Browsing by Author "Whetten, Kathryn"

Abstract

There are over 250 million children in adversity (CIA) globally; however, insufficient information on prevalence of CIA and their daily needs limits case management of this group by social welfare systems. Recently, mobile technology-based (mHealth) systems have been used successfully to extend health services and information to clients in hard-to-reach, under resourced areas. This study aimed to determine the suitability of mHealth systems for improving case management of CIA in Battambang Province, Cambodia.

Methods used included focus group discussions (FGDs), in depth interview and direct observation with government and NGO social workers, their supervisors and street-based CIA (10-17 years). Data on daily workflows, roles, responsibilities and case management activities of social workers were documented. Mobile phone ownership, use and attitudes among social workers were used to assess suitability of an mHealth tool in the Cambodian context. Daily life experiences and case management needs of CIA were documented.

Our data suggests that routine case management of CIA is limited by low capacity of social workers, logistical constraints, a burdensome paper-based data collection system, scanty resources and poor supportive supervision. All social workers participating in the study owned and used mobile phones, and enthusiasm for further incorporation of these devices into daily work activities was high. Street children came from different situations of adversity, were under-served and had diverse case management needs such as referral to vocational programs, early intervention to prevent violence in the home and continuous follow-up.

An mHealth system could be developed to overcome constraints in case management of CIA by streamlining social worker workflows, facilitating timely data collection, and enabling continuous training of social workers. Such a system, implemented in conjunction with other initiatives to strengthen the social welfare system, could promote better case management for CIA in Cambodia, and globally.

Scholars and practitioners recognize the importance of coordination in mitigating the costs of aid proliferation and improving the effectiveness of foreign aid. However, low levels of donor coordination persist. In this dissertation, I address this donor coordination puzzle. I offer a novel theory of coordination called Constrained Coordination, in which I posit that two key factors that play a crucial role in shaping coordination. First, I argue that donors strategic interests are a damper on coordination – the greater the strategic political, economic, and security interests of a donor government in a recipient country, the less coordination its aid agency will engage in. Second, I argue that aid agency autonomy is positively associated with coordination – the greater the level of autonomy – or freedom – that an aid agency has from its home government, the more that aid agency will coordinate. In order to test my Constrained Coordination theory, the dissertation uses mix-methods, and includes a quantitative analysis of hundreds of donor agencies coordination. I also leverage over one hundred extensive interviews with key stakeholders to present two qualitative case studies of donor coordination in Nigeria and Zambia. Finally, I use qualitative evidence to look at the coordination of South-South donors, a group of donors growing in importance. I find that a donor government’s strategic interests have a significant impact on whether its aid agency will coordinate within recipient countries. Similarly, when a recipient is strategic to a large number of countries, donors will not be well coordinated. Second, I find that aid agencies with greater levels of autonomy from their home governments coordinate more. And finally, I find that these effects amplify one another – a high autonomy donor working in a low priority country coordinates more than any other combination of strategic interests and autonomy.

Background: Worldwide, it is estimated that there are up to 150 million street children. Street children are an understudied, vulnerable population. While many studies have characterized street children’s physical health, few have addressed the circumstances and barriers to their utilization of health services.

Methods: A systematic literature review was conducted to understand the barriers and facilitators that street children face when accessing healthcare in low and middle income countries. Six databases were used to search for peer review literature and one database and Google Search engine were used to find grey literature (theses, dissertations, reports, etc.). There were no exclusions based on study design. Studies were eligible for inclusion if the study population included street children, the study location was a low and middle income country defined by the World Bank, AND whose subject pertained to healthcare.

In addition, a cross-sectional study was conducted between May 2015 and August 2015 with the goal of understanding knowledge, attitudes, and health seeking practices of street children residing in Battambang, Cambodia. Time location and purposive sampling were used to recruit community (control) and street children. Both boys and girls between the ages of 10 and 18 were recruited. Data was collected through a verbally administered survey. The knowledge, attitudes and health seeking practices of community and street children were compared to determine potential differences in healthcare utilization.

Results: Of the 2933 abstracts screened for inclusion in the systematic literature review, eleven articles met all the inclusion criteria and were found to be relevant. Cost and perceived stigma appeared to be the largest barriers street children faced when attempting to seek care. Street children preferred to receive care from a hospital. However, negative experiences and mistreatment by health providers deterred children from going there. Instead, street children would often self treat and/or purchase medicine from a pharmacy or drug vendor. Family and peer support were found to be important for facilitating treatment.

The survey found similar results to the systematic review. Forty one community and thirty four street children were included in the analysis. Both community and street children reported the hospital as their top choice for care. When asked if someone went with them to seek care, both community and street children reported that family members, usually mothers, accompanied them. Community and street children both reported perceived stigma. All children had good knowledge of preventative care.

Conclusions: While most current services lack the proper accommodations for street children, there is a great potential to adapt them to better address street children’s needs. Street children need health services that are sensitive to their situation. Subsidies in health service costs or provision of credit may be ways to reduce constraints street children face when deciding to seek healthcare. Health worker education and interventions to reduce stigma are needed to create a positive environment in which street children are admitted and treated for health concerns.

The social gradient of health is pervasive and unrelenting. Across nearly any layer of society – race, religion, economic standing, or others – the populations worst off in terms health are also the most socially disadvantaged. Over three studies, this dissertation examines some of the experiences that underlie the connection between social disadvantage and health, namely internalized perceptions of status, interpersonal interactions, and institutional actions. The first study examines the link between adolescents’ perceived social status and their mental health at a range of ages, identifying at what age mental health problems begin to track perceptions of status, as well as contextual factors that do (or do not) relate to perceptions of status. In the second study, data from a nationally representative survey in France are used to document rates of reporting discrimination within the healthcare setting by gender, immigrant status, race/ethnicity, and religion. Rates of foregoing medical care are also documented across the same groups, and the potential explanatory role of discrimination toward disparities in foregone care is then investigated. The third and final study looks at the role of institutional stigma, using state bans of Sharia law in the USA as an exemplary case of stigmatizing policies with minimal material consequences. National birth record data for the USA is used, and the variation in policy enactment over time and space is leveraged to examine birth outcomes for Muslim women who were pregnant at the time their state passed a ban. Findings reveal a decrease in the secondary sex ratio to targeted women, suggesting the stigmatizing policy acts as a population-level stressor with consequences for maternal health.

Background: By facilitating access to prevention and care services, HIV serostatus disclosure has been associated with improved physical health, psychological well-being, and improved health behaviors for people living with HIV/AIDS (PLWHA). Disclosure to sexual partners, in particular, can help prevent the forward transmission of HIV. Disclosure can increase social support but can also lead to negative social outcomes including stigma and discrimination. Thus, disclosing HIV status to friends, family, and sexual partners is a complex psychosocial challenge that PLWHA face, particularly adolescents and youth who have an increased lifespan due to current effective treatment protocols.

Objectives: This study had three objectives: 1) to determine gender-related differences in the rate and patterns of HIV serostatus disclosure to family, friends and sexual partners among HIV-positive youth in Haiti; 2) to identify gender-specific relational and psychosocial predictors of HIV disclosure to sexual partner; and 3) to qualitatively explore and describe motivations and experiences related to HIV disclosure in this population.

Methods: A cross-sectional study was conducted in a random sample of 680 sexually active HIV-positive young adults (18-29 years) from six clinics in Port-au-Prince, Haiti. Socio-demographic, health, sexual and reproductive history, sexual behavior, psychosocial and disclosure data were collected using a pre-tested interviewer-administered structured questionnaire. Rates and patterns of HIV serostatus were described, and factors associated with disclosure to all sexual partners in the past 3 months were analyzed using hierarchical logistic regression models, separately by gender. Qualitative data was collected through individual in-depth interviews with a purposefully selected sample of 12 young adult participants to explore whom they chose to disclose to, how they disclosed to these individuals, and how these individuals reacted. Content analysis allowed for the description of motivations and experiences related to HIV disclosure in this population.

Results: Slightly over half (56%) of participants had told at least one person about their HIV status. Female respondents were more likely than male respondents to have disclosed to family or friends. Male youth were more likely to disclose their status for the first time to sexual partners (35%), while female youth were more likely to choose their mother as their first confidant (51%). Overall, 33% of participants reported having disclosed their HIV status to all their sexual partners from the last 3 months, with no significant difference across genders. For both genders, older age and being unaware of partners' HIV status were significantly associated with lower odds of HIV serostatus disclosure. Additionally for young males, disclosure stigma was negatively associated with disclosure while HIV acceptance and personalized stigma were significant predictors of disclosure. Female youth who were single, had casual or multiple partners, and experienced greater personalized stigma were less likely to disclose, whereas the availability of social support was positively associated with disclosure to all sexual partners. While disclosure to sexual partners was motivated primarily by a desire to encourage partners to test for HIV and increase condom use, or by a sense of moral responsibility, important contextual differences emerged in qualitative analysis with regards to barriers to disclosure, particularly fear of stigma and fear of partner's reaction.

Conclusion: Rates of HIV serostatus disclosure to family, friends and sexual partners were low among this population of HIV-positive youth in Port-au-Prince. Context-specific gender-sensitive interventions are needed to increase social support, reduce HIV-related stigma, and assist youth living with HIV in making effective decisions on disclosure that will ultimately improve their well-being and quality of life. Further research is necessary to better understand the process and outcomes of HIV serostatus disclosure to sexual partners, as well as the relationship between HIV serostatus disclosure and sexual risk behaviors in this young HIV-positive population.

This dissertation consists of three papers, which together examine whether policies meant to address inequality, succeed in mitigating the impact of traditional institutions such as caste and enable ethnic minorities to claim their rights. Using experimental and quasi-experimental methods with data from a variety of primary and secondary sources, this dissertation analyzes whether policies meant to empower vulnerable groups in India have succeeded in doing so. The findings suggest that while legislations in the form of mandated political representation or freedom of information laws are necessary in terms of increasing the accountability of government towards citizens, they may not be sufficient in ensuring adequate and uniform delivery of public services, especially to citizens belonging to marginalized groups. Further, empowering citizens – especially those belonging to groups that have faced historic discrimination – to actively participate in civic and political life may require more active and intensive policy and programmatic interventions.

Background: While exclusive breastfeeding is known to protect against infant morbidity and mortality, its effects on growth are not well understood. This study aimed to identify individual and household characteristics associated with exclusive breastfeeding in a rural population in Haiti, and to test the association between duration of exclusive breastfeeding and infant height-for-age (HAZ), weight-for-height (WHZ) and weight-for-age (WAZ). In addition, qualitative methods were employed to identify community perceptions of exclusive breastfeeding and barriers to its adoption. Methods: A household survey was conducted to assess breastfeeding practices and maternal and infant nutritional status in rural Léogâne Commune (N=119), and linear regression was used to estimate the associations between duration of exclusive breastfeeding and infant HAZ, WHZ and WAZ. In addition, 32 community health workers completed a written survey and participated in focus group discussions of the benefits of exclusive breastfeeding and barriers to its adoption in their communities. Results: Survey variables associated with shorter duration of exclusive breastfeeding (α=0.10) included preterm birth, late initiation of breastfeeding, maternal employment and the practice of giving infants tea. The community health workers identified several additional socio-cultural and institutional barriers to exclusive breastfeeding in their communities, including the advice of community elders, poverty and food insecurity. Duration of exclusive breastfeeding was positively associated with both HAZ and WAZ (α=0.05), but not significantly associated with WHZ. Conclusions: This study provides evidence that duration of exclusive breastfeeding is positively associated with infant height-for-age and weight-for-age in a rural, resource-limited setting, suggesting that promotion of exclusive breastfeeding may be effective as part of a package of interventions to prevent underweight and stunting among infants at risk of malnutrition. In addition, qualitative findings suggest that efforts to promote exclusive breastfeeding should pay attention to underlying issues of poverty and food security, and the effects of the physical and social environment on the choices women make regarding infant feeding in Haiti.

Adolescent sexual health is a global concern because of its associations with HIV, STIs, early and unwanted pregnancies, and post-abortion complications. To address the health burdens associated with sexual and reproductive health in youth, organizations employ several programmatic models to encourage behavior change and to distribute correct and appropriate information. One of those models, discussed here, is the peer education model. The peer education model uses adolescents to target adolescents to achieve program objectives. This paper is a case study of Carolina for Kibera, a non-governmental organization working in Kibera, a large urban slum outside of Nairobi, Kenya. Carolina for Kibera implements this model in its efforts to promote adolescent sexual health. The case study uses a triangulation method, including qualitative focus groups and interviews, document review, and researcher observation to determine how the model is implemented both in the context of the organization and in the context of Kibera. Results of the case study include a completed program description and an assessment of barriers and benefits to implementing this model, and how the context of the urban slum frames programming decisions and success. As a means of discussion and conclusions, implications and recommendations for future programming at Carolina for Kibera, and globally, are presented.