0.0999, χ2 = 0.016). Despite no statistically significant differences between the beliefs about HIV transmission held by both men and women, the data indicated only 51.9% of women and 51.4% of men possess comprehensively correct knowledge about the transmission of HIV. Furthermore, although 91.8% of women knew where to get tested for HIV, only 78.1% of men knew where to get tested for HIV. However, an encouraging 73.8% of women and 71.8% of men between the ages of 18 and 19 stated they believed adolescents between the ages of 12 and 14 should be taught proper condom use to prevent HIV infection. Comprehensive adolescent and adult sex education programs are indicated to ensure all adolescents and sexually active men and women possess correct knowledge about the transmission of HIV and where to seek assistance for HIV testing and treatment.

BACKGROUND: Previous studies show a positive association between household wealth and overweight in sub-Saharan African (SSA) countries; however, the manner in which this relationship differs in the presence of educational attainment has not been well-established. This study examined the multiplicative effect modification of educational attainment on the association between middle-income and rich household wealth and overweight status among adult females in 22 SSA countries. We hypothesized that household wealth was associated with a greater likelihood of being overweight among middle income and rich women with lower levels of educational attainment compared to those with higher levels of educational attainment. METHODS: Demographic and Health Survey (DHS) data from 2006 to 2016 for women aged 18-49 years in SSA countries were used for the study. Overweight was defined as a body mass index (BMI) ≥ 25 kg/m2. Household wealth index tertile was the exposure and educational attainment, the effect modifier. Potential confounders included age, ethnicity, place of residence, and parity. Descriptive analysis was conducted, and separate logistic regression models were fitted for each of the 22 SSA countries to compute measures of effect modification and 95% confidence intervals. Analysis of credibility (AnCred) methods were applied to assess the intrinsic credibility of the study findings and guide statistical inference. RESULTS: The prevalence of overweight ranged from 12.6% in Chad to 56.6% in Swaziland. Eighteen of the 22 SSA countries had measures of effect modification below one in at least one wealth tertile. This included eight of the 12 low-income countries and all 10 middle income countries. This implied that the odds of overweight were greater among middle-income and rich women with lower levels of educational attainment than those with higher educational attainment. On the basis of the AnCred analysis, it was found that the majority of the study findings across the region provided some support for the study hypothesis. CONCLUSIONS: Women in higher wealth strata and with lower levels of educational attainment appear to be more vulnerable to overweight compared to those in the same wealth strata but with higher levels of educational attainment in most low- and middle- income SSA countries.

A lack of surveillance systems is an impediment to public health intervention for perennial vector-borne disease transmission in northern tropical savanna region of Kenya. The population in this area are mostly poor nomadic pastoralists with little acquired functional immunity to Plasmodium falciparum, due to infrequent challenges with the parasite. A common characteristic in tropical savanna climatic zone is the availability of riverbeds that have anthropogenic boreholes that provide malaria vector mosquitoes, such as Anopheles gambiae s.l and Anopheles funestus, with aquatic refuge habitats for proliferation and endemic transmission to proximity human households during the dry-season. Unfortunately, currently there have been no entomological investigations employing field or remotely sensed data that can characterize and model anthropogenic borehole habitats focusing on the dry-land ecology of immature Anopheles mosquitoes in sub-Sahara Africa. The goal of this investigation was three-fold: (I) to employ WorldView-3 (0.31 meter spatial resolution) visible and near infra-red waveband sensor data to image sub-Saharan land cover associated with vector-borne disease transmission; (II) to remotely identify anthropogenic boreholes in three riverbeds that were surveyed to determine whether they provide malaria vectors with refuge habitat and maintain their population during the dry season in Chemolingot, Kenya, and (III) to obtain a radiometric/spectral signature model representing boreholes from the remotely-sensed data. The signature model was then interpolated to predict unknown locations of boreholes with the same spectral signature in Nginyang Riverbed, Kenya. Ground validation studies were subsequently conducted to assess model’s precision based on sensitivity and specificity tests.

Background: HIV testing saves lives. It is fundamental to combating the global HIV epidemic. Key populations at higher risk for HIV in Mozambique, including Men who have Sex with Men (MSM), Female Sex Workers (FSW) and mineworkers, are in urgent need of effective HIV prevention strategies. This is the first analysis ever conducted in Mozambique to identify levels of HIV testing and associated factors that inform these strategies.

Methods: This analysis used data from seven cross-sectional surveys conducted between 2011-2012 among MSM, FSW and Mineworkers in Mozambique. Participants completed a questionnaire and provided blood samples for HIV testing. MSM and FSW were recruited used Respondent Driven Sampling in Maputo, Beira and Nampula. Mineworkers were recruited using Time Location Sampling in Ressano-Garcia. Participants with previous HIV-positive tests or missing HIV test histories were excluded (<5% overall). Weighted logistic regression was used to measure associations with recent HIV testing (<12 months). Theory-driven multivariate logistic regression was conducted in R v2.15 using the Health Behavior Model as a conceptual framework.

Results: The prevalence of recent testing for HIV ranged from 29.8-59.5%, yet 4.4-25.0% had HIV and did not know it. Between 11.9-57.4% had never been tested, and fear was given as the primary barrier. Recent HIV testing was positively associated with knowledge of ARV drugs, knowing the HIV status of a sexual partner, knowing where to go to get tested, and having had contact with a peer educator. It was negatively associated with having had a genital sore or ulcer and unprotected sex. Between 32.1-90.0% of HIV-positive undiagnosed, key population members had used a healthcare service in the previous 12 months and 23.4-47.5% had tested negative for HIV in that time period.

Conclusion: Routine testing with strengthened post-test counseling encouraging key populations to have annual HIV screenings need to be implemented in Mozambique.

Without exception, healthcare systems in the Sub-Saharan Africa, including Ghana, face many challenges. Difficulties in Ghana’s healthcare system stem from many factors, but the most notable one is professional migration, which has crippled the former British colony since 1980. Statistical data demonstrate the yearly migration of healthcare workers from Ghana and its impact on healthcare services (the doctor/nurse population ratio). This study used a quantitative multiple regression research method to examine and empirically analyze the relationship between healthcare workers, technological innovations, and changes in healthcare services in Ghana from 1990 to 2010. The main result was that technological innovations had a significant impact on healthcare services in Ghana during the observed period. Also, regional disparities in the number of medical doctors and nurses were largely explained by the degree of urbanization and economic development. Therefore, the pooled regression analysis from the panel data consistently showed that technological innovations significantly impacted the healthcare system in Ghana during the observed period. However, the numerical impact of the technological innovation coefficients was relatively lower in Ghana during the observed period.

Background: As the world becomes more urban and slums continue to grow in developing countries, research is needed to measure utilization of health services, health outcomes, and access to health care providers among urban slum residents. Estimating trends in urban health among slum residents relative to other urban inhabitants provides evidence of health disparities for priority-setting by program implementers and policy-makers. Research on the negative effects of slum environments on human health has started to emerge, yet there remains a paucity of evidence on morbidity trends over time and inequalities between slum residents and other urban residents. The goal of this study is to quantify maternal and child health care access, utilization and outcomes among urban slum dwellers in selected countries in sub-Saharan Africa and South Asia over time. These three areas are addressed in three separate dissertation manuscripts.

Methods: This dissertation offers an in-depth analysis of household and health facility data to measure trends in maternal and child health care utilization and health outcomes among slum residents over time, as well as inequalities in access, utilization and outcomes between other urban and rural populations. Manuscripts 1 and 2 apply a unique spatial inequality approach to existing population-based household data from the Demographic and Health Surveys (DHS) to identify a sample of slum residents. Manuscript 1 assesses trends in maternal and child health care (MCH) utilization and health outcomes using DHS data in Bangladesh, Ethiopia, Kenya, Malawi, Nepal, Nigeria and Tanzania between 2003 and 2011. In Manuscript 2, a trend analysis is performed in Kenya to examine diarrheal disease and acute respiratory infection (ARI) in children under-five in both slums and other urban and rural areas during the roll-out of a national slum upgrading program. Manuscript 3 further explores local-level dimensions of health care access from two slums in Kenya, generating evidence on service availability and readiness in slums. In this section, we analyze health facility data collected using a modified version of the World Health Organization’s (WHO) Service Availability and Readiness Assessment (SARA).

Results: Manuscript 1 reports significant disparities between slum dwellers and other urban residents’ utilization of key maternal health interventions—appropriate antenatal care (ANC), tetanus toxoid vaccination, and skilled delivery—in Bangladesh, Ethiopia, Kenya and Nigeria. In addition, child health outcomes examined in Manuscript 1 suggest that the prevalence of diarrheal disease in children under-five is declining among other urban and rural residents, but not significantly among slum residents. Nigeria was the only exception, with significant declines in diarrheal disease prevalence in slums over the study period. Because ARI improvements are found across populations, the data suggests this condition is not unique to slum settings. The trend analysis in Manuscript 2 supports these findings—ARI is declining steadily over time not only among slum residents, but also among other urban and rural residents as well. Diarrheal disease prevalence, on the other hand, has not changed significantly over time, with stable levels among slum dwellers between 1993 and 2014. In Manuscript 3, analysis of general service availability and readiness in two locations—the Nyalenda slum of Kisumu and the Langas slum of Eldoret—reveals that slums perform far below recommended benchmarks set by WHO. When we compare service availability and readiness indicators with regional, urban, and national averages, in general slums in Kisumu and Eldoret perform poorly. However, there were some instances—typically involving standard precautions for infection control—where Kenyan slums actually performed better than comparison sites.

Conclusions: This research provides a comprehensive view of health systems dimensions in urban slums in sub-Saharan Africa and South Asia. Manuscript 1 confirms evidence of an urban penalty and emphasizes a need to focus on maternal health care utilization in slums. Manuscript 2 detects little improvement in child health outcomes among slum dwellers in Kenya during the roll-out of the country’s national slum upgrading program. An integrated approach to health and urban policy development is recommended based on these results. Manuscript 3 identifies areas of service availability and readiness in two Kenyan slums that fall below global targets and are in need of improvement in order to achieve desired health outcomes. Taken together, this study makes a significant contribution to the crucial demand for research on growing marginalized urban populations in developing countries.

Men in sub-Saharan Africa are less likely than women to use HIV services and, thus, are more likely to die from AIDS. While much of the literature argues that men’s views of masculinity keep them from services, I use the theory of gendered organizations to provide another perspective. In this dissertation, I use a mixed methods approach to examine the gendered organization of facility-based HIV testing services in southern Malawi and how the organization of services creates additional barriers to men’s use of care.

I combine four types of data: (1) survey data with facility clients to assess if quality of care differs by sex of client; (2) in-depth interviews with healthcare providers and policy makers to examine perceptions of men as clients; (3) participant observation in health facilities to understand how institutional protocols are enacted at the local level; and (4) international and national policy documents to situate local health institutions within broader global constructs of gender and HIV priorities.

I find that heterosexual men have become an invisible category within both international and national HIV policy. When they are included, they are described as the problem, not part of the solution to HIV epidemics. On the ground, the organization of HIV testing services has followed suit.

Health institutions, like other organizations, are not gender-neutral. Men in southern Malawi were not recruited for health services, were less likely than women to receive health education when they did attend a facility, and were less likely to have access to HIV testing because services were, at times, only offered during hours for antenatal services. Furthermore, HIV testing was often located near antenatal services, again contributing to the perception that testing was designed for women – because it was. Based on these findings, I argue that HIV testing is gendered across three levels of the health institution: (1) the organizational HIV policies; (2) the physical environment in which testing occurs; and (3) interactions within facilities that require clients to enact qualities typically viewed as feminine in order to successfully receive care (e.g., waiting long hours, being compliant, and being a caregiver).

Among the multitude of interventions to address the worst forms of child labor (WFCL), one of the responses to the presence of WFCL has been the institution of child labor monitoring (CLM). While systems to systematically monitor children with respect to their exposure and risks have been implemented, the degree of their efficacy and ultimately their effect on the targeted populations begs academic scrutiny. This dissertation seeks to provide an empirical view of the community-level dynamics that emerge in response to a community-based CLM program and their effects, in turn, on the CLM itself.

An embedded multiple case study methodology, surveying longitudinally at two points in time using a mix of purposive and probability sampling techniques, was employed for this study. Two communities, Ahokwa in the Western Region, and Dwease in the Ashanti Region of Ghana, were selected as cases.

The study finds that between the two points of observation – before and after the introduction of CLM – a profound reduction of WFCL is observed in Dwease, whereas much less reduction was observed in Ahokwa. A point-by-point analysis within and between the two villages reveals that individual, social and institutional factors worked together to transform behavior in Dwease. The principal change catalysts in Dwease were (a) a heightened awareness of child work hazards and a deepened parental investment in child education working at the individual level, coupled with (b) new norms created by the town's opinion leaders and the emergence of peer accountability at the social level, and (c) monitoring carried out by the Community Data Collection (CDC) and enforcement carried out by the Community Child Protection Committee (CCPC) – the two new institutions constituting CLM at the community-level. The underlying social dynamic proved to be decisive: a tipping point was crossed in Dwease whereby progressive opinion leaders in the community, who, once sensitized to recognize the pejorative effects of CL/WFCL, created new social norms and spurred a critical mass of community members to rid their community of CL/WFCL.

This study shows that with sufficient local ownership, and if properly instituted, the tandem operation of child protection committees and child labor monitoring enables a community to effectively detect, police and mitigate the practice of child labor and WFCL.

Vulnerable populations, including immigrants, are often at risk for human immunodeficiency virus (HIV) infection because of their risk-taking behaviors. This study investigated risk-taking behavior for HIV infection among Sub-Saharan African (SSA) immigrants in United States. Using social capital as a theoretical foundation, the study aimed to address the question, is there any association between social capital assets of educational opportunity, employment, and eligibility for social assistance and HIV risk-taking behavior, defined as condom use before sex (CUBS) among SSA immigrant in the U.S? Potential participants were recruited through religious and social organizations in a southwestern US state. The survey generated 167 responses. The majority of the participants were Nigerians, single females, and Christians, with monthly income of more than {dollar}500.00. Analysis using Chi square statistic and unconditional logistic regression model showed that those without education opportunity were more likely to use condom but no significant association existed between social assistance opportunity and CUBS. Employed participants were 83 times more likely than those who were unemployed to use a condom before sex. Being employed was the strongest indicator of HIV risk-taking avoidance behavior among SSA immigrants in the U.S. This study provides insight into risk-taking behaviors among SSA immigrants. This information can be used by providers of services to immigrants and other vulnerable populations in the U.S., policy makers, and social advocacy groups that target HIV prevention. Implications for social change included the recognition of employment as a deterrent to HIV risk-taking behaviors among vulnerable populations.

Biomedical and behavioral interventions can virtually eliminate the risk of vertical (i.e., mother-to-child) HIV transmission. Pregnant and breastfeeding women’s adherence to prevention of mother-to-child transmission (PMTCT) interventions, however, remains a challenge across sub-Saharan Africa. Using a concurrent mixed methods approach, including a survey and semi-structured interviews, I test whether a relationship exists between women’s low power within married couples (based on domains from the Theory of Gender and Power) and adherence across the PMTCT cascade of care, including drug adherence during and after pregnancy, safe infant feeding practices, and pediatric HIV testing. The results of this study indicate that intimate partner violence is particularly detrimental to PMTCT adherence. Certain PMTCT protocols are also affected by partner controlling behaviors, participation in household decisions, and economic dependence, but not to the same extent as violence. Women with low power cite a lack of partner support and an unwillingness to disclose their HIV status to the husband due to fear of violence or abandonment as reasons for low PMTCT adherence. Conversely, women with high power cite partner support and the ability to prioritize PMTCT, sometimes even over the marriage, as enabling adherence. Based on these results, augmented efforts to address gender power dynamics both in society and within the home are recommended to promote the health of HIV-positive women and their families.

Health economists, national decision-makers and global health specialists have been interested in calculating the cost of a disease for many years. Only more recently they started to generate more comprehensive frameworks and tools to estimate the full range of healthcare related costs of illness in a user’s perspective in resource-poor settings. There is now an ongoing trend to guide health policy, and identify the most effective ways to achieve universal health coverage. The user fee exemptions health financing schemes, which grounded the tuberculosis control strategy, have been designed to improve access to essential care for ill individuals with a low capacity to pay. After decades of functioning and substantial progress in tuberculosis detection rate and treatment success, this thesis analyses the extent of the coverage (financial and social protection) of two disease control programs in West Africa. Learning from the concept of the medical poverty trap (Whitehead, Dahlgren, et Evans 2001) and available framework related to the economic consequences of illness (McIntyre et al. 2006), a conceptual framework and a data collection tool have been developed to incorporate the direct, indirect and intangible costs and consequences of illness incurred by chronic patients. In several ways, we have sought to provide baseline for comprehensive analysis and standardized methodology to allow comparison across settings, and to contribute to the development of evidence-based knowledge.

To begin, filling a knowledge gap (Russell 2004), we have performed microeconomic research on the households’ costs-and-consequences-of-tuberculosis in Burkina Faso and Benin. The two case studies have been conducted both in rural and urban resource-poor settings between 2007 and 2009. This thesis provides new empirical findings on the remaining financial, social and ‘healthcare delivery related organizational’ barriers to access diagnosis and treatment services that are delivered free-of-charge to the population. The direct costs associated with illness incurred by the tuberculosis pulmonary smear-positive patients have constituted a severe economic burden for these households living in permanent budget constraints. Most of these people have spent catastrophic health expenditure to cure tuberculosis and, at the same time, have faced income loss caused by the care-seeking. To cope with the substantial direct and indirect costs of tuberculosis, the patients have shipped their families in impoverishing strategies to mobilize funds for health such as depleting savings, being indebted and even selling livestock and property. Damaging asset portfolios of the disease-affected households on the long run, the coping strategies result in a public health threat. In resource-poor settings, the lack of financial protection for health may impose inability to meet basic needs such as the rights to education, housing, food, social capital and access to primary healthcare. Special feature of our work lies in the breakdown of the information gathered. We have been able to demonstrate significant differences in the volume and nature of the amounts spent across the successive stages of the care-seeking pathway. Notably, pre-diagnosis spending has been proved critical both in the rural and urban contexts. Moreover, disaggregated cost data across income quintiles have highlighted inequities in relation to the direct costs and to the risk of incurring catastrophic health expenditure because of tuberculosis. As part of the case studies, the tuberculosis control strategies have failed to protect the most vulnerable care users from delayed diagnosis and treatment, from important spending even during treatment – including significant medical costs, and from hidden costs that might have been exacerbated by poor health systems. To such devastating situations, the tuberculosis patients have had to endure other difficulties; we mean intangible costs such as pain and suffering including stigmatization and social exclusion as a result of being ill or attending tuberculosis care facilities. The analysis of all the social and economic consequences for tuberculosis-affected households over the entire care-seeking pathway has been identified as an essential element of future cost-of-illness evaluations, as well as the need to conduct benefit incidence assessment to measure equity.

This work has allowed identifying a series of policy weaknesses related to the three dimensions of the universal health coverage for tuberculosis (healthcare services, population and financial protection coverage). The findings have highlighted a gap between the standard costs foreseen by the national programs and the costs in real life. This has suggested that the current strategies lack of patient-centered care, context-oriented approaches and systemic vision resulting in a quality issue in healthcare delivery system (e.g. hidden healthcare related costs). Besides, various adverse effects on households have been raised as potential consequences of illness; such as illness poverty trap, social stigma, possible exclusion from services and participation, and overburdened individuals. These effects have disclosed the lack of social protection at the country level and call for the inclusion of tuberculosis patients in national social schemes. A last policy gap refers to the lack of financial protection and remaining inequities with regards to catastrophic health expenditure still occurring under use fee exemptions strategies. Thereby, one year before 2015 – the deadline set for the Millennium Development Goals – it is a matter of priority for Benin and Burkina Faso and many other countries to tackle adverse effects of the remaining social, economic and health policy and system related barriers to tuberculosis control. These factors have led us to emphasize the need for countries to develop sustainable knowledge.

National decision-makers urgently need to document the failures and bottlenecks. Drawing on the findings, we have considered different ways to strengthen local capacity and generate bottom-up decision-making. To get there, we have shaped a decision framework intended to produce local evidence on the root causes of the lack of policy responsiveness, synthesize available evidence, develop data-driven policies, and translate them into actions.

Beyond this, we have demonstrated that controlling tuberculosis was much more complex than providing free services. The socio-economic context in which people affected by this disease live cannot be dissociated from health policy. The implications of microeconomic research on the households’ costs and responses to tuberculosis may have a larger scope than informing implementation and adaptation of national disease-specific strategies. They can be of great interest to support the definition of guiding principles for further research on social protection schemes, and to produce evidence-based targets and indicators for the reduction and the monitoring of economic burden of illness. In this thesis, we have build on prevailing debates in the field and formulated different assumptions and proposals to inform the WHO Global Strategy and Targets for Tuberculosis Prevention, Care and Control After 2015. For us, to reflect poor populations’ needs and experiences, global stakeholders should endorse bottom-up and systemic policy-making approaches towards sustainable people-centered health systems.

The findings of the thesis and the various global and national challenges that have emerged from case studies are crucial as the problems we have seen for tuberculosis in West Africa are not limited to this illness, and far outweigh the geographical context of developing countries.

Keywords: Catastrophic health expenditure, Coping strategies, Cost-of-illness studies, Direct, indirect and intangible costs, Evidence-based Public health, Financial and Social protection for health, Health Economics, Health Policy and Systems, Informed Decision-making, Knowledge translation, People-centered policy-making, Systemic approach, Universal Health Coverage

Doctorat en Sciences de la santé publique
info:eu-repo/semantics/nonPublished

This case study was designed to explore policies that were in place to attract, recruit, and retain qualified faculty for 4 community colleges in Sierra Leone. The research was necessitated by the apparent inability of Sierra Leone educators to train and retain faculty possessing the required academic credentials. The research questions were designed to address the policies and strategies used to attract and recruit faculty, better prepare faculty, improve the quality of classroom instruction, and retain qualified faculty at community colleges. The literature review yielded results about the benefits of community colleges in developing countries, thus reinforcing the need for qualified faculty. Case study methodology and open-ended interviews with 12 purposely selected participants were used to ensure trustworthiness and reveal the essential characteristics of how community colleges in Sierra Leone may succeed in faculty attraction, recruitment, and retention. Participants reported that word of mouth solicitation was the primary method for faculty recruitment, and that the top challenge faced by these institutions was fiscal constraints. Although findings from this study are specific to 4 institutions, they may serve as a guide for qualified faculty retention at all community colleges in Sierra Leone, and hopefully bring about social change by improving academic excellence throughout the country.

HIV/AIDS-related stigma and discrimination (S&D), lack of social support, poverty, and gender inequalities have been identified as factors in the increased prevalence rate of HIV transmission in Enugu, Nigeria, especially among women ages 15 to 49 years. Despite the funding of reduction programs, HIV/AIDS-related S&D remain a major driving force in the increased rate of new HIV cases in Enugu. This study addressed a perceived need for behavioral change intervention approaches that span all societal factors to reduce the HIV infection rate in Enugu Nigeria. The study was guided by Goffman’s (1963) social S&D theory. The sample was composed of 132 women living with HIV/AIDS WLWHA ages 21 to 54 years, purposefully sampled from the 4 HIV and AIDS comprehensive initiatives care centers in Enugu, Nigeria. Fifteen WLWHA were interviewed and 114 participated in an online survey. The descriptive statistics and a multiple linear regression analysis and comparison revealed a convergent significant relationship between the S&D determinants (social, political, psychological, environmental, and cultural) and HIV/AIDS-related S&D towards WLWHA in Enugu F (4,109) = 45.09, p <.001). It also revealed that the cultural determinant of S&D was a significant predictor of HIV/AIDS-related S&D towards WLWHA in Enugu (? = 0.81, p < 0.001). The implications for positive social change include providing public health professionals evidence-based data to inform policy change, plan and to implement programs that will change societal attitudes and mobilize broad-based community actions to eradicate HIV/AIDS–related S&D toward WLWHA in Enugu, Nigeria, and in Sub-Saharan African Countries.

Malaria is a vector-borne disease that presents the most persistent and serious public health burden in Liberia. Numerous studies have examined the relationship between ITN use and malaria prevalence. However, little research has explored the effectiveness of ITNs in controlling malaria among children in postwar Liberia. The aim of this study was to examine the association between ITN ownership, parental economic status, ITN installation support, and malaria prevalence among children. This was a quantitative cross-sectional study guided by the health belief model. The study used secondary data from the 2011 Liberia Malaria Indicator Survey. Chi-square for association and Logistic regression were used to analyze the data. The results revealed a significant association between parental education and malaria prevalence. There was also a significant association between parental economic status and malaria prevalence. However, there was no significant association between ITN ownership and malaria prevalence after controlling for parental education and ownership of structure. These findings may foster social change by helping public health authorities in Liberia integrate ITN use with other strategies like mosquito larvae elimination and indoor/outdoor insecticide spraying as part of a comprehensive approach to malaria control. Additionally, massive awareness and economic capacity building should be undertaken to empower malaria endemic communities with the understanding that malaria can be rapidly reduced with other robust strategies in combination with ITN use. These strategies, if implemented, may effectively control malaria prevalence among children and the emotional and financial burdens endure by their families.

In recent years, much focus has been put on the sustainability of water and sanitation development projects. Experts in this field have found that many of the projects of the past have failed to achieve sustainability because of a lack of demand for water and sanitation interventions at a grassroots level. For years projects looked to create this demand through various subsidy schemes, with the "software" of behavior change and education taking a backseat to the "hardware" of infrastructure provision. Community-Led Total Sanitation (CLTS) is a fairly new way of looking at the issues of increasing basic sanitation coverage, promoting good hygiene practices, and facilitating the change in behaviors that is necessary for a level of basic sanitation coverage to be sustained for any significant length of time. CLTS looks to get people to come to the realization that open defecation is dangerous, and that they have to power to stop this practice. The purpose of this research study was to assess the water, sanitation, and hygiene situation on the ground in villages that through CLTS have achieved open defecation free (ODF) status in the Mopti region of Mali, West Africa. This assessment was done through a willingness-to-pay study, that showed how important sanitation infrastructure was in the daily lives of villagers in this region of Mali. This research study also examines any possible correlations between certain socioeconomic data and willingness-to-pay. A questionnaire was developed and completed with 95 household heads spread across 6 of the 21 ODF villages in the region. The results of this research study show that the behavior change brought about by CLTS was sustained. Every household in the study had at least one latrine (total latrines = 186), or had access to a neighbor's latrine because theirs had recently collapsed. Of these latrines 82.3% were reported as meeting the Malian nation government requirements of basic sanitation. 89.3% of the observed latrines were built by the participant families themselves using predominately materials that could be found in or harvested from the local environment (e.g., mud, rocks, sticks). Fifty-three percent of the latrines were built completely free of cost, and of the 88 latrines that were paid for in part or in whole the average cost was about US $13.00. The majority of the participants (64.2%) in the research study reported making improvements and maintaining their latrines, clearly showing the importance of sanitation infrastructure in the 6 study villages. The average cost of this maintenance was about US $1.50. Alongside of willingness-to-pay data, more qualitative data were collected on the relative importance of sanitation infrastructure in the daily lives of people in ODF villages in Mopti. This study found that on average throughout the 6 study villages, about 13% of discretionary funds are saved for or spent on maintenance and improvements to sanitation infrastructure on a monthly basis. When sanitation infrastructure investments were compared with other infrastructure and livelihood investments, on the average it was ranked 7th out of the possible 10. These data seem to indicate that future investment in sanitation infrastructure was not a high priority for the participants. This could be stem from the fact that many of the participants had not directly experienced the need for continued investments, because their original latrines were still functional. The willingness-to-pay regression analysis produced very few statistically valid results. Only a few of the correlations found between willingness-to-pay data and socioeconomic characteristics of the sample were found to be statistically valid. For example, the correlation coefficient between willingness-to-pay for pit maintenance, including emptying when full or covering the pit with top soil, digging a new one, and reconstruction, and education level of the participants was about 1.2 and was statistically valid with a t-statistic of about 2.2. Indicating that the more educated a participant was, the more they would be willing to pay for pit maintenance. None of the overall regressions explained enough of the variability in willingness-to-pay data to be considered statistically valid. Regressions for two scenarios, constructing a cement slab as an improvement to an existing latrine and sealing/lining the pit on an existing latrine with cement, explained 10.3% and 10.4% of the variability in willingness-to-pay data respectively. However, this did not meet the minimum criteria of 15%. While the willingness-to-pay data would have been useful to study partners that are piloting a Sanitation Marketing program in Mali, the main research objective of assessing the CLTS intervention was still met.

This study sought to examine health care decisions and choices that women make during pregnancy and childbirth in selected low-income and poor urban communities in Ghana. Specifically, it examined women's and community members' knowledge and perceptions about pregnancy and childbirth; existing forms of health care available to women during pregnancy and childbirth; and factors that influence preference for the type of health care that women use during pregnancy and childbirth. The study employed a two-phased data collection strategy involving in-depth interviews and focus group discussions to examine maternal health care seeking behavior of the target population. The findings revealed that the poor urban women have a wide range of perceptions and knowledge about pregnancy including knowledge about what constitutes a successful pregnancy and risk factors of pregnancy and childbirth complications. The study found that three major forms of health care exist for pregnant women: biomedical care; herbal-traditional birth attendant care; and spiritual care. While some women use or prefer to use either solely medical care or herbal-traditional birth attendant care for their pregnancy and delivery, others combine two or all the three forms of health care. Pregnant women seek traditional birth attendants (TBAs) and spiritual care for spiritual protection against death, due to affection and cultural attachment to TBAs, fears about medical care and health facilities, and due to cost of seeking medical care. Long waiting time and early reporting time at antenatal clinic were identified as partly limiting the use of medical care during pregnancy. Intimate partners of pregnant women were identified as negative normative influence since most of them do not support their wives during pregnancy. Quality and safety of care were the major reasons why pregnant mothers seek biomedical care other than other forms of care. However, majority of women who seek biomedical care do not seek timely antenatal care. Only 42 percent made their first antenatal visit in the first trimester. These findings have implications for policies and programs that are likely to help increase the use of skilled attendance and improve maternal health outcomes in the study population and other similar low-income urban communities in Ghana.

Thesis (Ph.D.)--University of Illinois at Urbana-Champaign, 2006.
Source: Dissertation Abstracts International, Volume: 68-02, Section: A, page: 0481. Adviser: William Trent. Includes bibliographical references (leaves 148-155) Available on microfilm from Pro Quest Information and Learning.

This dissertation aims to enrich understanding of issues affecting the care and protection of orphans and vulnerable children (OVC) in sub-Saharan Africa. The social risks and resources of OVC in selected contexts is examined using both quantitative and qualitative data and multiple datasets. Results pertaining to OVC's sexual risk, marginalization, available social support and reasons for limited support are presented. Chapter 1 investigates the onset of sexual behavior and sexual risk among orphans and non-orphans in South Africa. The sample for this analysis consists of 1694 Black African youth age 14-18. The analyses found both male and female orphans significantly more likely to have engaged in sex as compared to non-orphans (49% vs. 39%). Among sexually active youth, orphans reported younger age of sexual intercourse with 23% of orphans having had sex by age 13 or younger compared to 15% of non-orphans. Chapter 2 focuses on a sample of 692 youth-headed households (YHH) in Rwanda age 13-24 and describes their degree of marginalization and available social support. Most youth reported significant caring relationships: 73% reported access to trusted adult who offers them advice and guidance, and most indicated close peer relationships. However, many youth also perceived a lack of community support, with 86% feeling rejected by the community and 57% feeling the community would rather hurt them than help them. Chapter 3 expands upon the results presented in Chapter 2 to gain further insight into the marginalization and limited community support reported by YHH. The socio-cultural factors that influence the level of support Rwandan communities provide to OVC is explored through a triangulation of multiple methods and perspectives. The analyses cast light on the importance of three factors affecting community support and marginalization: stigma, NGO assistance and community discord. Overall, this dissertation enriches understanding of how OVC's vulnerability and social networks impact their care and protection. Data such as this should be used to inform efforts to support OVC. In hopes of achieving this aim, discussion throughout lends particular attention to the programmatic implications of these results
acase@tulane.edu

abstract: Diarrheal diseases caused by poor water, sanitation and hygiene continue to kill more children in Sub-Saharan Africa's burgeoning informal urban settlements than in any other part of the world. In recent years, Delegated Management Model (DMM), a partnership in which a utility delegates service management to slum residents have been promoted as new models to improve services. This dissertation examines the benefits of DMM by comparing water services in three informal settlements in Kisumu city, Kenya: two slums where DMM has been implemented, and one, a control, where it has not. In addition, the research examined how school-based hygiene interventions could be designed to improve safe water and hygiene knowledge in urban informal settlements. This study compared outcomes of two approaches to hygiene education, one which combined messages with participatory water testing; the second used hygiene messages alone. Results of the DMM study showed that DMM implementation had lowered water cost and improved provider accountability. However, unhygienic water collection and handling practices on the part of the service users could contaminate drinking water that was clean at the delivery point, thus preventing the intended health outcomes of DMM from being realized. Results of the hygiene education intervention showed that one week after the inventions, hygiene knowledge among students who received the intervention that combined hygiene messages with participatory water testing was significantly improved. Evaluation of the intervention 12 months after implementation showed that the hygiene knowledge gained was sustained. The research findings suggest that: i) regular monitoring of water quality at the kiosks is essential to ensure that the DMM model achieves intended health outcomes, ii) sanitation conditions at kiosk sites need to be regulated to meet minimum hygiene standards, and iii) customers need to be educated on safe water collection and storage practices. Finally, school-based hygiene education could be made more effective by including hands-on water testing by students. Making sustainable impact on health and wellbeing of slum residents requires not only building effective partnerships for water delivery, but also paying close attention to the other points of intervention within the water system.
Dissertation/Thesis
Doctoral Dissertation Sustainability 2014