Dissertations / Theses on the topic 'Child Healt'

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Health indicators are tools important for measuring a reality, a management avaliation and planning of the health actions in the swiral áreas. Among the more used health indicators to monitor the child health. However, in Maranhao are scarce existing information on child health and information about health conditions indicators and health dimensions of the child population and performance of the health system The general goal was to analyse child health indicators among little boys of Five years old dwelling in the State of Maranhão attended by the Bassic Attention. It deals with observational, descriptive, study, also under a quantitative approach, performed based on the SIAB reports. As to the demographical indicators there was reduction anridst all the child groups and increase of the age group of adults of 60 years old. The socio-environmental indicators showed that 34,8% of the registered families in the basic attention use water wittout any care. Only 6% of the family had a drain system in 2013. The operational indicators showed na increase of babies of four months year old under breastfeeding exclusive, with are increase of little boys under uptodate vaccines reaching. Among the related epidemiological indicators as to the morbity there was na increase in the proportion of children under low weight at birth. A stressed fall in the proportion of little boys under malnutrition. Among the epidemiological indicators there was a fall in the infantile general mortality and from all its components with supremacy of the postneonatal component. As to the infantile mortality by health macroregional, the Coroatá end Pinheiro macroregional presented infantily mortality rate superior to that one met in the State. The expansion of the population cover in Maranhão shoewed na increase of access of the infantule population towards the health service, so contribting to bether health conditions.
Indicadores de saúde são instrumentos importantes para medir uma realidade, avaliar e planejar ações de saúde nas diversas áreas, entre elas o monitoramento da saúde infantil. Entretanto, no Maranhão são escassas informações existentes sobre indicadores de saúde da criança e informações sobre condições sanitárias, assim como dimensões do estado de saúde da população infantil e o desempenho do sistema de saúde. Objetivou-se analisar indicadores de saúde infantil em menores de cinco anos residentes no Estado do Maranhão, atendidos pela Atenção Básica. Trata-se de um estudo observacional, descritivo, de abordagem quantitativa, realizado com base no Sistema de Informação da Atenção Básica, abordando indicadores socioambientais, demográficos, operacionais e epidemiológicos nos anos 1998, 2003, 2008 e 2013. Com o passar dos anos observou-se diminuição entre todas as faixas etárias infantis e aumento da faixa etária de maiores de 60 anos. Os indicadores socioambientais mostraram que 34,8% das famílias cadastradas na atenção básica utilizam água sem tratamento e somente 6% das famílias eram coberta por sistema de esgoto em 2013. Os indicadores operacionais mostraram aumento das crianças menores de quatro meses em aleitamento materno exclusivo; aumento das crianças menores de um ano com vacinas em dia. Entre os indicadores epidemiológicos relacionados à morbidade, houve aumento na proporção de crianças com baixo peso ao nascer e queda acentuada na proporção de crianças menores de um ano desnutridas. Houve queda na mortalidade infantil geral e de todos os seus componentes. Quanto à mortalidade infantil por macrorregionais de saúde, as Macrorregionais de Coroatá e Pinheiro apresentaram taxa de mortalidade infantil superior à encontrada no Estado. A expansão da cobertura populacional da Atenção Básica no Maranhão mostrou um aumento do acesso da população infantil aos serviços de saúde, contribuindo para melhorias nas condições de saúde.

Relatório de Estágio elaborado no âmbito do I Curso de Mestrado em Enfermagem em Associação na Área de Especialização de Enfermagem de Saúde Mental e Psiquiatria, reportando a realização de dois estágios (hospitalar e comunitário) que fundamentam a aquisição e desenvolvimento de competências especificas do enfermeiro especialista baseadas na experiência na prestação de cuidados à criança e adolescente. Enquanto processo autoformativo, considera-se a teoria de Patricia Benner para ilustrar a experiência. A prática em contexto hospitalar incluiu a implementação da Atividade Terapêutica Dança e Movimento, baseada na metodologia 5 Rhythms e cujos resultados mostram ser benéficos na aplicação com grupos de crianças e adolescentes; ABSTRACT: Internship Report from the 1st Masters Course in Nursing in Association in the Area of Specialization in Mental Health and Psychiatric Nursing, reporting the accomplishment of two internships (hospital and community) that reflect the acquisition and development of nurse specialist specific skills, based on an experience of a children and adolescents care setting. As a self-learning process, Patricia Benner's theory is used to illustrate the experience. The practice in the hospital context included the implementation of a Therapeutic Activity Dance/Movement, based on the methodology of Rhythms 5 and whose results show the benefits in the application with groups of young people.

Contexto do Estudo: Limeira-SP é uma cidade que abriga um dos principais pólos de produção de joias e bijuterias, que tem como característica o uso da mão de obra informal nos domicílios, envolvendo crianças e adolescentes nas atividades de montagem, soldagem e cravação de peças. Pesquisa no município revelou que 27% dos alunos da rede estadual de ensino trabalham montando e soldando joias e bijuterias, uma população 8.340 indivíduos envolvidos em tarefas repetitivas e perigosas para a saúde. O diagnóstico desta situação motivou a mobilização de instituições públicas e da sociedade civil na criação de uma rede intersetorial articulada pela Comissão Municipal de Erradicação do Trabalho Infantil de Limeira COMETIL que opera desde 2007. O objetivo deste projeto é avaliar o alcance, limites e possibilidades das ações intersetoriais desenvolvidas pela COMETIL, no período de 2007 2010, de modo destacar as estratégias utilizadas e avaliar as mesmas. Foi empregada metodologia qualitativa do tipo estudo de caso baseadas em: a) participação de pesquisadores que são membros da COMETIL (nos moldes de pesquisa-ação); b) análise de documentos e; c) entrevistas semiestruturadas com 13 indivíduos representantes de alguns segmentos envolvidos na referida Comissão. Os resultados foram ordenados cronologicamente para destacar os principais eventos percebidos como determinantes na história das intervenções realizadas pela COMETIL. Foi possível constatar: a importância das pesquisas acadêmicas na identificação de problemas socias; o papel da mídia na divulgação dos dados; a relevância de ações pautadas na promoção da saúde que visam a sensibilização da população e o desenvolvimento de habilidades técnicas entre os servidores público; a proeminência da articulação intersetorial e, sobre tudo, o apoio de instituições como o Ministério Público do Trabalho e Ministério do Trabalho e emprego; a necessidade de avançar nas ações de vigilância em saúde; e, por fim, a potencialidade da estratégia de territorialização para o desenvolvimento de ações no campo da Saúde e do Desenvolvimento Social. A Análise dos resultados possibilitou perceber as estratégias exitosas adotadas pela Comissão, bem como constatar os limites da articulação em rede em curso e apontar novos rumos para a superação dos mesmos. Alguns setores primordiais para o êxito das ações ainda apresentam resistência para participar de forma efetiva das ações intersetoriais. Os empresários de joias e bijuterias precisam repensar seu fluxo produtivo, de modo a torná-lo sustentável tanto do ponto de vista ambiental quanto da saúde do trabalhador; a rede estadual de ensino também precisa se engajar nos espaços instituídos pela COMETIL, uma vez que esses são loci privilegiados para pautar estratégias de atuação. É notória a penetração social que as escolas têm na sociedade e, por esse motivo, é imprescindível a participação dos mesmos, além disso, as crianças e adolescentes que tem maior potencial para a exploração do trabalho estão inseridos nas escolas da rede estadual. Considerações Finais: a COMETIL instituiu uma rede intersetorial descentralizada que atua de forma territorializada sobre o problema do Trabalho Infantil e Trabalho Adolescente desprotegido, muito embora ainda não haja indicadores quantitativos para evidenciar a sua contribuição para a redução dos índices de Trabalho Infantil. Algumas das estratégias desenvolvidas podem servir de exemplo para outras iniciativas com esse intuito. Novas pesquisas são necessárias para promover mudanças no fluxo produtivo de modo a troná-lo sustentável e verificar a efetividade das ações de promoção da saúde
Study context: The city of Limeira-SP houses the largest centers of jewelry and costume jewelry production in Brazil, which is characterized by the use of informal and domestic labor, including teenage and child labor in tasks of assembling, welding, and setting pieces. A study has revealed that in the city 27 per cent of students from the public state schools were working in assembling and welding jewelry, what meant a total of 8,340 individuals conducting tasks that were repetitive and dangerous to their health. This diagnosis of the situation led to the mobilization of public institutions and civil society in creating an inter-sectoral network articulated by the Municipal Commission for the Eradication of Child Labour in Limeira COMETIL, which operates since 2007. The objective of this project is to evaluate the scope, limits and possibilities of the inter-sectoral actions taken by COMETIL in the period between 2007 and 2010, in order to highlight and to evaluate their strategies. The methodology used in the study was qualitative and structured like a case study, based on: a) the participation of researchers who were members of COMETIL (along the lines of action research), b) a document analysis and c) semi-structured interviews with 13 individuals representing some segments involved in the committee. The results were organized chronologically to highlight key events perceived as crucial in the history of the interventions conducted by COMETIL. They include: the importance of academic research in identifying social problems; the role of the media in the dissemination of the results; the significance of the actions based on health promotion aimed at raising public awareness and the development of technical skills among public servants; the prominence of inter-sectoral articulation and specially the support of institutions like the Ministry of Labour and the Ministry of Labor and Employment; the need to advance on actions of health surveillance; and finally the potential of the strategy of territorialization to the development of actions in the field of Health and Social Development. The analysis of the results allowed to understand the successful strategies adopted by the Commission, as well as to observe the limits of the articulations of the network and to point out new ways to overcome them. There is still resistance from some essential sectors to participate in an effective way on the inter-sectoral actions. The jewelry entrepreneurs need to rethink the production flow in order to make it sustainable regarding both the environment and the workers healt h; the state educat ion system also needs to be engaged in the spaces established by COMETIL since these loci are privileged space to formulate strategic actions. The schools have significant social penetration in society and therefore their participation is essential. Moreover, the children and adolescents with greater potential for labor exploitation are inserted in the public state schools. Final considerations: COMETIL instituted an inter-sectoral decentralized network that operates territorially on the issue of unprotected Child and Adolescent Labour. Even though there are no quantitative indicators to demonstrate its contribution in reducing the rates of Child Labour, some of the developed strategies can serve as an example for other initiatives to this end. Further research is needed to promote changes in the production flow to make it sustainable and to verify the effectiveness of undertaken actions of health promotion

This study explores the Child-to-Child approach to health education. Child-to-Child claims that children can be effective promoters of health. The thesis provides an analysis and criticism of Child-to-Child, comparing theory with practice in the Little Teacher Programme in Botswana. It examines how Child-to-Child has sought to keep abreast of new thinking and to respond to experience and considers the extent to which its ideas have been implemented. It explores whether primary school children can be effective health educators and seeks to identify factors enabling or inhibiting their effectiveness. Research questions are focused in three main areas. First, what is meant by the Child-to-Child approach to health education? What does Child-to- Child mean theoretically? To what extent has current thinking departed from the original conceptualization of the approach? What does Child-to-Child mean to the practitioners of the Little Teacher Programme in Botswana and how successfully have they applied its ideas and methods? Second, how effective can children be as health educators using the Child-to-Child approach? A field study of the Little Teacher Programme is included to test the hypothesis that child educators can raise the knowledge level of preschool children and that performing their role can increase their own knowledge level. An extension of the main field study addresses a further question, what is the influence of the poor urban environment and of ethnicity on the effectiveness of children as health educators? Third, how can children be effective health educators and what factors enable or impede their effectiveness? The study considers how social, cultural and environmental factors may influence health behaviours. The study concludes that children can be effective health educators at the level of knowledge change but raises serious questions about the failure of Child-to-Child to take account of traditional resistance to some of its central ideas.

This inter-disciplinary project investigates the relationship between family structure and early child health. The two main aims are: (1) to determine whether family structure and changes in family structure are associated with children's physical health in the Millennium Cohort Study; (2) to explore potential pathways through which these associations operate. In spite of much public debate around families, marriage, and child outcomes, UK literature on this topic remains incomplete. This thesis aims to fill two gaps: first, testing whether there is a link with children's physical health, rather than more commonly reported outcomes such as cognitive function or education achievements. Physical health outcomes included are respiratory health, childhood growth, and unintentional injuries. Second, few studies use prospective, longitudinal data and methods. Cross sectional studies cannot examine the direction of the relationship, nor capture the dynamics of changes in family structure. Here, longitudinal techniques test a complex model made up of variables ordered a priori. In unadjusted analyses, family structure presented a consistent gradient in child health: cross-sectionally, children living with married parents had better health than those living with cohabiting parents, while those living with lone parents had the worst health. Longitudinally, those who experienced changes in family structure fared worse than those living with continuously married parents, with some important exceptions, such as those living with cohabiting parents who subsequently married. Socio-economic factors were important predictors of family structure and child health. Proximal pathways through which socio-economic characteristics and family structure affected child health varied according to health outcome. Maternal mental health appeared to be important across outcomes. Concluding, this work shows the importance of using nuanced definitions of family, particularly when it comes to capturing its fluidity over time. Children who experienced changes in family structure were a heterogeneous group with diverse backgrounds and outcomes. Socio-economic factors emerged as important antecedents to both family structure and child health.

This project was established to answer the following questions: Is the current, (in 1991), classification of paediatric diagnoses adequate for current and predicted future needs? If not, are there any available suitable alternatives? If not, what diagnostic classification will suit the requirements of specialists and generalists in the various fields of child health? How will any new paediatric classification fit in with other new classifications? These questions can only be answered when the following subsidiary questions have been addressed: Why are clinical classification systems necessary? Why is a specific one needed for child health? What systems were available at the start of the project? What problems were inherent in those systems?

Eugenics movements developed early this century in more than 20 countries, including Australia. However, for many years the vast literature on eugenics focused almost exclusively on the history of eugenics in Britain and America. While some aspects of eugenics in Australia are now being documented, the history of this movement largely remained to be written. Australians experienced both fears and hopes at the time of Federation in 1901. Some feared that the white population was declining and degenerating but they also hoped to create a new utopian society which would outstrip the achievements, and avoid the poverty and industrial unrest, of Britain and America. Some responded to these mixed emotions by combining notions of efficiency and progress with eugenic ideas about maximising the growth of a white population and filling the "empty spaces". It was hoped that by taking these actions Australia would avoid "racial suicide" or Asian invasion and would improve national fitness, thus avoiding "racial decay" and starting to create a "paradise of physical perfection". This thesis considers the impact of eugenics in Australia by examining three related propositions: 1. that from the 1910s to the 1930s, eugenic ideas in Australia were readily accepted because of concerns about declining birth rate; 2. that, while mainly derivative, Australian eugenics had several distinctive Australian qualities; 3. that eugenics has a legacy in many disciplines, particularly family planning and public health. This examination of Australian eugenics is primarily from the perspective of the people, publications and organisations which contributed to this movement in the first half of this century. In addition to a consideration of their achievements, reference is also made to the influence which eugenic ideas had in such diverse fields as education, immigration, law, literature, politics, psychology and science.

Eugenics movements developed early this century in more than 20 countries, including Australia. However, for many years the vast literature on eugenics focused almost exclusively on the history of eugenics in Britain and America. While some aspects of eugenics in Australia are now being documented, the history of this movement largely remained to be written. Australians experienced both fears and hopes at the time of Federation in 1901. Some feared that the white population was declining and degenerating but they also hoped to create a new utopian society which would outstrip the achievements, and avoid the poverty and industrial unrest, of Britain and America. Some responded to these mixed emotions by combining notions of efficiency and progress with eugenic ideas about maximising the growth of a white population and filling the "empty spaces". It was hoped that by taking these actions Australia would avoid "racial suicide" or Asian invasion and would improve national fitness, thus avoiding "racial decay" and starting to create a "paradise of physical perfection". This thesis considers the impact of eugenics in Australia by examining three related propositions: 1. that from the 1910s to the 1930s, eugenic ideas in Australia were readily accepted because of concerns about declining birth rate; 2. that, while mainly derivative, Australian eugenics had several distinctive Australian qualities; 3. that eugenics has a legacy in many disciplines, particularly family planning and public health. This examination of Australian eugenics is primarily from the perspective of the people, publications and organisations which contributed to this movement in the first half of this century. In addition to a consideration of their achievements, reference is also made to the influence which eugenic ideas had in such diverse fields as education, immigration, law, literature, politics, psychology and science.

Evidence suggests that child behavior, parent mental health, parent supervision, and home environment conditions impact a child’s risk of injury. Vulnerable families are at greater risk for the occurrence of child behavior problems, poor health, decreased supervision, and hazardous home conditions. Consistent with a model that proposes that parent, child, and environment factors interact within the lens of sociocultural factors to predict injury, the current study aimed to test a statistical model with maternal physical health and child externalizing behaviors as predictors of child injury, and home hazards and supervision as mediators of these relations. Analyses were conducted using a nationally representative sample of 3,288 vulnerable mother-child dyads. Results showed significant relations between parent physical health and child injury, and child aggression and child injury, though home hazards and supervision did not mediate either of these relations. Further research should continue to examine the mechanisms of action in the parent health- child injury relation so that injury prevention interventions can be developed.

Increasing immigration to Sweden has transformed a culturally homogeneous society into a more heterogeneous one. As a consequence intercultural communication and interaction have been increasing. Child health care agencies have encountered these increases. The aim of this study was to examine what the health care professionals experienced and communicated in these intercultural environments. Eight interviews with child health care nurses were carried through at four child health care centers in the south of Sweden. The results have shown that the child health nurses were affected by their different backgrounds and cultural diversity. An ethnocentric approach, including biased values of right and wrong, caused unsuccessful encounters with families from foreign countries. A culturally sensitive approach, on the other hand, with an understanding of cultural differences, proved to be successful and associated to plain communication and trust. A conclusion is that the nurses in childcare services should be provided with the opportunity to develop the necessary knowledge and tools needed for managing problems and obstacles they may encounter in their practices. Furthermore it was found that reflection was used for learning. We conclude that the nurses should be provided with opportunity to learn this way about their own culture and cultural relativity. A culturally sensitive approach leads to a better acceptance for cultural difference. From a health promotion point of view, this means that the prospect of promoting good health for immigrant children in the long run can be increased.

Keywords: Intercultural communication, child health centers, ethnocentrism, cultural sensitivity, reflection.

Background and aims: The immune, respiratory and central nervous system start developing during pregnancy and continue during the first years of life. Therefore, environmental exposures during these periods may play a role on the maturation of these systems. In particular, the exposure to indoor microbial agents, indoor factors such as pets or dampness, and to household cleaning products during infancy or childhood may have important implications in the development processes. This thesis aims to assess the long term effects of indoor exposure to microbial agents and chemical based cleaning products on respiratory and mental health among children from birth to the age of 13 years old. Methods: We used data from nine European birth cohorts that are part of three projects: the European HITEA project, the Spanish INMA project; and the German GINIplus and LISAplus birth cohort studies. Information on the exposure to indoor dampness, pet ownership, the use of cleaning products and allergy and respiratory health was periodically collected through questionnaires and health tests. Living room dust samples were collected when the children were 2-3 months and analysed for microbial agents concentrations (bacterial endotoxin, fungal extracellular polysaccharides (EPS) from Aspergillus spp. and Penicillium spp, and mould β(1,3)- glucans). Multivariable regression models were used to assess the associations between the exposures and the health outcomes. Results: 1) Concentrations of measured microbial agents varied differently across the cohorts. 2) Season of dust sampling, dog ownership, indoor report of dampness, and number of people living in the home is associated with the concentrations of microbial agents. 3) Early life exposure to endotoxin and dogs in the home is associated with lower levels of FeNO at school age. 4) Domestic use of cleaning sprays, air fresheners and solvents during pregnancy is associated with a higher prevalence of wheezing and LRTI during the first year of life. 5) At school age, bystander exposure to domestic cleaning sprays increases the levels of FeNO, and exposure to air freshening sprays and solvents decreases the lung function. 6) Persistent exposure to indoor dampness during early life has negative effects on the cognitive function and social competences at 4 years old. 7) Exposure to visible mould, dampness and pet ownership during the first 10 years of life increases the risk of borderline or abnormal scores in the SDQ at 10 years of age. Conclusion: Our results suggest that indoor exposure to microbial agents during early life and exposure to chemical based cleaning products during pregnancy, infancy and childhood play a role in the development of the respiratory, immune and central nervous systems.
Introducció i objectius: El desenvolupament dels sistemes immunitari, respiratori i nerviós central comença durant l’embaràs i continua al llarg la infància. Així, els primers anys de vida són moments crucials en que qualsevol exposició ambiental pot influir el desenvolupament d’aquests sistemes. Concretament, l’exposició durant la infància a agents microbiològics, humitat, animals de companyia i productes de neteja pot tenir implicacions importants en els processos de maduració d’aquests sistemes. L’objectiu principal d’aquesta tesi és el d’avaluar els efectes a llarg termini de la exposició a agents microbiològics i a productes de neteja de base química a la llar, sobre la salut respiratòria i mental des del naixement fins a l’edat de 13 anys. Mètodes: En aquesta tesi hem fet servir dades de nou cohorts de naixement europees que formen part de tres projectes: el projecte europeu HITEA, el projecte espanyol INMA, i els estudis alemanys GINIplus i LISAplus. La informació sobre la exposició a humitat, a animals de companyia, la utilització de productes de neteja, al·lèrgies i salut respiratòria es va recollir en tots els projectes mitjançant qüestionaris administrats als pares/mares i proves mèdiques o tests neuropsicològics. A més, es van recollir mostres de pols dels menjadors de les cases quan els nens/es tenien 2-3 mesos d’edat que es van analitzar per determinar les concentracions d’agents microbiològics (endotoxines bacterianes, polisacàrids extracel·lulars (EPS) d’Aspergillus spp. i Penicillium spp i β(1,3)-glucans fúngics). Per l’avaluació de les associacions entre exposicions i resultats de salut s’han desenvolupat models de regressió múltiple. Resultats: 1) Les concentracions d’agents microbiològics mesurats en pols de les llars varien per cohort. 2) L’estació de l’any en que es recull la mostra de pols, la presència de gossos a la casa, reportar humitat a la casa i el número de persones que hi viuen estan associats amb la concentració d’agents microbiològics a la pols. 3) L’exposició durant els primers mesos de vida a endotoxines i gossos a la llar s’associa amb nivells baixos de FeNO a edat escolar. 4) L’ús d’esprais i dissolvents per la neteja de la casa, i ambientadors durant l’embaràs està relacionat amb un increment en la prevalença de sibilants i infeccions respiratòries de vies baixes al llarg del primer any de vida. 5) En edat escolar, la exposició passiva a productes de neteja domèstics utilitzats en forma d’esprais incrementa els nivells de FeNO, i l’exposició a esprais ambientadors i dissolvents per la neteja de la llar disminueix la funció pulmonar. 6) L’exposició persistent a humitat a la llar durant els 2 primers anys de vida té un efecte negatiu sobre la funció cognitiva i les competències socials mesurades als 4 anys d’edat. 7) L’exposició a fongs procedents de la humitat, a humitat i a animals de companyia a casa al llarg dels primers 10 anys de vida incrementa el risc de puntuacions “borderline” o anormals al questionari SDQ administrat als 10 anys. Conclusió: els resultats presentats en aquesta tesi suggereixen que l’exposició a agents microbiològics durant els primers mesos de vida i l’exposició a productes de neteja durant l’embaràs i la infància juguen un paper important en el desenvolupament dels sistemes respiratori, immunològic i nerviós central.

This dissertation consists of three essays that investigate the effect of children’s health shocks on children’s and parent’s wellbeing. In the first chapter, we investigate the effect of C-sections on newborn health. We use variation in the probability of unplanned C-section by the time of day as an instrument for type of delivery and find a small negative impact on neonatal health. In the second chapter, we use a similar methodology to analyze the long-term effects of C-sections. We find that unplanned C-sections increase the risk of asthma, but do not affect other immunemediated disorders previously associated with C-sections. In the last chapter, I study the impact of a child’s adverse health event on parental labor market outcomes. I do this by comparing parents across families in similar parental and child age cohorts whose children experienced a health shock at different ages. I show that parental earnings suffer a substantial and persistent decline after the event. I also find an impact on parents’ mental well-being.
Aquesta tesi està formada per tres assajos que investiguen l’efecte dels xocs en la salut dels infants, en el seu benestar i el de la seva família. Al primer capítol, investiguem l’efecte de néixer per cesària en la salut neonatal. Utilitzem variació en la probabilitat de cesària no planificada segons l’hora del dia com a instrument pel tipus de part i trobem un efecte negatiu, petit, en la salut neonatal. Al segon capítol, utilitzem una metodologia similar per analitzar l’efecte de néixer per cesària a llarg termini. Trobem que néixer per cesària no planificada augmenta el risc de patir asma, però no afecta altres malalties immunològiques que prèviament s’havien trobat associades amb la cesària. A l’ últim capítol estudio l’impacte que té que l’infant pateixi un xoc en la seva salut, al mercat laboral de les mares i pares. La meva estratègia d’identificació es basa a comparar progenitors amb la mateixa edat, amb fills de la mateixa edat, però que pateixen el xoc en diferents moments. Els ingressos de les mares i pares pateixen una caiguda substancial i persistent després de l’episodi. També trobo que aquest esdeveniment afecta la salut mental de les mares i pares.
Esta tesis está formada por tres ensayos que investigan el efecto de shocks en la salud de los niños y niñas, en su bienestar y el de su familia. En el primer capítulo, investigamos el efecto de nacer por cesárea en la salud neonatal. Utilizamos variación en la probabilidad de cesárea no planificada según la hora del día como instrumento para el tipo de parto, y encontramos un efecto negativo, pequeño, en la salud neonatal. En el segundo capítulo, utilizamos una metodología similar para analizar el efecto de nacer por cesárea a largo plazo. Encontramos que nacer por cesárea no planificada aumenta el riesgo de sufrir asma, pero no afecta otras enfermedades inmunológicas que previamente se asociaban con nacer por cesárea. En el último capítulo estudio el impacto de sufrir una hospitalización severa durante la infancia, en el mercado laboral de las madres y padres. Mi estrategia de identificación se basa en comparar progenitores con la misma edad, con hijos de la misma edad, pero que sufren el evento en diferentes momentos. Los ingresos de las madres y padres sufren una caída sustancial y persistente después del episodio. También encuentro que esto afecta a la salud mental de las madres y padres.

This thesis comprises four empirical essays on the economics of child health in developing countries. Chapter 1 investigates intergenerational persistence in health, its spatial variation, and trends, using micro-data on 2.24 million children born of 0.6 million mothers in 38 developing countries between 1970-2000. A standard deviation decrease in mother's height or BM! raises the risk of poor child health by between 5 and 10 percent. Disaggregra- tion shows significant continent variation; the relationship was strongest in Africa, where it strengthened over time. Chapter 2 investigates whether in- come, women's education or public health (infant immunization rates) affect intergenerational persistence. Improvements in these in the foetal and birth year weaken the relationship, and these gradients are steeper for shorter women. Chapter 3 studies the impact of exposure to a serious, unusual, and unforeseen malaria epidemic in Brazil in 1938-1940 on subsequent human capital attainment, exploiting cohort- and regional-heterogeneity in expo- sure to identify effects. I argue disease related mortality is likely to differ by gender and migrant status, and allow for differential effects for these groups. A model of (mortality) selection and scarring is used to frame results. Selec- tion dominates for non-migrants whilst migrants are less selected or scarred. Scarring effects are particularly evident for female migrants. Chapter 4 investigates whether child health determines work and schooling. Unob- served heterogeneity and simultaneity concerns are addressed by exploiting panel data from the Philippines, with a first-difference instrumental vari- ables estimator used. The change in health between age 11/12 and 14/15 is instrumented for by health and breastfeeding duration in the first two years of life. A change in boys height-for-age of one standard deviation raises the probability of work by 36 percentage points, weekly hours of work by 11 hours, and lowers probability of school attendance by 30 percentage points. Estimates for girls are statistically weaker and may be affected by lack of data on domestic work.

Reducing maternal and child mortality was established as a global priority with the signing of the Millennium Declaration in September 2000. Neonatal vitamin A supplementation and very early breastfeeding initiation are scalable interventions which may improve infant survival. Although breastfeeding has proven benefits for infant health, the potential health consequences of breastfeeding for HIV-infected women are not well studied. In paper one, “The effect of neonatal vitamin A supplementation on morbidity and mortality at 12 months: A randomized trial”, we assessed the efficacy of neonatal vitamin A supplementation (NVAS) in reducing infant morbidity and mortality. Using data from an individually randomized clinical trial of 31,999 infants in Tanzania, we found that NVAS did not affect the risk of death or the incidence of morbidities. However, we noted that postpartum maternal vitamin A supplementation modified the effect of neonatal vitamin A supplementation on infant mortality. In paper two, “Effect of delayed breastfeeding initiation on infant survival: a systematic review and meta-analysis”, our objective was to synthesize the evidence regarding the association between breastfeeding initiation time and infant morbidity and mortality. We pooled five studies, including 136,047 infants. We found a clear dose-response relationship; the risk of neonatal mortality increased with increased delay in breastfeeding initiation. We found a similar pattern when the analysis was restricted to exclusively breastfed infants or low birthweight infants. There was limited evidence regarding the association between breastfeeding initiation time and infant morbidity and growth. We concluded that health policy frameworks and models to estimate newborn and infant survival should consider the independent survival benefit associated with early initiation of breastfeeding. In paper three, “Breastfeeding and Maternal Health among HIV-infected Women in Tanzania”, our objective was to assess the relationship between infant feeding practices and the incidence of maternal mortality, morbidity, and indicators of poor nutritional status from six weeks to two years postpartum in a prospective cohort of Tanzanian women living with HIV. We concluded that breastfeeding may be associated with mixed health outcomes. Additional research should investigate whether HIV-infected women require nutritional support, in addition to antiretroviral therapy, during and after lactation.

This dissertation is a collection of three separate essays on the health of women and children. In the first essay, I along with my co-authors, analyzed the impact of two large, national-level health policies (the Janani Suraksha Yojana (JSY) and the National Rural Health Mission (NRHM)) on maternal health outcomes (proportion of institutional deliveries) in India. We used data from the India Human Development Survey (IHDS) and found that the JSY and the NRHM had a greater impact on institutional deliveries in high-focus states. We also found that the conditions of the public health facilities, did not change after the implementation of the JSY and the NRHM. Finally, we found that adequacy of health facilities was not associated with the likelihood of mothers in high-focus states having an institutional delivery. In the second essay, I examined whether a key social determinant of health in South Asia- gender inequality, is associated with physical health outcomes among Indian women. I found that the gender inequality expressed as the gendered household practice of seclusion was negatively associated with body weight of Indian women. Further, I found that participation in all household decisions by women of the household was generally not associated with body weight outcomes. The association between gendered household practices and women’s body weight outcomes was generally similar among rural and urban Indian women. In the final essay, I examined whether perinatal food environments (FE), maternal gestational weight gain (GWG) and early childhood weight (ECW) outcomes are associated. I used data on mother-children dyads from the Early Childhood Longitudinal Study – Birth cohort (ECLS-B), Area Resource Files (ARF) and Current Business Practices (CBP). I found that maternal GWG was associated with ECW outcomes. I also found that measures of food environment were associated with ECW outcomes. Specifically, I found that having an additional full-service restaurant per one thousand population in the maternal perinatal county of residence was associated with lower Body Mass Index (BMI) among children at age two years. Finally, I found that GWG did not mediate the association between food environment and ECW outcomes.

The purpose of this study was to identify to what degree specific factors influence the level of satisfaction experienced by foster parents whose foster children are recieving mental health services from agencies that they have been referred to by a Coming of Age Foster Family Agency.

At present not enough is known about the health of preschool children in the poorer communities of Cape Town. This study, was undertaken to assess the health and health care of preschool children in one such community: that of the Hout Bay harbour township. A clinic and community-based surveillance programme was devised to make this assessment. Data were obtained by monitoring the records at the Community Health Centre in the township. A study sample of 214 children from the community was also selected by random stratified cluster sampling. This sample was assessed by means of a questionnaire and a full physical examination. Analysis of data was performed on the IBM main-frame computer. A large number of medical problems were identified on screening the community sample. Most of these problems were minor ones and could be managed appropriately at the Health Centre. On the basis of the referral patterns and the small number of newly diagnosed functionally important health problems, the provision of health care in-the area was considered to be adequate. The high immunisation rate in the preschool children and the excellent attendance figures at the child health clinics indicates that the services provided are well utilised by the population. Dental caries was found to be a major health problem in the area. A strong case for the introduction of a dental health educational programme and for the fluoridisation of drinking water can made on the basis of these findings. An ongoing health screening programme would be beneficial. It could be accomplished by utilising appropriately trained nursing personnel.

Since the early 1980s, child health policies promoted by the international health community and national governments in the developing world have focused on a selective disease control approach which targets the leading causes of infant and child mortality through low cost medical interventions and their dissemination to the population through social marketing and mass media techniques. More recently, investment in maternal education has been increasingly addressed as an essential component of child survival strategies in the developing world following increasing evidence in national and cross-national surveys which demonstrates a positive relationship between maternal education and reductions in child mortality. With respect to the impact of disease-specific interventions on child health and survival, numerous constraints to the impact of medical interventions have emerged as these interventions were transferred from clinical settings to field situations in the 1980s and 1990s. With regard to the role of maternal education in child health and survival, despite considerable research on this relationship at the aggregate level, there remain significant research gaps surrounding the pathways through which maternal education affects child health at the household level; these gaps have partially constrained the inclusion of maternal education as a fundamental component of child health policies at the implementation level. This thesis examines these issues concurrently in a sample of 401 households in rural Egypt.

Perfluoroalkyl substances (PFAS), such as perfluorooctanesulfonic acid (PFOS) and perfluorooctanoic acid (PFOA), are synthetic chemicals commonly used in industrial and commercial products including consumer care products, fire-fighting foams, ski wax, and oil- and water-repellents for leather, paper, and textiles. Prenatal PFAS exposure may modulate fetal growth, fat accumulation, metabolic function, and immune response yet evidence coming from birth cohort studies is limited. In this thesis we first evaluated the transfer of PFAS from mother to fetus and the determinants of maternal PFAS exposure during pregnancy. This led us to the main objective of this thesis, to evaluate the association between prenatal exposure to PFAS and child health outcomes, specifically: fetal growth and preterm birth, obesity and cardiometabolic risk, and immune and respiratory health in early and mid-childhood. Data from the “Infancia y Medioambiente” (INMA) population-based Spanish birth cohort was used. The results from the present thesis indicate that PFOA can cross the placental barrier more efficiently than other PFAS, and that mothers were ubiquitously exposed to PFOS and PFOA during the years 2003-2008. We found little evidence for an association between prenatal PFAS exposure and child health outcomes (i.e. fetal growth and preterm birth, obesity and cardiometabolic risk, and immune and respiratory health). Prospective studies with follow-ups beyond mid-childhood are recommended.
Els compostos perfluorats (PFAS per la seva abreviació en anglès), com l'àcid perfluorooctanosulfònic (PFOS) i l'àcid perfluorooctanoic (PFOA), són productes químics sintètics utilitzats habitualment en productes industrials i comercials, per exemple escumes antiincendis, cera d'esquí, i repel·lents d'oli i aigua per a cuir i tèxtils. Durant les primeres etapes de la vida, l'exposició a PFAS pot influenciar el creixement fetal, l'acumulació de greix i la resposta immune però hi ha poca informació provinent d'estudis de cohort de naixements. En aquesta tesi primer es va avaluar la transferència de PFAS de la mare al fetus i els determinants de l'exposició materna durant l'embaràs. Això ens va conduir a l'objectiu principal d'aquesta tesi, que era avaluar l'associació entre l'exposició prenatal a PFAS i la salut infantil, específicament: el creixement fetal i el part prematur, l'obesitat i el risc cardiometabòlic, i la salut immunològica i respiratòria durant l'infància. Es van utilitzar dades de la cohort poblacional de naixements Infància i Medi Ambient (INMA) a Espanya. Els resultats de la present tesi indiquen que PFOA travessa la placenta més eficientment que els altres PFAS i que les mares van estar exposades a PFOS i PFOA de manera ubiqua durant els anys 2003-2008. En general, l'exposició prenatal a PFAS estava poc associada amb els resultats de salut infantil avaluats. Es recomanen estudis prospectius amb un seguiment posterior a l'infància.

Alloparenting has played a pivotal role in every society throughout human history in ensuring the survival and healthy development of children. A large amount of theory (e.g. kin-selection) and evidence exists to support this claim, and though alloparenting is certainly not unique to humans, it is difficult to suggest that any other species benefits from it more, and certainly not one as ubiquitous as Homo sapiens. However, there is a surprising dearth of empirical research examining the causes of individual variation in the amount and type of alloparental behavior that a child receives, and what effect this variation has on previously validated measures of child well-being. We propose how different measures of familial relatedness and the spatial distribution of relatives might be used to predict the amount and type of alloparental care a child receives, and how these variables may interact to affect a child’s health. We employed a variety of different methods; genealogical modeling, genetic analysis, geospatial mapping, ethological behavioral observations, and anthropometric measurements in order to generate objective data to test these predictions. As members of a relatively isolated native people in Sonora, Mexico, our study population (the Comca'ac) is uniquely suited to help us test our hypotheses. From just this pilot study, we have made many methodological developments and found strong support for many of our hypotheses. There are many new questions to answer as well, which together suggest the future directions for an intensive study of a broader sample of this population, and alloparental behavior in humans in general.

Research shows that the integration of physical and mental healthcare in paediatric settings is beneficial in terms of clinical and cost effectiveness (Kahana, Drotar, & Frazier, 2008; Douglas & Benson 2008, Griffin & Christie, 2008). Due to the high rates of mental health problems within this population, several studies have shown that referral to paediatric psychology should be increased (e.g. Wagner & Smith, 2007). However, there are few studies investigating factors influencing healthcare professionals’ referral behaviour. The current study used theory of planned behaviour (Ajzen, 1988; 1991) to develop a questionnaire which explores factors influencing the referral of children and families to paediatric psychology. Psychometric properties of the questionnaire were examined. Findings indicate that the questionnaire holds good reliability and validity and that the main constructs of theory of planned behaviour are useful in predicting intention to refer to paediatric psychology. Specific beliefs about referral were also shown to influence intention to refer. Findings that individual referrer factors such as attitudes and beliefs can impact healthcare professionals’ referral behaviour indicates that multidisciplinary interventions and inter-professional education relating to the psychological aspects of illness are required. Recommendations for future research are discussed.

The central aim of this study is to identify and describe the experiences of first time mothers who are underusers of child care clinics. An attempt is made to counterbalance the tendency of researchers in this area to be judgmental of underusers who "neglect" their children, and their own health care needs, -by reporting the mothers' views of the child health services in their own terms. Underusers within a certain Health Authority area were identified using a purposely developed Index of Uptake. The achieved sample of predominantly working class mothers constituted a group of people who are particularly difficult to research. It is believed that success in locating and eliciting evidence from this group was in itself an important contribution to the research literature. In depth interviews were undertaken, and the data analysed in two ways; (1) A Subsample, made up of those having made least use of the services available to them, was analysed interpretively to provide detailed material of an idiographic kind on the lifeworld of the person and the place of medical care within it; (2) All interviews were subjected to content analysis to provide a more general picture of mothers' experiences of health care provision. The main findings include the following; (1) The particular population studied had a generally low level of visage as assessed by the index, but use of specifically medical provision was greater. A process of rational decision making is implicated. (2) Accounts of underusers' experiences highlight as a central theme the mothers' vulnerability to personal undermining by many aspects of health care provision. The thesis concludes with a discussion of the approach which health care providers adopt towards'underusers, and argues that there must be an explicit recognition of the point of view of the clients if the services are to reach this deprived segment of the community. Such recognition is rarely found in research or comment on the problem of underusage. In fact apparently irrational and blameworthy behaviour by underusers can be. rendered explicable when considered in the light of the individuals' perceptions and experiences, and this leads to a serious questioning of the utility and appropriateness of the negative judgements made of them.

Coeliac disease (CD) is an autoimmune condition of the gastrointestinal tract. In untreated patients, an inflammatory response to gluten results in destruction of the gut mucosa resulting in villus atrophy. This often presents with overt clinical symptoms but can also be silent in nature. Continual gluten insult can inevitably lead to a range of complications including nutritional problems from poor growth to deficits in bone mineral density (BMD). The CHIC study aimed to create a comprehensive picture of CD in children, taking into account growth and nutritional status, bone health, micronutrient status and further assessing children with the dual diagnosis of type 1 diabetes mellitus and CD. It is well established that early diagnosis of CD and the prompt initiation of gluten free dietary treatment (GFD) reduces the manifestation of complications. Yet in many previous studies the quality of a GFD and children's compliance to it have not been accounted for. This study assessed nutritional status and body composition in paediatric patients with newly diagnosed CD and found that the presentation of CD has changed, with the majority of patients presenting with normal and even over nutrition. Furthermore, the introduction of GFD with good compliance supports normal growth velocities and enables catch up growth in children presenting with short stature. When considering bone health in paediatric patients with CD the results remain inconclusive. Many previous studies have used the widely available DXA to assess bone mineral content, but in paediatric patients this may not accurately determine bone health. This study used peripheral quantitative computed tomography to distinguish changes in bone mineral density and investigate any alterations in bone microarchitecture. Thus, for the first time in paediatric CD patients identifying disruption to the remodelling mechanisms of trabecular bone, which may be particularly sensitive to resorption and mineral loss in patients with active CD. Furthermore, restoration of BMD was evident with good compliance to dietary treatment. Investigations into micronutrient status revealed that newly diagnosed children are vulnerable to micronutrient deficiency, this is likely due to malabsorption in the gut in patients with active CD. Deficiencies in zinc and magnesium were also identified in children treated with a GFD. This may be due to the inadequate micronutrients intakes with consumption levels of riboflavin, vitamin A, vitamin K, calcium, iron, magnesium and zinc lower than expected in treated CD children.

Parent-child sexual health communication (PCSHC) can have a positive impact on adolescents’ sexual health choices, outcomes, and capabilities for communicating with others about sexual health. Many parents are hesitant and feel unprepared for and uncomfortable with communicating about sexual health with their children. Other parental factors as well as child factors can impact the quality, frequency, coverage, and effectiveness of PCSHC. Some adolescent sexual health outcomes have improved, however, teen birth rates in the United States are elevated compared to other developed countries and half of all sexually transmitted infection (STI) diagnoses are made to adolescents and emerging adults. This emphasizes the importance of PCSHC as a protective factor for children and opportunity for them to develop understanding and skills for good sexual health decision-making. While challenging to recruit and retain participants, parent sex education programming designed to promote PCSHC can instill a sense of parental necessity and responsibility, and equip parents with knowledge and skills to confidently and successfully engage their children. The theory of planned behavior (TPB) provided the framework for this mixed methods study designed to learn more about PCSHC, differences in PCSHC based on gender of children, parental beliefs about PCSHC, intentions for and actual engagement in PCSHC. Included in the literature review for this study is a systematic review of literature focused on parent education programming designed to improve PCSHC. Parents of children in grades 4 – 11 completed a pencil/paper or an electronic Qualtrics baseline survey containing questions about their perceptions of and engagement in PCSHC. The quantitative data collection instrument included items measuring TPB constructs of behavioral, normative, and control beliefs, intentions for and actual engagement in PCSHC and condom use instruction delivery, communication openness, communication ability, sexual health topics discussed with children, and respondents’ demographics Many of the respondents (N = 205) were residents of the program target community, Winchester/Clark County, Kentucky, and were eligible to participate in parent programming, as were all residents that were parents of children in grades 4 – 11. The program, I’ll Have a Side of Sex Education, was designed as a six-week series of 50 minute lunch time sessions with the intention to improve parents’ sense of comfort, confidence, and skills in communicating with their children in general, and particularly about sexual health. Of the 205 parents who completed the baseline survey, 50 enrolled in and attended some or all of one of five offerings of the six-week parent education series and were invited to complete a post-program and six-week follow up surveys. Post-program data were collected with a paper- pencil survey and six-week follow up data were collected with a Qualtrics survey. The systematic review of parent sex education literature provided insight into components of programming related to successful program delivery and positive parental outcomes. The systematic analysis of the baseline data including examining PCSHC factors from the parental perspective and how these related to the gender of children and determining the usefulness of the TPB constructs for understanding PCSHC Results of Chi-square tests of mean differences showed a significant difference in parents actually providing their children with instructions for correct condom usage, χ2(2, N = 203) = 6.96, p = 0.03, and MANOVA results revealed the degree to which parents address certain sexual health topics with their children related to the gender of their children. Results of logistic regression showed behavioral beliefs having the greatest predictive power of parents’ intentions to give condom use instructions (p < 0.01) and actual delivery of condom use instructions (p = 0.04) and engagement in PCSHC, generally (p = 0.03). The current study contributes to the greater body of literature addressing parental and child factors related the promotion, delivery, and effectiveness of PCSHC and parent education programming designed to improve the quality, frequency, and impact of PCSHC. Its findings expand our understanding of how gender of children and parental beliefs relate to PCSHC and lend themselves to the consideration of the greater social influences impacting parents’ ability and motivation to engage their children in communication about sexual health. Differences in communication based on gender of children signal to a double standard in the messaging about sexual health and behaviors related to gender and these discrepancies leave adolescents and emerging adults, both males and females, vulnerable at worst to poor sexual health choices and outcomes and at least to being undereducated about sexual health topics. Although these findings give little support for the overall TPB model contributing to the understanding of parental intentions and behavior related PCSHC, the relationship between behavioral beliefs informed by attitudes about the value of PCSHC and parental intentions and behaviors does provide insight to health promoters and educators. Assessing parental attitudes toward PCSHC and tailoring messages and educational opportunities that may improve these attitudes and motivate parents to engage in and seek support for effective PCSHC holds promise. The piloting of a parent education program adapted from a previously evaluated parent sex education programming and the summative evaluation offered by participants gives support for efforts on the part of health promotion and education professionals to invest time, energy, and resources into program design and delivery and recruitment and retention of parents.

Almost half of young children in the United States live in poverty or near poverty. The American Academy of Pediatrics is committed to reducing and ultimately eliminating child poverty in the United States. Poverty and related social determinants of health can lead to adverse health outcomes in childhood and across the life course, negatively affecting physical health, socioemotional development, and educational achievement. The American Academy of Pediatrics advocates for programs and policies that have been shown to improve the quality of life and health outcomes for children and families living in poverty. With an awareness and understanding of the effects of poverty on children, pediatricians and other pediatric health practitioners in a family-centered medical home can assess the financial stability of families, link families to resources, and coordinate care with community partners. Further research, advocacy, and continuing education will improve the ability of pediatricians to address the social determinants of health when caring for children who live in poverty. Accompanying this policy statement is a technical report that describes current knowledge on child poverty and the mechanisms by which poverty influences the health and well-being of children.

Background This work in child population medicine describes child health problems, increases knowledge of health services, systems, and wider determinants, and makes recommendations for improvements. Aims To explore trends in UK child health and health service quality and highlight policy lessons from the UK and other European countries To study child health and health services in western Europe and derive lessons from different approaches to common challenges To enhance knowledge on child to adult transition care To describe trends in UK and EU15+ child and adolescent mortality and seek explanations for deteriorating UK health system performance, and make recommendations for improving survival Methods Population level measures of health status and system performance; primary and secondary research on policies and practice for health system assessments. Quantitative: mortality rate trends, excess deaths, DALYs, healthcare processes Qualitative: case reports, system descriptions, analyses  Results European child survival has improved, but variably between countries. The UK has not matched recent EU mortality gains. There are 6,000 excess deaths annually in children under 15 years in EU14 countries. There are child survival inequities; countries investing in social protection have lower mortality. Children in the UK, compared with other EU countries, are more likely to be poor than adults. Non-communicable diseases are now dominant causes of child death, disease, and disability. Mortality, processes, and outcomes of healthcare amenable conditions varies between countries. Better outcomes seem to be associated with flexible health care models promoting cooperation, team working, and transition. Conclusions Child health in Europe is improving, but unevenly. Child health systems are not adapting sufficiently to meet needs. Recommendations are made for improving health systems and services.
How do European countries compare when it comes to child health statistics? How do different child health services, systems, and wider determinants impact long term influences for good or harm? Why do some countries seem to do better than others in safeguarding their children’s and young people’s health and wellbeing? And what can we  do to make things better for children? This thesis explores some of these difficult but important issues, and despite describing some serious signals of concern about child health, offers recommendations and clear ways forward for countries to ensure healthier futures for children.

Maternal and child health (MCH) mortality is a formidable challenge for health systems around the world according to the World Health Organization. Health professionals and practitioners within the United Arab Emirates were studied to determine the extent they were involved in the policy-making process, and the potential impact that analysis may have on new or revised MCH policies. Research on MCH policy-making and development processes are limited. The Andersen model of healthcare services utilization provides an appropriate framework for this research, enabling the analysis that influences the policy-making process in the area of MCH. Independent variables included nationality, education, work experience, and organizational support, and the dependent variable included policy-making process. The quantitative methodology included the data collection from a sample of 380 health professionals and practitioners. The results of the study revealed statistical correlations where the most significant predictor of policy-making was organizational support, which explained the 42% variation in policy-making. This predictor was followed by nationality and education. The research adds value for decision-makers when considering and evaluating the extent of MCH policy, laws and regulations, current challenges, and strategies. The research findings could positively influence decision makers' action plan in formulating new guidelines, public policies, and strategies for the development of maternal and child health across the UAE region. Future research should aim to include other factors that may have an influence on the policy-making process.

The robustness and responsiveness of a country's health system predict access to a range of health services, including maternal and child health (MCH) services. The purpose of this cross-sectional study was to examine the influence of 5 health system characteristics on access to MCH services in Sierra Leone. This study was guided by Bryce, Victora, Boerma, Peters, and Black's framework for evaluating the scaleup to millennium development goals for maternal and child survival. The study was a secondary analysis of the Sierra Leone 2017 Service Availability and Readiness Assessment dataset, which comprised 100% (1, 284) of the country's health facilities. Data analysis included bivariate and multivariate logistic regressions. In the bivariate analysis, all the independent variables showed statistically significant association with access to MCH services and achieved a p-value < .001. In the multivariate analysis; however, only 3 predictors explained 38% of the variance (R� = .380, F (5, 1263) = 154.667, p <.001). The type of health provider significantly predicted access to MCH services (β =.549, p <.001), as did the availability of essential medicines (β= .255, p <.001) and the availability of basic equipment (β= .258, p <.001). According to the study findings, the availability of the right mix of health providers, essential medicines, and basic equipment significantly influenced access to MCH services, regardless of the level and type of health facility. The findings of this study might contribute to positive social change by helping the authorities of the Sierra Leone health sector to identify critical health system considerations for increased access to MCH services and improved maternal and child health outcomes.

Child maltreatment, and recurrent maltreatment in particular, occurs at an alarmingly high rate. Frequency of reports to Child Protective Services (CPS) is associated with negative psychological outcomes, and children whose reports are unsubstantiated experience similar risk of behavioral, emotional, and substance use disorders as those whose reports are substantiated. Prior research has demonstrated that children with no CPS reports and children with one CPS report showed no significant differences in rates of maltreatment perpetration or substance use in adulthood, suggesting that prevention efforts after one report may have strong merit in reducing negative outcomes in adulthood. However, patterns and risk factors of unsubstantiated reports have been only minimally explored thus far, despite having been found to predict subsequent maltreatment. The current study extends upon previous research by (a) examining both substantiated and unsubstantiated reports to identify longitudinal patterns of timing and recurrence and (b) assessing the extent to which service provision mediates long-term recurrence after each type of report. Analyses were conducted using subsamples of a longitudinal national dataset from 2011-2015 containing data from CPS reports for 3,655,951 children. Measures included child, caregiver, and CPS case characteristics obtained at the time of first report in 2011. Latent class analysis of referral patterns indicated four classes of recurrence patterns: (1) 2011 unsubstantiation followed by moderate recurrence, (2) 2011 unsubstantiation followed by low recurrence, (3) 2011 substantiation followed by moderate recurrence, and (4) 2011 substantiation followed by low recurrence. Multinomial logistic regression with most likely class membership as the outcome variable indicated that domestic violence, caregiver substance abuse, and poverty were better predictors of initial substantiation status than of long-term recurrence. Prior victimization was predictive of initial substantiation status as well as long-term recurrence. Asian American race predicted low rates of recurrence. Latent class analysis of service provision revealed only two classes: a class of children who received services and a class of children who did not. Service provision partially mediated associations between initial substantiation status and five-year maltreatment recurrence, as measured by number of subsequent reports, number of subsequent substantiated reports, and number of subsequent years in foster care. Limitations are considered and implications of using predictive modeling to drive service prioritization are discussed.

The purpose of the present study was to examine how low-income, racial and ethnic minority, urban families experience and manage their child’s asthma. The rationale for this study stems from existing literature on asthma disparities and documented predictors of increased asthma morbidity and mortality. In particular, this study considered how specific types of stress may disproportionately impact low-income, racial and ethnic minority, urban families that have a child with asthma. This study aimed to determine associations between urban stressors (stressful life events, perceived discrimination, subjective socioeconomic status) and child asthma outcomes (emergency department visits, school days missed, asthma control), and considered depressive symptoms and asthma self-efficacy as mediators in these associations. Analyses were conducted in a sample of 97 urban caregivers and their children in Richmond, Virginia. Findings revealed that neighborhood stress was significantly associated with asthma control. Stressful life events were significantly associated with school days missed. Perceived discrimination and subjective SES were not significantly related to any child asthma outcomes. Bootstrapping procedures demonstrated that child depressive symptoms mediated the relation between neighborhood stress and asthma control. Child asthma self-efficacy did not significantly mediate associations between neighborhood stress and any child outcomes. Caregiver depressive symptoms and caregiver asthma self-efficacy did not significantly mediate any associations between caregiver-reported urban stressors and child asthma outcomes. Results from the present study suggest that urban stressors, especially neighborhood stress and stressful life events, are important to consider in the context of child asthma management and subsequent health outcomes. Exposure to urban stressors may further contribute to pediatric asthma disparities because they are disproportionately experienced by low-income, racial and ethnic minority, urban families. Each urban stressor that was related to a child outcome was associated with a particular asthma outcome. Specifically, child-reported neighborhood stress was related to asthma control. Caregiver-reported stressful life events were associated with school days missed. These findings suggest that exposure to specific types of stress may impact asthma management differently. Future research should, therefore, explore the impact and contribution of specific stressors in greater depth. Further, child depressive symptoms significantly mediated the relation between neighborhood stress and asthma control, although caregiver depressive symptoms did not significantly mediate any associations between urban stressors and child asthma outcomes. Additionally, both child and caregiver depressive symptoms were significantly associated with multiple urban stressors and child asthma outcomes. Depressive symptoms may, therefore, be important to target in future research as possible explanatory variables or variables that contribute to stress appraisals and child asthma outcomes.

Cambodia is one of the poorest countries in Southeast Asia, many people suffer from impaired health after all the years of war. The purpose of this study is to describe health workers' experience of promoting child health in Cambodia. The study was performed according to a qualitative approach and consists of interviews conducted with health workers who work in government, NGOs and the private clinic. Interviews and text material was analyzed by qualitative content analysis. The results show that at the state level are given opportunities to work health promotion in order to influence children's health and at the practical level turns out, however, limitations in the form of various health obstacles. The result can be used to discuss what can promote and restrict children's health. Health workers believe that it is important to invest in that all children should have the opportunity to go to school and that education leads to one of the fundamental rights, the best possible health.
Program: Graduate Diploma in Specialist Nursing, Primary Health Care

Purpose: The purpose of this study is to describe children’s dental disease status and functional health literacy of families enrolled in the Child Health Investment Partnership program in Roanoke Valley. Methods: This was a prospective cohort study of children (n=166) enrolled in the Child Health Investment Partnership of Roanoke Valley, Virginia (CHIP). The parents of the 166 children completed the Life Skills Progression (LSP) survey at enrollment between September 2004 and September 2008 to assess their functional health literacy levels. Their LSP scores were used to determine their subsequent health care literacy (HCL), personal health literacy (PHL), and dental-child utilization (LSP22) scores. Descriptive statistics were recorded and a paired t-test was used to determine a relationship between the three measures of functional health literacy at baseline and at their most recent literacy assessment. Dental disease status was determined by an epidemiological dental exam and evaluated using d1d2-3f criteria. This was a visual exam that measured the presence of frank (d2-3) and non-cavitated carious lesions (d1), as well as filled teeth. Results: Descriptive analysis of the cohort reveals: 58% of the children enrolled had no carious teeth at the dental screening exam. The average mean of LSP scores for all three scales: HCL, PHL, and LSP22 were significantly different from baseline: p<.0001, p<.0009, and p<.0001, respectively. Conclusion: An improvement of parental functional health literacy has been documented in a low-income pediatric dental population when preventative efforts and education is delivered within the context of a home-visitation health program. The population of high-risk children had low levels of dental disease.

The purpose of this investigation is to test the mediational effect of parenting style on the association between child health status and child behavioural outcomes in children. Using cross-sectional data of children 4 and 5 years old from National Longitudinal Survey of Children and Youth (NLSCY) Cycle 4 2000-2001 the paper explores the degree to which child health status is related to child behavioural outcomes. In addition, the present study investigates the extent to which child health status is linked to parenting style. Another aim of this study is to explore the association between parenting style and child behavioural outcomes. Child outcome measures assessed in this study include: hyperactivity-inattention, emotional-disorder anxiety, conduct disorder — physical aggression, and indirect aggression. Child health status is assessed using the Health Utility Index Mark 3. The Health Utility Index gives a description of an individual's overall functional health, founded on eight attributes that include: vision, hearing, speech, mobility, dexterity, cognition, emotion, pain and discomfort. Parenting style is measured using several parenting scales that consist of: positive interaction, hostile/ineffective parenting, consistent parenting, and rational (punitive/aversive) parenting. Statistical analysis was conducted using Ordinary Least Squares (OLS) and logistic regression to test the conceptual model and the significance of relationships between the variables of interest. There was partial support for the mediational model of parenting style on the association between child health status and children behavioural outcomes. Specifically, both ineffective and rational parenting each showed a mediational effect. Child health status and child behavioural outcomes were found to have a strong relationship to each other. However, ineffective parenting was more strongly related to child behavoiural outcomes than child health status. This suggests that children that are exposed to ineffective parenting are at greater risk for developing behavioural difficulties than children receiving other forms of parenting. Moreover, children who receive this type of parenting and have poorer health are at even greater risk for developing these behavioural problems. However, these conclusions are tentative as the directionality of these relationships is uncertain because of the cross-section design of this study.

Introduction: In recent years the idea of inequality has been revitalised in the global discourse of development. Despite experiencing significant achievements in addressing the Millennium Development Goal, the fight against inequality remained an unfinished agenda. Disparities in child and maternal health & nutrition exist in almost every low and middle-income country. The global community is increasingly recognising the fact that while a country may be on track to achieve specific targets, the situation concerning some subgroups of the population may remain the same or even worsen over time. To address inequalities within a country, it is thus critical to understand the determinants of inequalities. Social determinants of health, which denote the economic and social conditions and their distribution among the population, have significant influences on individual health conditions. To reduce inequalities in maternal and child health and undernutrition in Bangladesh, it is thus imperative we take proper action on the social determinants of health. But the foremost task is to understand the specific role of social determinants of inequalities in the health and nutrition of the mother and the child. Objectives: Overall the research aims to examine the role of social determinants of health in explaining the inequalities in child health, child under-nutrition and maternal health services in Bangladesh. The specific objectives are to examine the role of social determinants in explaining the inequalities in childhood mortality, childhood malnutrition and maternal health services in Bangladesh. The research also aims to assess the feasibility of monitoring social determinants of health in Bangladesh and testing innovative approached to address inequality in child undernutrition. Methods: Data for Chapter 3, 4, 5 and 6, data were derived from Bangladesh Demographic and Health Surveys, while data for Chapter 7 and 8 were derived from Bangladesh Maternal Mortality and Health Care Survey 2010. Multilevel logistic regression analysis was used in Chapters 3 and 8. The study used decomposition of concentration index method to assess the contribution of social-determinants to the inequality in Chapters 4, 5, 6 and 7. The study also used horizontal inequity index (HII) to measure the horizontal inequity. For measuring the feasibility of monitoring social determinants of health and testing of a mobile-based integrated package to improve maternal and child nutrition among low-income families, the study undertook a mixed method approach. Results: Chapter 3 reported the current situation of universal health coverage in Bangladesh based on priority indicators from a suggested UHC framework. For several priority public-health interventions, the country has reached relatively high levels of coverage with greater equity. For example, Bangladesh has achieved high vaccine coverage while reducing disparities significantly between different wealth quintiles. The primary treatment coverage for diarrhoea and acute respiratory infections (ARI) has also improved. In 2011 81% of under-five children with diarrhoea were treated with ORS. Among children with ARI, 35% were taken to a health facility or a health care provider, and 71% received an antibiotic. Bangladesh’s progress with interventions to combat malnutrition has been mixed. According to the latest DHS, 90% of children are breastfed until the age two years and 64% of children less than age 6 months are exclusively breastfed. However, a mere 21% of children age 6-23 months are appropriately fed based on recommended infant and young child feeding practices. The country has done less well with specific interventions that require relatively higher clinical care, For example, the rate of delivery assisted by skilled birth attendants is only 32%. Chapter 4 examined the mortality differentials in children of different age groups by key social determinants of health (SDH). Our study reported that the mother’s age, parental education, the mother’s autonomy to make decisions about matters linked to the health of her child, the household socio-economic conditions, the geographical region of residence, and the condition of the roads were significantly associated with higher risks of neonatal, infant, and under-five mortality in Bangladesh. Chapter 5 measured the extent of socioeconomic‐related inequalities in childhood stunting and identified the key social determinants that potentially explain these inequalities in Bangladesh. The study reported significant inequality in stunting prevalence in Bangladesh. The negative concentration index of stunting indicated that stunting was more concentrated among the poor than among the well‐off. Our results suggest that inequalities in stunting increased between 2004 and 2014. Household economic status, maternal and paternal education, the health‐seeking behaviour of the mothers, sanitation, fertility, and maternal stature were the significant contributors to the disparity in stunting prevalence in Bangladesh. Chapters 6, 7 and 8 examined the inequities in access to maternal health services (facility delivery and caesarean section) and identified the key social determinants that can potentially explain such inequities. Chapter 6 reported that the use of caesarean sections for delivery is mainly driven by the social determinants of health. Household economic status; women’s education, and neighbourhood prevalence of caesarean sections contributed the most to this socioeconomic inequality. Chapter 7 reported that facility delivery in Bangladesh Nepal and Pakistan is driven mostly by the social determinants of health rather than individual health risks. Household socioeconomic condition, parental education, place of residence and parity emerged as the most critical factors. Chapter 8 reported that there is a substantial amount of variation at the community level in the use of facility delivery services. Among the community level factors place of residence, low concentration of poverty in the community, the high concentration of use of antenatal care services in the community, the high concentration of media exposure and high concentration of educated women in the community were found to be significantly associated with facility delivery. Among other individual and household level factors maternal age, educational status of the mother, religion, parity, delivery complications, individual exposure to media, individual access to antenatal care and household socioeconomic status showed strong association with facility delivery. Chapter 9 reported the relevance of a set of indicators of social determinants of health in tracking progress in universal health coverage and population health in Bangladesh and three other countries. For most countries, monitoring is possible. However, a qualitative assessment showed that technical feasibility, reliability, and validity varied across indicators and countries. Producing understandable and useful information proved challenging, and particularly so in translating indicator definitions and data into meaningful lay and managerial narratives, and efficiently communicating links to health and ways in which the information could improve decision-making. Chapter 10 tested an intervention package of voice messaging, direct counselling through mobile phones and an unconditional cash transfer for changing perceptions on nutrition during pregnancy and first year of the child’s life. The study aims to assess the feasibility and acceptability of an integrated package of nutrition counselling, and unconditional cash transfers all on a mobile platform for changing perceptions on nutrition during pregnancy and the first year of the child’s life. The study was a mixed method pilot study with 340 women. The women were either pregnant or lactating. The intervention consisted of an unconditional cash transfer combined with nutrition counselling both delivered on a mobile platform. The participants received BDT 787 per month and a mobile phone. The nutrition messages were delivered by a voice messaging service. Additional nutrition counselling were provided by a nutrition counsellor from a call centre. The poor rural women were interested both in voice messages and direct counselling. Most women reported that they had no problem in operating the mobile phones and listen to the voice messages. There were also able to interact freely with the counsellor. Charging of the mobile handsets posed some challenges. No significant barriers were identified with the use of mobile banking for cash transfers. Regarding the use of cash, our study reported that one of the highest priorities for low-income families was purchasing food. Chapter 11 describes the study protocol of a cluster randomised controlled trial that aims to assess the impact of a cash and nutrition counselling based interventions, randomised among villages with an objective of improving the nutritional status of children less than two years of age to reduce stunting. The proposed trial will provide high-level evidence of the efficacy and cost-effectiveness of a behaviour change communication intervention combined with unconditional cash transfers in reducing child undernutrition in rural Bangladesh. This trial of an innovative approach to enhancing the impact of cash transfers on child nutrition will be a leading study to guide future policies about how to reduce inequalities in child undernutrition in low income and food insecure populations. Conclusions: Health equity is considered as a critical component of progressive achievement of universal health coverage as part of the Sustainable Development Goals (SDG 3). The results of the research presented in this thesis demonstrate the importance of reducing the inequalities in social determinants of health to reduce socioeconomic inequalities in health and nutrition outcomes. There is no simple solution to tackle inequalities in the social determinants of health. The mechanisms producing social hierarchy are different in different settings so there is no strategy that will be effective for every socio-political context. It is now well established that contextual factors that produce the social hierarchy or social stratification are within people’s control. There are evidence-based actions that can address the determinants of health inequities adequately, and such steps are politically achievable. Policymakers should not limit their focus towards intermediary determinants but also try to tackle the underlying structural determinants of health inequalities. A coordinated multi-sectoral approach will be needed to combat the inequalities in the social determinant of health.

Children with autism are at an increased risk of experiencing coping challenges in healthcare environments. Since Child Life Specialists [CLSs] seek to maximize development and coping in hospitalized children, their understandings of autism are key to intervention. To better understand CLSs' perceptions of autism, this researcher surveyed 126 CLSs using a combined qualitative and quantitative questionnaire. CLSs were expected to express both strengths-based and deficit-based perceptions of autism, with more strengths-based perceptions from CLSs with education or training in disability or access to a special educator. Overall, participants expressed more strengths-based sentiments. No differences were found among CLSs based on education or access to a special educator. However, having a relative with autism was associated with more positive feelings about autism. Additionally, participants drew from child life theory; education, training, and experience; and their understandings of autism to inform their interventions with this population. This research adds to the current literature on perceptions of disability among healthcare professionals and opens the door for future research on how those perceptions are established.

Thesis (M. S.)--Public Policy, Georgia Institute of Technology, 2010.
Committee Chair: Susan E. Cozzens; Committee Member: Barbara D. Lynch; Committee Member: Marilyn A. Brown. Part of the SMARTech Electronic Thesis and Dissertation Collection.

The home is supposed to provide support and safety for children but can also be the place where children suffer abuse and other adverse treatment by their parents. Violence against children in homes has been banned in Sweden for more than 30 years but it is still a considerable problem in the society and a threat to public health. The overall aim of this thesis was to create comprehensive knowledge of the phenomenon Child Physical Abuse (CPA) in Sweden after the ban on corporal punishment. The focus has been on examining the characteristics of cases reported to the police as well as self-reported CPA, prevalence of CPA and finally associations between CPA and health-problems/risk-taking behaviors among adolescents. Two samples are used in this thesis. The first comprises cases reported to the police during 11 years (n=142) in a Swedish police-district and the second is a population-based youth survey of the total number of pupils in three different school grades (13, 15 and 17 years old) in Södermanland County, Sweden. Cases of severe abuse constituted 14 % of the total number of cases reported to the police. The main difference between the group of severe cases and the remaining was the higher occurrence of convictions in court in the severe cases and the pattern of reporting to the police. The severe cases were reported by agencies to a greater degree than minor cases. Cases of severe abuse were characterized by an accumulation of risk factors in different areas as perpetrator factors, stress- and strain factors, factors of insufficient social network and finally child-related factors. In the cross-sectional study a prevalence of 15 % was found for self-reported CPA (n=8 494). There were associations between risk factors in different areas and abuse and there was a dos-response relationship between risks and reported abuse. It was shown that children who reported parental intimate-partner violence were at considerably higher risk for CPA than other children and that only 7 % of the children exposed to violence had disclosed this to authorities. The study of associations between health and risk-taking behaviors, were performed among the 15 and 17 years old pupils (n=5 933). Associations with health-problems and risk-taking behaviors were shown and the associations became stronger when the pupils reported repeated abuse. Finally there was a cumulative effect of multiple abuse in the form of being exposed to child physical abuse plus other types of abuse (parental intimate partner violence, bullying and being forced to engage in sexual acts) and the associations increased with the number of concurrent abuse.