Impact of Large-Scale Health Interventions on Population Health, Economic Functioning, and Investments in Human Capital in Sub-Saharan Africa

Donations from the United States are a major source of global health funding. The United States invests a large portion of its global health aid portfolio in bilateral aid programs which focus on combatting specific diseases in low-resource countries, including HIV and malaria. These large-scale programs have the potential not only to improve the specific diseases they target, but also to generate spillover effects to other sectors, including economic and education outcomes. Understanding the impact of large-scale programs on population-level health and their potential spillover effects is essential for learning about the returns on such investments. My dissertation investigates the impact of interventions supported with funding from two of the largest US bilateral aid programs, the President’s Malaria Initiative (PMI) and the President’s Emergency Plan for AIDS Relief (PEPFAR), on child mortality, economic functioning of households, and investments in human capital. This dissertation leveraged data from multiple sources, including publicly available data on child mortality and population coverage of malaria interventions from 32 countries in sub-Saharan Africa and household socio-economic data from a large community-randomized trial of a novel HIV testing and treatment strategy in Uganda and Kenya.Doctor of Philosoph

The Health of Immigrants to New York City From Mainland China: Evidence From the New York Health Examination and Nutrition Survey

Very little is known about the newest New Yorkers of Chinese heritage, the largest and fastest growing immigrant group in the city. This article compares measures of the health of immigrants to New York from Mainland China to the health of other New Yorkers of Asian heritage along with all other New Yorkers. We did so using the 1,999 subjects in the 2004 New York Health and Nutrition Examination Survey, controlling for age and gender. We found that New Yorkers born in Mainland China have a lower body mass index, a smaller waist circumference, a more sexually conservative lifestyle, highly favorable high-density lipoprotein profiles, and lower rates of herpes II infection. However, they also have higher blood levels of lead, cadmium, and mercury than either reference group. This article provides the first study of the health needs of New York's largest and most rapidly growing immigrant group

The US President’s Malaria Initiative and under-5 child mortality in sub-Saharan Africa: A difference-in-differences analysis

Despite substantial financial contributions by the United States President’s Malaria Initiative (PMI) since 2006, no studies have carefully assessed how this program may have affected important population-level health outcomes. We utilized multiple publicly available data sources to evaluate the association between introduction of PMI and child mortality rates in sub-Saharan Africa (SSA)

Evaluation of a national program to distribute free face masks in Uganda: Evidence from Mbale District

Background: COVID-19 posed a major threat to countries around the world, but many nations in sub-Saharan Africa avoided large-scale outbreaks. In Uganda, the government first enacted strict lockdowns but later focused on public health policies like masking and distancing. The government also embarked on an ambitious campaign to deliver a free face mask to all Ugandan citizens (approx. 30 million masks). We test whether mask distribution, and public education and encouragement of mask use by community health volunteers, affected mask behavior. Methods: We collected data about mask behavior before and after masks were distributed in the Mbale district of Uganda. Trained enumerators directly observed mask wearing in public places and asked about mask use via phone surveys. We compared observed and self-reported mask behavior before and after masks were distributed. We also tested whether training volunteers from randomly selected villages to educate the public about COVID-19 and masks affected behavior, attitudes, and knowledge among mask recipients. Results: We collected 6,381 direct observations of mask use at baseline (February 2021) and 19,855 observations at endline (April 2021). We conducted a listing of 9,410 households eligible for phone surveys and randomly selected 399 individuals (4.2%) at baseline and 640 (6.8%) at endline. Fewer than 1% of individuals were observed wearing masks at baseline: 0.9% were seen with a mask and 0.5% wore masks over mouth and nose. Mask wearing significantly increased at endline but remained low: 1.8% of people were observed with masks and 1.1% were seen wearing masks correctly after the distribution campaign. At the same time, a high proportion of people reported using masks: 63.0% of people reported using masks at baseline and 65.3% at endline when walking around their villages. When respondents were asked about mask use in public places, 94.7% reported using masks at baseline and 97.4% reported using masks at endline. We found no differences in knowledge, behavior, or attitudes among mask recipients in villages where volunteers were tasked with conveying information about COVID-19 and masks during distribution. Conclusion: Mask use remained low in Mbale district of Uganda during study observation period even after free masks were distributed. Encouraging new health behaviors may need to involve more intensive interventions that include reminders and address social norms

Low risk of attrition among adults on antiretroviral therapy in the Rwandan national program: a retrospective cohort analysis of 6, 12, and 18 month outcomes

Background: We report levels and determinants of attrition in Rwanda, one of the few African countries with universal ART access. Methods: We analyzed data abstracted from health facility records of a nationally representative sample of adults [≥18 years] who initiated ART 6, 12, and 18 months prior to data collection; and collected facility characteristics with a health facility assessment questionnaire. Weighted proportions and rates of attrition [loss to follow-up or death] were calculated, and patient- and health facility-level factors associated with attrition examined using Cox proportional hazard models. Results: 1678 adults initiated ART 6, 12 and 18 months prior to data collection, with 1508 person-years [PY] on ART. Attrition was 6.8% [95% confidence interval [CI] 6.0-7.8]: 2.9% [2.4-3.5] recorded deaths and 3.9% [3.4-4.5] lost to follow-up. Population attrition rate was 7.5/100PY [6.1-9.3]. Adjusted hazard ratio [aHR] for attrition was 4.2 [3.0-5.7] among adults enrolled from in-patient wards [vs 2.2 [1.6-3.0] from PMTCT, ref: VCT]. Compared to adults who initiated ART 18 months earlier, aHR for adults who initiated ART 12 and 6 months earlier was 1.8 [1.3-2.5] and 1.3 [0.9-1.9] respectively. Male aHR was 1.4 [1.0-1.8]. AHR of adults enrolled at urban health facilities was 1.4 [1.1-1.8, ref: rural health facilities]. AHR for adults with CD4+ ≥200 cells/μL vs <200 cells/μL was 0.8 [0.6-1.0]; and adults attending facilities with performance-based financing since 2004–2006 [vs. 2007–2008] had aHR 0.8 [0.6-0.9]. Conclusions: Attrition was low in the Rwandan national program. The above patient and facility correlates of attrition can be the focus of interventions to sustain high retention

Expectations about future health and longevity in Kenyan and Ugandan communities receiving a universal test-and-treat intervention in the SEARCH trial

Expectations about future health and longevity are important determinants of individuals’ decisions to invest in physical and human capital. Few population-level studies have measured subjective expectations and examined how they are affected by scale-up of antiretroviral therapy (ART). We assessed these expectations in communities receiving annual HIV testing and universal ART. Longitudinal data on expectations were collected at baseline and one year later in 16 intervention communities participating in the Sustainable East Africa Research in Community Health (SEARCH) trial of the test and treat strategy in Kenya and Uganda ({"type":"clinical-trial","attrs":{"text":"NCT01864603","term_id":"NCT01864603"}}NCT01864603). A random sample of households with and without an HIV-positive adult was selected after baseline HIV testing. Individuals’ expectations about survival to 50, 60, 70, and 80 years of age, as well as future health status and economic well-being, were measured using a Likert scale. Primary outcomes were binary variables indicating participants who reported being very likely or almost certain to survive to advanced ages. Logistic regression analyses were used to examine trends in expectations as well as associations with HIV status and viral load for HIV-positive individuals. Data were obtained from 3126 adults at baseline and 3977 adults in year 1, with 2926 adults participating in both waves. HIV-negative adults were more likely to have favorable expectations about survival to 60 years than HIV-positive adults with detectable viral load (adjusted odds ratio [AOR] 1.87, 95% CI 1.53–2.30), as were HIV-positive adults with undetectable viral load (AOR 1.41, 95% CI 1.13–1.77). Favorable expectations about survival to 60 years were more likely for all groups in year 1 compared to baseline (AOR 1.53, 95% CI 1.31–1.77). These findings are consistent with the hypothesis that universal ART leads to improved population-level expectations about future health and well-being. Future research from the SEARCH trial will help determine whether these changes are causally driven by the provision of universal ART

Control of aggregation temperatures in mixed and blended cytocompatible thermoresponsive block co-polymer nanoparticles

A small library of thermoresponsive amphiphilic copolymers based on polylactide-block-poly((2-(2-methoxyethoxy)ethyl methacrylate)-co-(oligoethylene glycol methacrylate)) (PLA-b-P(DEGMA)-co-(OEGMA)), was synthesised by copper-mediated controlled radical polymerisation (CRP) with increasing ratios of OEGMA:DEGMA. These polymers were combined in two ways to form nanoparticles with controllable thermal transition temperatures as measured by particle aggregation. The first technique involved the blending of two (PLA-b-P(DEGMA)-co-(OEGMA)) polymers together prior to assembling NPs. The second method involved mixing pre-formed nanoparticles of single (PLA-b-P(DEGMA)-co-(OEGMA)) polymers. The observed critical aggregation temperature Tt did not change in a linear relationship with the ratios of each copolymer either in the nanoparticles blended from different copolymers or in the mitures of pre-formed nanoparticles. However, where co-polymer mixtures were based on (OEG)9MA ratios within 5-10 mole% , a linear relationship between (OEG)9MA composition in the blends and Tt was obtained. The data suggest that OEGMA-based copolymers are tunable over a wide temperature range given suitable co-monomer content in the linear polymers or nanoparticles. Moreover, the thermal transitions of the nanoparticles were reversible and repeatable, with the cloud point curves being essentially invariant across at least three heating and cooling cycles, and a selected nanoparticle formulation was found to be readily endocytosed in representative cancer cells and fibroblasts

Diversity of muskox Ovibos moschatus (Zimmerman, 1780) (Bovidae, Mammalia) in time and space based on cranial morphometry

Muskox Ovibos moschatus is a Pleistocene relic, which has survived only in North America and Greenland. During the Pleistocene, it was widely distributed in Eurasia and North America. To evaluate its morphological variability through time and space, we conducted an extensive morphometric study of 217 Praeovibos and Ovibos skull remains. The analyses showed that the skulls grew progressively wider from Praeovibos sp. to the Pleistocene O. moschatus, while from the Pleistocene to the recent O. moschatus, the facial regions of the skull turned narrower and shorter. We also noticed significant geographic differences between the various Pleistocene Ovibos crania. Siberian skulls were usually larger than those from Western and Central Europe. Eastern Europeanmuskoxen also exceeded in size those from the other regions of Europe. The large size of Late Pleistocene muskoxen from regions located in more continental climatic regimes was probably associated with the presence of more suitable food resources in steppe-tundra settings. Consistently, radiocarbon-dated records of this species are more numerous in colder periods, when the steppe-tundra was widely spread, and less abundant in warmer periods