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Abstract: Background Globally, maternal mortality remains a significant public health problem. In order to reduce maternal mortality, emergency obstetric care (EmOC) must be available and accessible to all women. EmOC refers to the services used for the treatment of complications that arise during pregnancy and childbirth. One EmOC indicator, as per the WHO, is that Caesarean sections (CS) as a proportion of all births should be between 5% and 15%; morbidity and mortality rates rise significantly beyond this range in many countries in the world. Worldwide, CS rates have been rising in the last several decades in developed and developing countries. The Ethiopian national CS rate is low at 1.5%, while in Addis Ababa, the capital city, the CS rate is 21.8%. The difficulty with instituting interventions to modify CS rates is that more information is required concerning both the indications and the appropriateness of surgical delivery. The WHO has concluded that the Robson classification system is the most appropriate classification system of indications for CS for international use. A major limitation of the Robson system is that it does not account for the urgency of the CS. Combining the Robson criteria with urgency criteria provides a more useful tool to analyze and compare CS performed globally. Objective The objective of this study was to analyze Caesarean section rate trends and maternal and perinatal outcomes in a specialized hospital in Ethiopia, a low-income country. Methods This was a retrospective cohort study of deliveries at an Ethiopian national specialized hospital in the Ethiopian calendar years 2002-2006 (between Meskerem 1, 2002 and Pagume 5, 2006; the equivalent period in the Gregorian calendar is September 11, 2009 to September 10, 2014). Cluster sampling of all deliveries of gestational age ≥ 28 weeks in this period was used (N=4,816). Women were categorized into one of 10 Robson groups. All mothers who delivered by CS were assigned into one of four urgency groups: Emergent, Urgent, Scheduled, Elective. Maternal morbidity rate was used to characterize maternal outcomes. The perinatal mortality and perinatal distress rates were used to characterize perinatal outcomes. Results The total CS rate rose from 24.5% in 2002 to 32.8% in 2006 (p= 0.001). An increase in the rate of referral by health care workers and a decrease in hospital instrument deliveries can partially explain the increase in CS rate. Within Robson groups, the only group which had a statistically significant change in CS rate in the 5-year time period was Robson group 1 (Nulliparous women with a single cephalic pregnancy, at greater than or equal to 37 weeks gestation in spontaneous labour) (15.9% in 2002 to 24.1% in 2006; p= 0.02). For nine of ten Robson groups, the largest urgency subgroup was the Scheduled group. The overall maternal morbidity rate increased from 3.5% in 2002 to 4.1% in 2006, with higher morbidity rates in the middle years (p= 0.02). The perinatal mortality and perinatal distress rates did not significantly change over time. Conclusions The overall CS rate at SPHMMC significantly increased. Low-risk nulliparous women are the most significant contributors towards the overall CS rate at SPHMMC, followed by women who had a previous CS. The majority of CS performed were done for women requiring an early delivery, and not on an ‘emergent’ basis. The maternal morbidity rate increased slightly over time, but perinatal outcomes did not significantly change from 2002 to 2006. Despite little evidence of increased complications, increased use of CS without medical indications can result in harm as well as unnecessary drain on limited health care resources. Evidence-informed interventions to reduce both primary and repeat CS need to be studied and implemented at this Ethiopian hospital.

Abstract: Tuberculosis (TB) incidence in the Indigenous people of Canada continues to be disproportionately higher than that of the non-Indigenous and foreign-born people. For more than a decade, the rate of TB in the Indigenous people of Canada has remained relatively constant despite recent population growth. Most researchers have speculated that demographic and geographic risk factors along with the colonially and historically rooted poor social circumstances are associated with the ongoing transmission in the Indigenous people, thus raising concerns for TB control efforts. This thesis combined conventional and molecular DNA fingerprinting of Mycobacterium tuberculosis isolates to (1) identify and describe the demographic and geographic characteristics of all transmission events from Canadian-born pulmonary TB cases on the Prairie Provinces in 2007 and 2008; and (2) describe the predictors of new infection and secondary cases based on host, environmental, and behavioral characteristics of the transmitters. We found that transmission was most common from Registered First Nations potential transmitters who resided in reserve communities. Recent infection was slightly higher in contacts with reportedly lower exposure to the transmitter, but active disease was most notable in the infected close contacts. A significant proportion of transmission events suggested extensive geographic mobility between the residence of transmitters and their contacts, which poses a considerable challenge to jurisdictionally contain TB transmission. Upon further investigation, the likelihood of observing a transmission event was significantly greater in transmitters with advanced stages of pulmonary disease and in those that resided in households with poor ventilation. In light of these findings, it is clear that provincial TB control programs must strive to prioritize the demographic, geographic, clinical, and social determinants in the Indigenous people of the Prairies. Collaborative effort of healthcare workers, educators, and community leaders is required to disrupt the chain of transmission in this population group, whilst acknowledging traditional Indigenous values.

Abstract: Background: The impact of the wide-spread availability of antiretroviral therapy (ART) on the sexual behaviour of the general population who are not on ART in African countries is understudied. Additionally, there are concerns of a return to risky behaviours by people on ART or increased opportunities for the general population to continue to engage in risky behaviours. The purpose of this study was to assess whether the fear of contracting HIV/AIDS had reduced in the era of ART and to describe the culture of HIV prevention among the general population in Rwimi sub-county, Kabarole District, Western Uganda. Methods: A cross-sectional random cluster survey and a focused ethnography were conducted in Rwimi. We administered survey questions to 639 participants between June and August, 2013. We assessed whether the availability of ART has reduced the fear of HIV. In addition, we also assessed participants’ knowledge of and attitudes towards HIV/AIDS and current prevention practices. Logistic regression was used to assess associations for the outcomes general fear and personal fear of HIV with demographic variables and some knowledge measures. We carried out four focus group discussions. Data was collected in the local language, Rutooro, audio-recorded and thereafter translated and transcribed into English and analysed using content analyses. Results: The majority of participants felt that the availability of ART had reduced the fear of contracting HIV/AIDS in the community (89.4%; 95%confidence interval [CI]: 86.9–91.7%). No statistical difference was found for this outcome and any knowledge measures or demographics in logistic regression modelling. In contrast, few participants (22.4%; 95%CI: 17.7-25.6%) mentioned that their personal fear of the disease had reduced with the availability of ART. Participants who had at least a secondary level education had a lower odds (OR=0.29, p=0.022) of reporting a personal reduced fear; but those who were aware of the negative effects of ART had a higher odds (OR= 1.72, p= 0.047) of reporting reduced personal fear of HIV/AIDS. Overall, the majority of participants (94.1%; 95%CI: 93.8-97.1%) were still fearful of contracting HIV/AIDS. Participants generally expressed a positive attitude toward HIV/AIDS prevention practices, but the mode of prevention practiced were influenced by factors such as policy, gender-based perceptions and trust in their relationships. Conclusions: The fear of contracting HIV/AIDS still persists, although participants perceived other people as being less fearful than they were of the disease because of the availability of ART. Additionally, although the community is considerably knowledgeable about HIV/AIDS and the fear of HIV is still present, condom use as a prevention practice remains surprisingly low. There is the need to take into account socio-cultural influences such as gender-based perceptions; relationship dynamics such as power structure and trust; and socio-economic factors that play into HIV prevention in designing sustainable programs that encourage adherence to prevention practices.

Abstract: Adherence to antiretroviral therapy is critical to treatment success. Using an epidemiological and community-based participatory research approach, my thesis reports on two papers related to antiretroviral therapy success (and subsequent failure). My thesis also includes a third paper which discusses an effective and appropriate knowledge translation plan. In the first paper, I used logistic regression to compare initial treatment success among treatment-naïve HIV-positive individuals cared for at the Northern Alberta HIV Program. For individuals achieving initial treatment success, I used survival analysis to determine the probability of subsequent treatment failure. Results showed that compared to Canadian-born, non-Aboriginal patients, the odds of achieving initial treatment success were similar for foreign-born patients and significantly lower for Canadian-born Aboriginal patients. Of those individuals who achieved initial treatment success, compared to Canadian-born, non-Aboriginal patients, foreign-born and Canadian-born Aboriginal patients had similar rates of treatment failure. I concluded that HIV clinicians, researchers, HIV community services organizations, and HIV-positive individuals, work together to better understand adherence to antiretroviral therapy. As such, my second study used focused ethnography to understand, from the perspective of HIV-positive individuals who maintain adherence to their antiretroviral therapy, reasons for antiretroviral therapy success. I conducted one-on-one interviews with 14 individuals with “chaotic” lives (e.g., unstable housing, substance use, involvement in the sex trade, and incarceration) but who nonetheless had demonstrated sustained adherence to antiretroviral therapy and involved a ‘grand tour question’; “what is your secret for taking your HIV medication all the time?”. My data revealed “control” as the cornerstone for maintaining adherence. Participants felt that while they had little or no control over their life circumstances they recognized that, by taking their ART, they could have control over their HIV treatment, which enabled them to make additional positive life changes. The third paper is a commentary describing my knowledge translation plan (a video and peer-educators) to move the knowledge generated from the previous project into action. My evaluation of this knowledge translation plan emphasized the importance of “humanizing” the experience of ART adherence; peer-educators became local HIV medication “celebrities” to their peers. Together, the findings from this thesis consider antiretroviral therapy in a new light by emphasizing success; clinicians must be aware of the extent to which individuals believe they can control their HIV treatment and incorporate support for this sense of control in efforts to improve adherence.

Abstract: A community-based antiretroviral therapy (CBART) program has been operating in Rwimi sub-county in Western Uganda since 2005. The purpose of this study was to evaluate whether this CBART program led to increased knowledge and awareness of HIV and ART, improved attitudes towards people living with the disease, and improved HIV prevention practices in the broader community. Surveys and focus group discussions (FGDs) were carried out from September to December 2009 with 405 residents of Rwimi sub-county and 193 adult residents of a nearby sub-county without a CBART program. Logistic regression was used to describe associations with ART knowledge, HIV/AIDS-related attitudes, HIV testing, and condom use. Residents of Kisomoro had more positive results in all areas. However, in the multivariable models this was only statistically significant for HIV/AIDS-related attitudes. Findings from the FGDs confirmed that, overall, the CBART program did not appear to significantly increase HIV/AIDS knowledge, attitudes, and prevention practices.

Abstract: Immigrant-receiving countries like Canada must meet the challenge of tuberculosis (TB) in their foreign-born populations. One puzzling question is why, despite fluctuating levels of immigration from high incidence source countries, only modest variations in foreign-born TB incidence have been reported for decades. An additional concern is the disproportionate reactivation of latent TB infection (LTBI) in certain groups within this population. Despite these factors, routine screening for LTBI has not been widely implemented, primarily due to concern regarding cost-effectiveness. Another issue related to foreign-born TB is the potential importation of hypervirulent strains and/or strains with increased transmissibility. It is frequently speculated that the Beijing family of strains is included in this category. If true, TB resulting from Beijing strains could impact national TB control efforts. This thesis aimed to (i) explain the relative constancy of TB incidence in the foreign-born in Canada by examining the trends in TB incidence among immigrant groups; (ii) identify high-yield target groups for routine screening for LTBI; and (iii) determine whether Beijing strains constitute an increased public health threat relative to other genotypes in Alberta, Canada in terms of infectiousness, drug-resistance and transmission. These investigations found that relative constancy in foreign-born TB incidence is explained by a complex convergence of factors, including annual immigration levels, age at arrival, country of birth, and time since arrival. Consequently, immigrants ≤2 years post-arrival who were aged 15-35 years at arrival and born within countries with TB incidence rates >50/100,000 population were recommended as high-yield targets for the screening for LTBI. In Alberta, Beijing strains had similar disease presentations as non-Beijing strains apart from the former having significant associations with polyresistant-TB and multidrug-resistant TB as well as an association of borderline significance with respiratory TB. Beijing strains also had no greater of an association with recent transmission than non-Beijing strains in Alberta. The high global prevalence of TB, the emergence of extensively and totally drug-resistant TB, and unprecedented levels of human migration indicate that immigrant-receiving countries will be challenged by TB in their foreign-born populations for the foreseeable future. Serious consideration must be given to the implementation of effective screening strategies.