Browsing by Subject "Global health"

Now showing 1 - 2 of 2
  • Thumbnail Image
    Item
    HIV-associated Cryptococcal Meningitis in sub-Saharan Africa: Factors affecting short and long-term survival
    (2013-09) Rolfes, Melissa
    Cryptococcal meningitis (CM) is a wide-spread, yet under-recognized, fungal opportunistic infection occurring primarily among people living with advanced HIV/AIDS. While vast advances in understanding the pathogenesis and treatment options for CM have reduced mortality, major gaps remain in understanding factors that contribute to mortality rates of 12-20% in the first two weeks. The intent of this dissertation was to contribute towards the efforts to address these gaps and provide evidence that could further improve short and long-term recovery from HIV-associated CM in sub-Saharan Africa. The first paper was focused on mortality in the days after CM diagnosis and understanding whether lumbar punctures (LPs) to reduce intracranial pressure also reduce mortality. Raised intracranial pressure is common in CM patients and contributes to many of the disease's signs and symptoms. Two hundred forty-eight HIV-positive, CM patients from Uganda and South Africa were evaluated for the occurrence of therapeutic LPs and mortality within 11 days of CM diagnosis. Analysis was conducted using a marginal structure model, with time-varying exposure. The results suggest that undergoing at least one repeat LP reduced 11-day mortality by 69% (95% CI: 18% to 88%), adjusted for heart rate, CSF fungal burden and altered mental status. This beneficial effect was independent of the baseline CSF opening pressure, demonstrating that increases in intracranial pressure may be common among all CM patients and that all patients may benefit from an additional LP during initial therapy. The second paper was aimed at investigating baseline demographic and clinical features predictive of CM treatment success. The recommended initial treatment regimen for CM rapidly reduces infection; however, nearly 50% of CM patients will continue to have viable fungus in their central nervous system at the end of therapy. Being able to predict patientutcomes has many advantages including optimizing treatment for each patient and reducing drug toxicities. One hundred seventy-seven HIV-positive, CM patients undergoing 2 weeks of antifungal treatment, including amphotericin B and fluconazole, were evaluated for sterility of a CSF culture by the end of therapy. The baseline CSF quantitative fungal burden was a strong and practical predictor of achieving CSF sterility, along with the rate of fungal clearance over the first week of treatment, and the baseline hemoglobin. Information on the baseline burden of infection could be used to tailor the duration of treatment, thus avoiding unnecessary toxicity and treatment costs for individuals with a lower burden of infection and potentially shifting resources to allow for more aggressive treatment of high-risk patients. The third paper aimed to understand the consequence of residual fungal infection at the end of initial antifungal therapy in terms of mortality in the first weeks and months after 2-week therapy ends. Among 154 HIV-positive individuals surviving the initial 2-week phase of therapy, there was no evidence that either the presence or the amount of residual cryptococcal infection in the CSF had an association with mortality in the following 3 weeks or 6 months. It is possible that a higher dose of fluconazole used at the end of amphotericin therapy in the present cohort may have contributed to the lack of association. The objective of this dissertation was to expand the understanding of CM treatment and recovery in resource-limited settings. The results suggest that additional benefits could be gained from the use of therapeutic lumbar punctures during the acute phase of treatment, the possibility of customizing therapy to further reduce treatment toxicities, and, finally, describing the relationship between residual infection and CM mortality with indirect support for higher doses of fluconazole during subsequent phases of CM therapy.
  • Thumbnail Image
    Item
    Well-Being, Community Development, and Andean Worldview: An Analysis of Meanings and Changes in Pedro Moncayo, Ecuador using Photovoice
    (2019-04) Fricas, Jennifer
    The goals of the research presented in this dissertation were to understand and analyze how communities in Andean Ecuador think about, initiate, and engage with their own community development. The study focused on health-related community development and its findings contribute to broader debates about what constitutes development and about how community members act as agents of their own development. The findings also resist the traditional discourse and practices of international development and complicate the ways in which U.S. university faculty educate students about global (health) development. The study was framed by decolonial theoretical approaches and the notion of cosmovisión Andina – an epistemology of the south – which I bring into conversation with the capability approach. Data collection was informed by ethnography, community-based participatory research, and the visual arts. The data collection method was photovoice, a form of participatory photography which enables co-researchers to build capacity in basic photography, after which they engage with the themes under investigation by capturing photos of parts of their daily lives and belief systems, which they then choose to bring forward for further explanation, discussion, and debate. I spent a total of four and a half months in Cantón Pedro Moncayo and during this time I also employed the ethnographic research methods of participant observation, interviewing, and document review. The study findings are presented here in two separate results chapters, the first of which deals with the characteristics of sumak kawsay/buen vivir, the way they appear in and condition everyday life, and the ways in which they have changed in the last two decades. These findings are analyzed in terms of embodiment, which can be thought of as a way of looking at the interaction between human bodies and their environments by regarding the body not just as an object, but an existential ground for culture. Embodiment presupposes certain ideas that also align with principles of Cosmo vision Andina, such that the human being is social and intersubjective, living in a community and an environment simultaneously, as well as within an evolving historical context. Particularities of embodiment appeared repeatedly in the co-researchers’ explanations of what it means to actively enact a good life and how these meanings are under tension, changing, and continually negotiated with a context of various internal and external development-related pressures. The second results chapter pertains to modes of participation and area programs and services which either operate to help co-researchers live in alignment with sumak kawsay/buen vivir or need improvement in order to do so. These study findings point to the ways in which co-researchers and their communities simultaneously work to produce and survive community development. What emerged was an interesting tension between the scale of services (both among governmental levels and within areas of parishes), citizen involvement in services, and their perceptions of the utility of their involvement. Issues of scale and friction help to problematize the effectiveness of sumak kawsay/buen vivir at a national versus a hyper-local scale and shed light on the sources of and possible solutions to frustrated development aspirations and cross-level community development collaboration. This study produced a number of implications for the fields of international development, global health, and U.S. higher education teaching and research in these disciplines. First, the study reinforces the need for a discourse and practice of development which centers hyper-local development, which is better aligned with the epistemologies and praxis of indigenous knowledges and represents a refusal of being coopted into discourses of sustainable or participatory development. Second, those working in health and development nonetheless need to expand their notions of what constitutes well-being. An enlargement of notions of well-being which is more aligned with the embodied characteristics of sumak kawsay counters the narrowmindedness of traditional economically-based notions of development. Third, and based on the previous two points, I argue that we must actively resist the single narrative of development and the single narrative of well-being in U.S. higher education institutions. Finally, I outline the ways in which visual research methods hold unique possibilities for advancing active participation and additional understanding of indigenous knowledges of well-being and practices of hyper-local development. I also outline the challenges which stem from an international, participatory, visual arts, and cross-language research study and how I dealt with these. What all of the study implications share is a decolonial focus on the absolute necessity of coupling concepts and praxis in resistance to the status quo, whether that be in development practice, health practice, teaching practice, or research.