자료유형  

 학위논문

Control Number  

0016933223

International Standard Book Number  

9798379910006

Dewey Decimal Classification Number  

614

Main Entry-Personal Name  

Baynes, Colin.

Publication, Distribution, etc. (Imprint  

[S.l.] : University of Washington., 2023

Publication, Distribution, etc. (Imprint  

Ann Arbor : ProQuest Dissertations & Theses, 2023

Physical Description  

1 online resource(158 p.)

General Note  

Source: Dissertations Abstracts International, Volume: 85-01, Section: B.

General Note  

Advisor: Sherr, Kenneth.

Dissertation Note  

Thesis (Ph.D.)--University of Washington, 2023.

Restrictions on Access Note  

This item must not be sold to any third party vendors.

Summary, Etc.  

요약Although on the decline, the global burden of preventable child mortality remains concentrated in sub-Saharan Africa. In recent decades, governments in the region have sought to ameliorate this disparity by introducing numerous evidence-based interventions known to improve child survival. In Tanzania, these strategies were effective, as evidenced in 2015 by the country's achievement of the child survival Millennium Development Goal (MDG). Contemporaneously, however, fertility levels in Tanzania stalled despite anticipation that a transition would ensue in the wake of widespread child mortality reduction. Understanding the determinants and mechanisms through which child survival interventions in Tanzania achieved impact can guide strategy to address global inequalities in child mortality risk. Furthermore, knowledge about how mortality and fertility processes are linked in the context of rural Tanzania in the MDG era (2000-15) can help programs influence the course of population change in this region. In this dissertation, we bridge theory and methods from demography and implementation science to address those objectives. In Chapters 2 and 3, we use data from a cluster-randomized trial of the impact of a community-health worker (CHW) program that was conducted from 2011-15 in rural settings of Tanzania that comprised sentinel areas of the Ifakara and Rufiji Demographic Surveillance Systems (HDSS). The first paper uses data from a 2011 facility survey that quantified the implementation of maternal, newborn and child health (MNCH)-related inputs at the health facility level. We combined weighted-additive methods, principal components analysis and Bayesian mixed effects modelling to reduce these data into three scales of the implementation strength exerted by groups of facilities on communities from which their clients came. We linked these scales to longitudinal data on the survival of children that were born in these communities in 2011 and followed up through 2015. We fit survival time regression models which reported that increases in the strength of MNCH implementation gauged by two scales were associated with child mortality risks that were appreciably lower. We conclude that strong implementation of MNCH services can enhance child survival, and that routine data from facilities can be used to detect small area inequalities in the effectiveness of MNCH coverage and to measure the impacts of health systems strengthening. In Chapter 3, we report on a mixed methods analysis that explains the outcomes of the CHW intervention. Program effects on MNCH service utilization, childhood morbidity and sick childcare seeking were evaluated using difference-in-difference regression analysis with outcomes measured through pre- and post-intervention household surveys in intervention and comparison trial arms. A qualitative process evaluation was conducted from 2012-2014. The CHW program reduced incidence of childhood illness and improved access to timely and appropriate sick childcare; however, there was no effect on MNCH service utilization. The positive outcomes were achieved through mechanisms that triggered high levels of acceptability of CHW among community-members, and motivation and confidence of the CHW. Implementation factors that generated these effects were related to the engagement of communities in program startup; the training, remuneration and configuration of supervision and support to the CHW from the health system and community. Null results were attributed to the fragile health systems context and health systems' limited capacity for strategic change. We conclude that strategies that strengthen and align communities' and health systems core capacities, as well as their ability to learn, adapt and integrate evidence-based interventions, are needed to maximize the MNCH impact of CHW. Our third paper, in Chapter 4, we employ generalized hazard regression analysis to examine the fertility response to child mortality using longitudinal data compiled by the Ifakara and Rufiji HDSS from 2000-2015. The analysis adjusts for individual and contextual covariates, including annual cluster-level child mortality rates. Results show that child mortality accelerates parity progression. Time to conception is most reduced if a child dies during its subsequent birth interval, representing the "replacement" effect of child loss on fertility. Deaths occurring during prior birth intervals were, to a lesser magnitude, associated with accelerated time to conception during future intervals, which is consistent with hypothesized "insurance" effects of anticipating future child loss. Investigation of interactions suggests that contrary to evidence from similar studies and expectations raised by classical demographic theory, insurance effects on fertility tend to be greater, and replacement effects lower, in communities in which child mortality is relatively rare. We conclude that future research should interrogate this finding and generate evidence on ways that programs can optimize women's opportunities and abilities to adapt their fertility intentions, and achieve them, in the context of demographic change in transitional societies, like Tanzania.  

Subject Added Entry-Topical Term  

Public health.

Subject Added Entry-Topical Term  

Demography.

Subject Added Entry-Topical Term  

Health care management.

Subject Added Entry-Topical Term  

Obstetrics.

Index Term-Uncontrolled  

Child survival

Index Term-Uncontrolled  

Demography

Index Term-Uncontrolled  

Implementation science

Index Term-Uncontrolled  

Maternal and child health

Index Term-Uncontrolled  

Tanzania

Added Entry-Corporate Name  

University of Washington Global Health

Host Item Entry  

Dissertations Abstracts International. 85-01B.

Host Item Entry  

Dissertation Abstract International

Electronic Location and Access  

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Control Number  

joongbu:639300