Global Health in the Humanities

Tools and methods for zika prevention in Cachoeira, Bahia

Florence Tesha

March 20, 2017

Zika virus, which is mainly transmitted by Aedes aegypti and Aedes albopictusmosquitoes, has become a major health threat in Latin American countries, especially in Brazil. Zika has also been associated with microcephaly, an infant brain abnormality. This project aimed to investigate the various tools and methods employed by the rural health centers in Brazil to prevent zika. The results of the study show that education and house visits by community health workers are the main tools used by these health centers. Rural health centers are also not as equipped as urban centers in the fight against zika. As the virus evolves genetically and habitually, rural areas are at a high risk for future outbreaks.

Background on zika virus

Zika virus (ZIKV), which is a mosquito-borne flavivirus, was initially isolated from a rhesus monkey in the Zika forest in Uganda in 1947. ZIKV circulated in other parts of Africa and Southeast Asia for decades, leading to no serious adverse outcomes or reports of outbreaks (Bell 2016; 589). The ZIKV outbreak in Brazil began in early 2015 and the vast majority of outbreaks are happening in the areas affected with dengue and chikungunya (Bell 2016; 590). In December 2015, Brazil reported preliminary estimates of 440,000 to 1.3 million cases of zika infections (Mlakar, 2016: 1). The transmission of zika has crossed borders and is now reported in other territories in Latin Americas, Cape Verde and the Pacific Islands (Bell 2016; 589).

Although zika affects people of all ages and gender, attention is focused in preventing ZIKV infections in pregnant women because growing evidence suggests an association between maternal ZIKV infection and infant brain abnormalities such as microcephaly (Bell 2016; 588). Microcephaly is a birth defect whereby a baby is born with a small head or the head stops growing after birth. Microcephaly can develop developmental disabilities due to poor brain growth of the baby (Facts 2016). Severe microcephaly can be life threatening; however, milder forms of microcephaly can lead to a child developing seizures, vision problems and intellectual disabilities. The major concern about microcephaly is that there is no vaccine or treatment, and the problems associated with it are often lifelong (Zika 2016). Additionally, the other problems detected among fetuses and infants infected with ZIKV before birth are absent or poorly developed brain structures, defects of the eye, hearing deficits and impaired growth (Questions 2016).

According to the 2016 World Health Organization (WHO) report on the ZIKV situation in Brazil, between October 2015 and February 2016, there have been 5640 reported cases of microcephaly including 120 deaths. 583 out of 5640 cases of microcephaly are related to ZIKV (ZIKA 2016; 9). In addition, recent reports from the Ministry of Health of Brazil suggest that cases of microcephaly have increased by a factor of approximately 20 among newborns in the northeast region of the country where there are more cases of ZIKV infections, hence indicating a possible association between ZIKV infection in pregnancy and fetal brain malformations (Mlakar, 2016: 2).

This study aimed to investigate the various tools and methods used to prevent and control ZIKV infections in the community by the Center for Endemic Diseases (Centro de Endemias; also known as Policlínica) in Cachoeira town and a rural health center in Alecrim named USF Justiniano de Jesus. Both health centers are funded and operated by the SUS (Sistema Único de Saúde; Unified Health System), Brazil’s publicly funded health care system. The major objectives of the study were to (1) explore the various ways that the urban and rural health care centers in Cachoeira work with the community to provide education of preventative measures of zika, dengue and chikungunya; (2) examine the perception of the health workers on the effectiveness of the methods and tools used by their health centers and the government to control and prevent zika, dengue and chikungunya; and (3) investigate whether there is an increase in the number of women seeking contraceptives after the outbreak of zika due to the scientific assumptions that it may be related to microcephaly and brain anomalies in newborns.

Background of the study location

This study was conducted in Cachoeira, an inland town of Bahia- Brazil, on the Paraguaçu River. The town of Cachoeira is a growing commercial and industrial center. The majority of the population in Cachoeira is young people between the ages of 18 to 45 and there are more women than men. 51% of the area is considered the urban area and 49% is the rural area. The urban area is more densely populated than the rural area. In 2010, the life expectancy of Cachoeira was approximately 70.7 years (Souza, Andréa; lecture March 2016). Cachoeira provides all primary and basic health services for everyone through the Family Unit Program. Families with a poor/low income receive support from the program of Bolsa Família as long as they fulfill the required conditions. One of the health conditions required under Bolsa Família includes getting vaccination.

Cachoeira is one among the many places in Brazil affected by zika infections with a few cases of microcephaly. I specifically chose to do this project in Cachoeira because it is less populated compared to big cities like Salvador, and thus there are more opportunities to interact with the health care workers since the hospitals are not always busy or full of people. The SIT, Salvador program’s relationship with the Alecrim health center also helped me to establish initial contact with the clinic and thus I had great support from the health care workers. Through the same network of people, I was introduced to the Centre of Endemic Diseases in Cachoeira, which became my second point of contact.

According to the data records of zika at the office of Secretary of Health in Cachoeira, zika cases peaked around the months of June to July 2015, but have been decreasing significantly ever since as can be seen in Figure 1. However, the number of cases reported has begun to increase in the month of March 2016.

The significant decrease in the number of zika cases from the months of July to August 2015 could be due to factors such as (1) weather changes, which affect the natural habitats of the mosquitoes; (2) intense and aggressive preventative measures that began to be implemented; or (3) changes in people’s behavior in trash management and proper maintenance of the environment. If the main factor for the decrease was weather patterns, then the number of zika cases reported is expected to rise significantly beginning April 2016 to July 2016, despite the preventative measures in place. If the number of zika cases continues to drop or rises slightly, then the sharp decrease would suggest successful implementation of the preventative measures against zika infections.

Figure 1. The number of zika reported cases in Cachoeira Municipal from April 2015 to March 2016 is shown.


All the data in this project was collected through questionnaires and informal interviews using the local language Portuguese. A total of 30 questionnaires were distributed. All the questionnaires were returned except 1 in Alecrim, and thus a total of 29 questionnaires were returned. The questionnaires used are reported in the appendices.

Participants and Selection Process

The main participants of this project were health care workers because they are the one’s responsible for organizing and/or conducting and implementing any events/training/programs of infectious disease prevention in the community. One of the secondary goals of this project is to evaluate the workers’ knowledge and perception of zika and the current zika related programs.

The Alecrim health center and the Center for Endemic Diseases in Cachoeira serve many people and thus the health workers have accumulated experience with community related programs. In addition, most of these workers have been working with the community to control and prevent dengue and chikungunya, which are also spread by Aedes aegypti.

All the participants were selected randomly through the connections of personal contacts. Some of the questionnaires stayed with the clinic’s receptionist and any health worker who wanted to participate in the project could take a questionnaire and return it to the receptionist. I collected the filled in questionnaires from the receptionist and individuals, depending on their preference.

Results and Discussion

The total number of health care workers who responded to the questionnaires was 29, with 24 females and 5 males. 78% of the respondents were between the ages of 30 to 49 years. Only 9% were between the age of 18 to 39 years and 13% were above 49 years old. Among the 29 participants, 18 had worked in their current position for more than 5 years, while 11 had experience of less than 5 years.

Knowledge of Zika

The health care workers are one of the primary sources of information for the community about zika and other related infections/diseases. The results of this study show that less than 50% of the health care workers had knowledge of zika above the scale of 5 (1=little/no knowledge, 10=fully knowledgeable). Therefore, more than half of the health care workers do not fully understand the history, causes, effects and prevention methods of zika.

Zika training among health care workers

51% of the health care workers received some form of training or informational session on zika organized by the Municipal Secretary of Health and conducted by medical doctors and nurses. All 29 respondents said that they would like to receive training and/or educational sessions about zika, dengue and chikungunya. This shows that there is demand for training from the health care workers.

Among those that had received training, 78% rated the usefulness of the training they received a 5 on a scale of 1 to 10, 1 being not useful at all and 10 being very useful. These data show that although most of the health care workers received some form of training or educational session about zika, the training was not very informative and effective in preparing them to take the front line in its prevention in the communities.

These results suggest that education and training of health care workers should be made a priority for zika infection prevention. For successful prevention programs, the health care workers need to be fully knowledgeable on the subject so that they can in turn be informants to the community.

Zika Perceptions among the health care workers

Since the outbreak of zika in Brazil, assumptions about the disease have proliferated. Although much research remains to be done concerning zika, preventative measures have already been established and implemented. Interestingly, one of the factors that affect prevention efforts is the perception of the danger or negative effects caused by infection. Thus, in order to evaluate how serious the preventative measures are being taken, one has to evaluate the perception of zika’s effects. Data collected through the questionnaires and interviews indicate that the majority of the health care workers believe zika is a dangerous disease. On a scale of 1 to 10, 10 being very dangerous, 18 out of the 29 respondents rated zika a 10, while none of the respondents rated it below 8. These results may suggest that preventative measures are being taken as recommended because of the perception of zika as a very dangerous disease.

Zika, Microcephaly and Contraception Use

90% of the health care workers agreed that there has been an increase in the number of women seeking contraception’s due to the perceived association of zika to microcephaly. 7% said there hasn’t been any major difference and 3% said that they do not know.

Zika Prevention Methods and Tools

Figure 2. The relative importance of tools and methods used by health centers to prevent and control zika in Cachoeira is shown. The size of each portion corresponds to the perceived effectiveness of the respective tool.

Education was ranked as the most effective tool in the prevention and control of zika, dengue and chikungunya. The work done by community health agents to visit houses and apply the Pyriproxyfen powder, a powder that prevents mosquito breeding in standing water areas, ranked second among the other methods. These data show that the community recognizes the work done by the community health workers and they have seen the positive effects of this work.

Perception of health care workers on the effectiveness of the tools and methods used by their health centers

The health care workers had differing opinions about the effectiveness of the tools and methods used by their health centers in the fight against zika, dengue and chikungunya. 93% of the health workers in Alecrim said they were not satisfied with the tools and methods employed by their health center in the fight against the infectious diseases. On the other hand, about 89% of the health workers at the Center for Endemic Diseases rated the effectiveness of the tools and methods employed by their health center a 5 and above. The Alecrim health center is in a rural part of Cachoeira, while the Center of Endemic Diseases is in the urban part. There are more cases of zika, dengue and chikungunya in the urban areas than in the rural areas, resulting in a greater concentration of efforts in the urban areas. For example, health centers in rural areas like Alecrim do not receive Pyriproxyfen powder to prevent mosquito breeding and thus the community health workers only rely on flyers and other educational materials to spread awareness in the community and in schools.

The concentrated efforts to control zika and other related infectious diseases in the urban areas may have proven to be fruitful as the number of zika cases has decreased significantly since the month of August 2015 to date. However, there is no absolute proof that the decrease has been due to the preventative methods in place. Other factors such as climate and weather conditions may play a major role in the habitats and breeding patterns of the mosquitoes, which transmit the diseases. Research shows that the Aedes aegypti mosquito adapts easily to human environments and like other species, the mosquito is evolving and forming new strains. These new strains are more resistant and may reach rural areas, which are now considered safer than urban areas (Schinrring 2016). Efforts to fight infectious diseases like zika and dengue will need diagonal approaches whereby both the rural and urban areas are well equipped and protected from further outbreaks. As of now, the rural areas are at high risk of an outbreak and this will probably be much harder to control because there are few health resources in the rural areas.

Challenges faced by the health centers in prevention of zika

More than 50% of the health worker respondents listed delay of test results as one of the major challenges facing the health centers in the fight against zika. Once a person arrives at the health center with symptoms, he or she must first be tested for both dengue and chikungunya. Once they rule out both diseases, then the person is confirmed to have zika. The problem is that the molecular testing of dengue, which detects the genetic material of the dengue virus in the blood, takes up to 5 days after symptom onset (fever). Antibody tests, which detect two different types of antibodies produced by the body in response to a dengue fever infection, may take 2 to 4 weeks. The tests for chikungunya are normally available 4 to 14 days after the specimen is collected. Unfortunately, in hot weather climates like Brazil, the reporting times for the test results may take longer because the arbovirus activity increases and thus takes longer to detect. Thus, it may take weeks for a person to be confirmed to have zika, which also affects reporting and planning of control measures.

Perception of health care workers on efforts made by the Brazilian government to control and prevent zika

Data from this research show that about 79% of the respondents rated the government’s efforts to control and prevent zika a 5 and below (10=the government makes great efforts to prevent zika, 1= the government is not making any efforts to prevent zika). However, none of the respondents rated it below a 3, which means they all perceive the government to be making some form of efforts.


The outbreak of zika in Brazil as well as the increase in the number of microcephaly in newborns has been an ongoing discussion among health experts, political leaders and economists. The same mosquito that carries dengue causes zika, and thus the outbreak of zika could suggest that the policies that were in place to fight dengue were not effective and successful. In this case, zika has been a necessary public health wake up call. Brazil’s political system has been unstable with ongoing strikes and protests. Efforts to fight zika will largely depend on leadership, and with the current political instability, a lot is at stake. The economy of the country has also been largely affected after the zika outbreak and with the increased numbers of babies with microcephaly, a lot of money will have to be invested in providing them with the necessary health needs as well as special education.

Due to the increase of congenital anomalies after the outbreak of zika in Brazil and neighboring countries, all member states should establish and maintain heightened capacity to detect and confirm zika cases and introduce public health measures to reduce risk of zika spread and infection.

It is important to ensure that health care providers are knowledgeable and up to date with the latest findings on zika because they play the primary role of care provision to the communities. Similarly, up-to-date information should be well shared among public health, political and religious leaders to ensure appropriate measure and actions are taken.

Limitations of the study

Language: Language barrier was one of the main limitations of this study. My level of Portuguese is still at beginners’ level and thus it was hard to fully understand people when in the field, and it was also difficult to fully participate in related conversations. Due to this, I think there is some important and useful information that I missed during these interactions. This challenge can be overcome by having the ability to speak and understand Portuguese at an intermediate or advanced level. Another way is by having a translator who is fluent in both Portuguese and English.

Time: Four weeks is a short time to fully engage in a new community and community study project. It takes time to get accustomed to a place’s new culture and way of living as well as establish contacts. Thus, although I was able to reach the goals of the project, I was able to do so in a small scale.


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  3. Bell, B. P., Boyle, C. A., & Petersen, L. R. (2016). Preventing Zika Virus Infections in Pregnant Women: An Urgent Public Health Priority. Am J Public Health American Journal of Public Health, 106(4), 589-590. doi:10.2105/ajph.2016.303124
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I thank God in heaven for all the guidance during this project. I also want to extend my warm gratitude to Gabriela Ventura, Dr. Rita Maluf, my host family in Alecrim and my family.

A longitudinal study examining mental health outcomes by gender for orphaned and separated children in Delhi, India

Sriramkumar Sridharan1, Anna Bensley1, Jin Huh1, and Deepthi Nacharaju1

1Duke University, Durham, North Carolina, USA

March 20, 2017

Previous studies indicate that orphaned and separated children (OSC) tend to report worse mental and physical health outcomes than their non-OSC counterparts. As part of a larger body of work, this longitudinal study evaluated the health outcomes within a population of OSC children living within a residential care program in New Delhi, India. Samples of children were randomly selected from eleven gender specific group homes in 2014 (n=89), 2015 (n=82) and 2016 (n=95) and were interviewed using measures of self-concept, peer and guardian attachment, self-concept, depression, ego-resiliency, and trauma symptoms. Here we specifically report on the gender-based variations in the responses of children who remained in our longitudinal sample over all three years of data collection (n=65). We discovered that females consistently performed, on average, worse than their male counterparts on all measures, but most significantly on measures of trauma and depression. Moreover, the 2016 data suggest at least a slight divergence between male and female scores in trauma, depression, and ego-resiliency scores, indicating that female performance on these tasks is worsening while male performance is improving in the longitudinal sample over time. Additionally, attachment scores across both genders are consistently falling, while depression scores remain above the clinical threshold for risk in both 2015 and 2016.


Due to difficult past histories and the various accompanying challenges of residing in an institution, orphaned and separated children (OSC) living in low- and middle-income countries (LMIC) are considered to be a vulnerable population. OSC face a multitude of potentially traumatic events beyond the loss of a parent (Whetten et al. 2011) that can greatly impact mental health outcomes. Previous research suggests that orphan children exhibit lower self-concept and ego-resiliency, greater levels of historical trauma, and increased anxious or avoidant attachment compared to non-orphans (Block & Kremen, 1996; Alessandri et al., 2012; Bryne 1986; Dwyer et al., 2010: Rubin et al., 2004; Belsey & Sherr, 2011; Chapman 1990). These five constructs together help compose a concise snapshot of mental health and thus were selected as measures for our study.

Both self-concept and ego-resiliency are considered to be crucial contributing factors for the construction of social identity. Self-concept is defined in developmental psychology as an “individual’s belief about himself or herself including [his] or [her] attributes and who/what the self is” (Baumeister, 1999). Ego-resiliency is conceptualized as an individual’s resourcefulness and flexibility in the face of unfamiliar or adversarial situations (Wanat et al. 2010). These two constructs could be exceptionally important measures of a child’s development of personal identity and self-confidence. Furthermore, resiliency has been found in some studies to mediate the relationship between past trauma and depression (Ding et al. 2016; Wingo 2010).

Attachment theory historically has focused on the relationship between infants and caregivers when the infant is separated from the caregiver, feels threatened, or is displaying negative affect in order to predict behavior in future relationships (Ainsworth et al, 1978; Bolby, 1969/1982; Main, 2000). Generally researchers have focused on two major classes of attachment types—secure and insecure. Insecure attachment can be further broken down into three types: anxious, avoidant, and disorganized-disoriented. In OSC populations, specifically, measuring the development of a child’s peer and guardian attachment over time and monitoring attachment trends may be an important indicator of how the child is adjusting to the loss of biological family members (Dozier, Zeanah, Wallin, & Shauffer, 2011; van IJzendoorn et al., 2011; van IJzendoorn & Kroonenberg, 1988; Keller, 2013).

Clinical depression is characterized by diminished mood, reduced interest or pleasure in all or most activities, insomnia, fatigue, feelings of worthlessness, and/or retraction from social interactions. Depression symptoms are more prevalent in OSC populations largely due to past traumatic events (PTEs). Depression has been associated with increased morbidity and contributes to decision-making behaviors, especially in adolescents.

In order to further explore the effect of PTEs on present behavior, trauma symptoms were also examined. In the context of vulnerable populations, trauma is often characteristic of mental abuse, physical abuse, sexual abuse, or neglect. Trauma manifests in a variety of symptoms including: anxiety, depression symptoms, phobias, and identity disorders. Due to the increased exposure of risk factors in their environment, OSC tend to express more traumatic symptoms.

The effect of gender on mental health outcome is of particular interest in this study. Although previous studies have explored gender-based variation in mental health outcomes of OSC populations, a clear consensus has not been reached. In fact, despite the heavy emphasis on gender in OSC research, some studies report no significant difference in mental health outcomes between males and females (Gray et al. 2015; Li et al. 2009; Whetten et al. 2011). Because there is little precedent in gender-based OSC mental health research in the context of residential care homes in India, our analysis is heavily focused on gender in order to help describe any gender-based variance that exists within our longitudinal sample.

In continuation of a longitudinal study with a New Delhi-based residential care program, Udayan Care, we measured the mental health outcomes of orphaned and separated children living in residential care. We examined the five aforementioned constructs: self-concept, ego-resiliency, attachment, depression, and trauma symptoms to elucidate trends in mental health outcomes over time and between genders.


Participants: Children across 11 residential care homes were interviewed on various mental health outcomes in the summers of 2014, 2015, and 2016. In 2014, 89 children were randomly sampled from 11 residential care homes (ghars) within Delhi, India based on gender and age characteristics. All children ages 4-8 within the homes were included in the study to have an equal number of participants from each of the three age groups (ages: 4-8, 9-14, and 15-18). Additionally, since 7 of the 11 group homes are female, children were sampled to reflect the overall gender proportions enrolled in the residential home program. The 2016 sample of children (n=95) consisted of 65 children who were previously interviewed both in 2014 and 2015. Furthermore in 2015 an additional mental health construct was assessed, depression. 66 children answered depression related questions in both 2015 and 2016.

Measures: Children were assessed on five mental health constructs—attachment, self-concept, ego resiliency, trauma, and depression—during one-on-one interviews. Inventory of Parent and Peer Attachment (IPPA), Piers-Harris Children’s Self-Concept Scale (PH2), Trauma Symptoms Checklist for Children (TSCC), Ego-Resiliency Scale (ER-89), and Center for Epidemiological Studies Depression Scale (CES-DC) were chosen for their cross-cultural validity or extensive use within the United States. All measures were translated and back translated prior to use for reliability purposes.

Data Analysis: All data analysis was conducted using IBM SPSS Statistics software and Microsoft Excel. In the case of three-year and two-year data, factorial within-subjects ANOVA were used to test for significance (p < 0.05). Raw scores from the Piers-Harris Children’s Self-Concept Scale and Trauma Symptoms Checklist for Children were converted into normalized t-scores for analysis.


Peer and Guardian Attachment: Attachment was separated into peer attachment and guardian attachment and measured using the IPPA for both constructs. Norms are not established for IPPA, but scores range from 25-125 with higher numbers representing greater attachment to either peers or guardians depending on the section. On average across three-years, sampled children show peer and guardian attachment on the upper half of the IPPA scale (midpoint = 75). Peer attachment was higher than guardian attachment during all three years in the longitudinal sample (n=55; p=0.02). Scores for both peer attachment and guardian attachment consistently decreased from 2014 to 2016 (p=0.00 for both). Additionally, males reported higher peer IPPA and guardian IPPA scores than females in 2014, 2015 and 2016, but this effect was not significant (peer: p=0.058; guardian: p=0.109).

Figure 1.Guardian Attachment Scores by Gender.Whole longitudinal sample (n=55; blue) exhibits decreasing guardian attachment (IPPA range is 25 to 125) between 2014 and 2016 (p=0.00). Males (n=20; orange) show slightly higher guardian attachment than females (n=35; green) (p=0.109).
Figure 2.Peer Attachment Scores by Gender.Between 2014 and 2016, IPPA Peer attachment scores (range is 25 to 125) reported from the longitudinal sample show a main effect of time (p=0.00)Males (n=20; orange) show higher peer attachment than females (n=35; green)(p=0.058). 

Self-Concept: Self-concept scores were measured using the Piers-Harris 2 in 2014, 2015, and 2016. Scores from the longitudinal sample (n=64) increased consistently between 2014 and 2016 (p=0.063). Generally, males in the longitudinal sample consistently had higher mean averages than females in the longitudinal sample during all three years but not significantly so (p=0.148). However, both males’ scores and females’ scores increased from 2014 to 2016.

Figure 3.Longitudinal Self-Concept Scores by Gender.Combined sample three-year data for longitudinal sample (n=64; blue) shows a general increase in self-concept (p=0.063). Gender differences are not significant (p=0.148).

Trauma-Symptoms: Trauma related symptoms were measured using the Trauma Checklist for Children (TSCC) during all three years of the study. The TSCC assesses the current posttraumatic stress and psychological symptomology of children who have experienced traumatic events such as violence, abuse, major loss, or natural disasters. The TSCC scores are normalized to t-scores, and scores above 65 are considered to reflect significant risk. The longitudinal sample (n=57) was administered the TSCC in 2014, 2015 and 2016. Mean scores during all three years (2014: 42.1, 2015: 40.4, 2016: 43.3) were under the threshold for significant risk and remained fairly uniform. In all three years, males (n=23) performed significantly better than females (n=34) (p=0.038). Gender specific scores diverged significantly between 2015 and 2016, with females displaying an increase in trauma symptoms and males displaying a decrease compared to 2015 (time by gender interaction p=0.029).

Figure 4.Longitudinal TSCC Scores by Gender.In the longitudinal sample, between 2014 and 2016, females (n=34; green) report more trauma symptoms than males (n=23; orange) (p=0.038) and there is a significant time by gender interaction (p=0.029).

Ego-Resiliency: Ego-resiliency was measured using the ER-89 in 2014, 2015, and 2016. The ER-89 scores are graded as follows using tertiles: very high (47-56), high (35-46), undetermined (23-34), low (11-22), and very low (0-10). Overall, the longitudinal sample (n=26) displayed high average ER-89 scores in 2014, 2015, and 2016. When scores were separated across genders, there seemed to be a convergence effect between 2014 and 2015 and a divergence between 2015 and 2016, with females reporting lower mean scores than males in 2014 and 2016. However across the three years there was not a significant difference between male and female levels of ego-resiliency (p=0.382). The pattern highlights the importance of longitudinal collection because year-to-year trends can be volatile but the overall pattern of males showing higher scores over time provides more insight and confidence in interpreting group and individual needs.

Figure 5.Longitudinal Sample Ego-Resiliency Scores by Gender.Overall longitudinal sample (n=26; blue) and both genders are exhibiting above average ego-resiliency (scores > 44) across all three years. Three-year gender differences were not significant (p=0.382). 

Depression: In 2016, 92 total children were administered the Epidemiological Studies Depression Scale (CES-DC) in order to measure depression symptoms, and the longitudinal sample participants (n=67) were administered the CES-DC in 2015 and 2016. Children who scored above a 15 on the CESD-C are considered to exhibit depression symptoms and are identified as potentially at risk for clinical depression (CES-DC scale ranges from 0-60). These children are typically referred to mental health professionals for further diagnostic confirmation and potential treatment. The 2016 CESD-C scores ranged from 1-54 with a mean score of 20.74 and median score of 21.06. Additionally, 65 out of 92 participants (70.7%) reported scores above 15. Thus, a significant majority of participants scored above the threshold for risk. However, further examination and professional analysis is needed to diagnose and appropriately provide depression support and clinical services.

In the longitudinal sample (n=67) there was a slight increase in mean CESD-C score between 2015 (20.07) and 2016 (21.39). However, this effect was not significant (p=0.496). Mean scores from the longitudinal sample during both years are above the scale threshold for depression. The longitudinal scores were also separated by gender. Females (n=41) had higher CES-DC scores than males (n=26) in both 2015 and 2016 (males [2015: M=19.1154, SD=13.79; 2016: M=18.65, SD=9.20], females [2015: M=20.68, SD=10.18; 2016: M=23.13, SD=10.07]) but were not statistically different (p=0.133). Moreover, the scores appear to diverge in 2016 (i.e. females’ scores increased from 2015 to 2016 while males’ scores decreased slightly).

Figure 6. Longitudinal Sample Ego-Resiliency Scores by Gender.Overall longitudinal sample (n=26; blue) and both genders are exhibiting above average ego-resiliency (scores > 44) across all three years. Three-year gender differences were not significant (p=0.382). 


This longitudinal gender analysis among an OSC population in Delhi, India shows that over three years, females are consistently reporting higher average trauma symptoms, lower attachment, and lower self-concept scores than their male counterparts, though these average differences are not always significant, indicating high variation within gender scores as well. Furthermore, while the CES-DC was only administered in 2015 and 2016, during both years, females reported higher levels of depression than males. These findings suggest that overall males could be outperforming females in mental health outcomes within this residential care environment.

The significance of attachment results is ambiguous. The scores still remain around the norm for the IPPA, and in general, it is natural for children to become less attached to guardians as they age. However, we expected this trend to be paired with increased peer attachment, which is not observed. It has been postulated that high attachment scores actually may represent a compensatory mechanism that arises in children who have experienced difficult backgrounds. In this case, attachment manifests as dependence on others. If this framework is accurate, decreasing attachment scores might actually be positive and could represent a natural transition of maturing.

Gender differences in trauma outcomes may be attributed to differences in internalizing trauma (Goldenson, Geffner, Foster, & Clipson 2007) possibly leading to lower coping behaviors. Females may have initially internalized their traumatic experiences, not facing the mental health ramifications of their past until they reach adolescence. Interestingly, males reported a higher level of peer and guardian attachment, a construct thought to be a protective factor against internalizing trauma.

It is important to note that aside from trauma, none of the gender differences were significantly different. For example, ego-resiliency for both genders across all three years is graded as high on the ER-89 (slight fluctuations may be attributable to normal development patterns). Additionally, both males and females report average scores above the clinical threshold for depressive symptoms.

Our findings thus far tend to support prior studies conducted within OSC populations in LMIC showing female and male mental health to be comparable (Gray et al. 2015). Therefore, it will be important to increase systems of mental health support for both males and females, while taking into consideration gender-based variations for specific mental health constructs such as trauma.

Overall, our results are far more promising than our initial expectations. Both males and females within the longitudinal sample are performing comparably to non-OSC counterparts on all of our measures except for depression and trauma. Accordingly, these data could indicate support for notion that children residing with our organizational partner, Udayan Care, are having success in staying at relatively healthy mental health levels and possibly counteracting some of the mental health detriments associated with OSC populations. Further longitudinal examination of this sample, along with time and past-history based controls will help confirm changes in children’s mental health outcomes and assess the stability of current gender-varied trends.

Because our sample was obtained primarily from group homes within a single organization, it would be difficult to generalize the results of our analysis to the wider population of OSC in India. An expansion of the current mental health literature in India would be invaluable in measuring the results from our partner organization against peer organizations or controlled norms. Mental health awareness in general must be improved in India, especially in the context of OSC, in order to validate the given results and devise solutions for this and other vulnerable populations.


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This research was supported by the Duke Global Health Institute Student Research Training Program. We thank our faculty mentor Dr. Sumedha Ariely for her indispensable guidance and support.  We would also like to thank our community partners Dr. Kiran Modi and Dr. Monisha Nayar-Akhtar for their partnership, backing of our work on the ground, and thoughtful advice. We would like to acknowledge all the Udayan staff for their passion and determination to provide a better future for the Udayan children. Lastly, we are grateful for 2014 and 2015 Duke Student Research Training Program (SRTP) India Teams for collecting 2 years of data that were used for our analysis.

Leveraging Technology and Cross-sector Partnerships to Improve Stroke Care in China

Sahil Sandhu, Lillian Blanchard, Chunxi Ding, Alexandria Hurley, Chelsea Liu, Jackie Xu, Natalie Yu 

February 26, 2018


A lack of coordination in healthcare is a major barrier globally to high-quality care and population health. A health system consists of a diverse set of actors with their own roles and incentives. Health outcomes suffer when different sectors (academia, industry, and government) across distinct levels of care (prevention, treatment, and recovery) do not work together. Although such fragmentation is problematic in the Chinese healthcare system, the prevalence of technology in China has opened the opportunity to connect these stakeholders who can develop new tools to improve communication to provide patient-centered care. Seven members of our Bass Connections team traveled to China during this past fall break to learn more about healthcare infrastructure and the use of technology.

Our Bass Connections team, Global Alliance on Disability and Healthcare Innovation (GANDHI), studies comparative health systems and explores outcomes related to disability after acute hospitalization. This academic year, we are focusing on stroke outcomes in China with the goal of improving transitions across components of the care continuum. These include health promotion and public health prevention interventions in the community, stroke symptom awareness, acute hospital care, rehabilitation therapy, follow-up care in outpatient settings, and home care. To better understand these different levels in the Chinese healthcare system and the different stakeholders addressing healthcare fragmentation, we visited an academic institution, a public hospital, and private health service organization.

Peking University: Electronic Health Records and Disease Prevention Research

To understand preventative care work conducted in China, we visited Dr. Pei GaoDr. Xun Tang, and their research team at Peking University School of Public Health, Department of Epidemiology and Biostatistics. Dr. Gao and Dr. Tang work to improve disease risk prediction models for non-communicable diseases like stroke. They redesign statistical formulas developed in Western settings to fit the Chinese population. Among other sources, they draw data a data system integrated with a regional electronic health record (EHR) from Ningbo, a city just south of Shanghai. Ningbo was one of the first locations selected by the Chinese National Commission of Health and Family Planning to test these new EHR systems. Since the mid 2000s, health centers in Ningbo have been collecting patient data, supplemented with interviews, to create an incredible base for longitudinal cohort studies and mining field for researchers.

While Dr. Gao and Dr. Tang expressed excitement over having access to this data, the barriers they encountered revealed inherent difficulties in collaboration between academia and the healthcare system. For example, government approval to use this data for research has been a slow and laborious process. After finally obtaining permission, the Peking research team had to expend huge efforts to “harmonize” and “tidy” these government-maintained administrative datasets. Due to concerns over patient data security and variation in the type of data collected, administrative data often looks different from research data.

Sometimes, health researchers resolve this discrepancy in data types through double data entry: personnel enter one record for administrative purposes and another intended for a research study. Other times, academics stick to retrospective analyses with the administrative data they have access to, making the best of missing entries and inconsistent measurement methods. In these cases, they have no control over how the data was collected. When asked if Chinese researchers have a role in designing EHR systems, Dr. Gao responded with a “not really” and a chuckle.

As Dr. Gao’s explained all these difficulties with data collection and analysis, we began to realize how messy public health research can be. In our research methods classes at Duke, our professors teach us about the importance of high quality data and designing rigorous studies. Rarely, do we actually talk about realities of the research process and how imprecise it can be. For example, even when researchers can build their own studies, a lack of a consistently trained staff affects data quality. Similarly, selection bias from unenrolled patients taints the applicability of database findings. In China, patients have no financial incentive to answer follow-up questions, and most are wary of calls from unrecognized numbers due to the high presence of fraudulent phone calls. Some research teams are beginning to harness the power of WeChat, a widely popular and all-encompassing mobile messaging app (similar to Facebook’s Messenger in the United States) to collect follow-up information.

Our visit at Peking University revealed the need for greater collaboration with other sectors of healthcare and for new technology to drive high-quality data collection. The quality of stroke prevention research in China would greatly improve if researchers could work prospectively with clinicians and government to determine how health data is collected.

Tiantan Hospital: Acute Care and Quality-Improvement Research

After learning about preventative care at Peking University, we went to Tiantan Hospital to learn about hospital care for stroke patients. As the first stroke unit established in China, Beijing Tiantan Hospital’s Comprehensive Stroke Center is officially an academic institution that conducts research on stroke and comprises a 24-hour neuroimaging center for stroke patients in the hospital. Much of its research is directly applied to acute treatment in the hospital and follow-ups in outpatient settings.

When we arrived at Tiantan Hospital, we were greeted by Dr. Liping Liu, a neurologist who is the director of the Neurological Intensive Care Unit. With one of her doctoral students, we walked through a typical stroke patient’s experience at the hospital. When patients first arrive at the hospital after a stroke, they are triaged at the emergency department. There, a diverse team of health professionals collaborate to move patients along the appropriate treatment pathway. Nurses take the patients’ vitals and perform blood tests; medical students record patients’ electrocardiography and assess the Glasgow Coma Score; and neurologists stationed in the ER put patients on different clinical pathways based on the suspected time of stroke onset and the imaging results.

Patients on the “green pathway” can bypass further neuroimaging to receive a tissue plasminogen activator (tPA) drug, the gold standard treatment for ischemic stroke. The timeframe for diagnosis is especially important for tPA treatment since it can only be administered 4.5 hours after stroke onset. Any patients diagnosed after 4.5 hours must undergo additional testing and explore other treatment options. After receiving tPA or other treatments, stroke patients are placed in the Emergency Intensive Care Unit (EICU) for a mandatory period of observation. Then patients are either discharged, transferred to a community hospital, or moved to the inpatient unit at Tiantan.

Tiantan Hospital has already cut down its total door-to-treatment time, putting it ahead of many American hospitals. The stroke center itself is a leader in treatment efficiency and outcomes with its continual innovation and research. One of its major achievements has been the development of the China National Stroke Registry (CNSR), which has informed many of its practices in acute and outpatient settings. The CNSR is a multicenter, prospective, and comprehensive registry of stroke patients in China, first launched in 2007 and currently completing the third iteration of data collection. This registry contains a broad range of data collected during stroke patients’ hospitalization and after discharge. There are over 400 centers in the registry’s network and it serves to create a comprehensive picture of how stroke care can be improved in China. Using data in this registry, physician-researchers at Tiantan have identified many quality indicators and best practices that they have since applied to treatment of stroke patients. In fact, they have published over 100 papers in international journals on these findings.

The comprehensive stroke unit offers an example of how large amounts of data collected from clinical settings can be used to inform healthcare management. However, for all the discussion on data collection in China, Tiantan remains singular in implementing such a system. The challenge that healthcare providers in China now face is translating their ideas into a unified approach towards building health databases across the country.

Pinetree: Home Health and Community-Based Care

To understand patient care after a hospitalization, we had the opportunity to visit Pinetree Rehabilitation Nursing and meet with company executives. Pinetree, a Beijing-based company run by Ninie Wang, provides care for older patients who have had a stroke or any acute hospitalization. Pinetree applies an innovative home care model utilizing both physical door-to-door visit and telemedicine remotely using phone and video technology. Already in Beijing, Shanghai, and Hangzhou, Pinetree plans to extend its services to other regions.

Pinetree hires professional personnel with backgrounds in nursing, physical therapy and medicine to answer questions and provide care. Cultivating the top talent from many disciplines has allowed Pinetree to become an industry leader. The company actively recruits young professionals to bring innovative ideas into geriatric care. After multidisciplinary training, these caregivers then form teams to provide personalized treatment and establish relationships with their patients. Pinetree also partners with hospitals to recruit recently discharged patients for post-hospital care. In fact, some hospitals even provide Pinetree office space for consultations.

Once the patient returns home, Pinetree uses remote communication devices to communicate and manage care. The HealthPlus (小鱼儿) device, a tablet platform with text-to-speech and video chat functions, allows patients to communicate with Pinetree staff. HealthPlus also functions as a data transmission platform: patients can input their daily blood pressure data, which is then monitored by Pinetree. If a Pinetree staff member notices a significant fluctuation in patient blood pressure, he/she will send them a WeChat message to check in.

The need for post-hospital care is not widely acknowledged in China. As a result, health insurance only covers primary and hospital care. While high income patients can afford home-health services and low income patients may be able to receive government subsidies, middle-class citizens are currently unable to afford this rehabilitative care. Pinetree is actively working


We ended our trip by visiting Duke Kunshan University, where we attended the Duke Kunshan Conference on Digital Health Science and Innovation: Partnerships between Academia and Industry. We interviewed experts to learn their perspective on partnerships for facilitating improved health with digital health technology. The discussions and presentations at the conference encouraged us to think critically about our three experiences in Beijing. While Peking University, Tiantan Hospital, Pinetree Rehabilitation each played a critical role in the care continuum for patients, they each represented a different sector of healthcare: academia, government, and industry respectively. All three leveraged new technologies to improve stroke patient outcomes, but greater collaboration across these sectors is still needed.

Ultimately, health system strengthening requires collaboration across academia, government and industry. Fostering a culture of interdisciplinary collaboration can never start too early. Of the seven Bass team members who went to China, no two had the same majors. Our majors stretched from electrical and computer engineering to public policy to psychology. Every team member engaged in this experience with a unique lens and raised different questions. Moving forward, we hope to integrate these perspectives to develop innovative solutions in addressing the global burden of stroke and other non-communicable diseases.

Maternal Health in Rural Central Uganda: Cross-Sectional Assessment of Family Planning Usage and Attitudes

Primary Researchers and Authors: John Bollinger and Catherine Yang

DGHI Faculty Mentor: Dr. Sumedha Ariely

Project Mentors and Coordinators: Dr. Christopher Kigongo, Robinah Jevelah

February 26, 2018



Maternal and child health poses unique challenges to the global health community and has received much attention in terms of policy. As such, the Millennium Development Goals specifically target these health challenges. Goal 4 simply states, “Reduce child mortality” (“United Nations Millennium Development Goals” 2017). In 2016 the infant, child, and overall under-5 mortality rates in Uganda were 43, 22, and 64 per 1,000, respectively (Uganda Bureau of Statistics 2016).  These mortality rates are driven by global health factors, including anemia, malaria, soil-transmitted helminth infection, and malnutrition. Anemia is a condition that results from a lack of red blood cells, such that the number of red blood cells cannot support the needs of the individual’s body (WHO 2011). Malaria is a prominent disease caused by plasmodium parasites spread by mosquito vectors. The African Region has a disproportionately high burden of malaria cases and deaths, 90% and 91%, respectively(“WHO | Malaria” 2017). Soil-transmitted helminth infection is one of the most common infections globally, particularly in sub-Saharan Africa, the Americas, and East Asia. These infections can lead to adverse nutritional and developmental effects as well as anemia (“WHO | Soil-Transmitted Helminth Infections” 2017). Malnutrition often compounds susceptibility to other illnesses, resulting in situations of comorbidity. In developing regions such as Uganda, malnutrition poses a severe threat to maternal and child health, especially in the presence of other disease burdens such as anemia, malaria, and helminth infection (Uganda Bureau of Statistics 2016). Naturally child health is closely related to maternal health, and MDG goal 5 reads, “Improve maternal health.” This goal is broken down into subcategories and includes universal access to reproductive health, including meeting the unmet need for family planning products and services (“United Nations Millennium Development Goals” 2017). In the North Central Region of Uganda, 24.1% of women have an unmet need for family planning (Uganda Bureau of Statistics 2016). With the presence of comorbidity between diseases and the strong connection between maternal and child health, future research that incorporates the connection between these areas should be pursued moving forward.

Family Planning

Family planning includes any and all conscious efforts by a couple towards limiting or spacing the number of children they have through modern or traditional contraceptive methods. The modern and traditional classifications for contraceptive methods refer to the manner in which couples pursue family planning. Modern methods include female or male sterilization, birth control pills, implants, injections, condoms, etc. Traditional contraceptive methods include rhythm, withdrawal and other techniques considered folk methods. In the North Central Region of Uganda, 47.4% of women use family planning methods, including modern and traditional methods (Uganda Bureau of Statistics 2016). Of this group, 39% of currently married women are using a method of family planning, with 35% employing a modern method and 4% choosing a traditional method. Among modern methods, injections and implants are the two most common choices due to convenience and their long-lasting effects. However, 24.1% of women still have an unmet need for family planning methods. Having an unmet need includes women who wish to postpone their next birth for two or more years or want to stop childbearing altogether but are not using family planning methods. If a woman’s previous pregnancy was unplanned or unwanted, that is also considered to be an unmet need (Uganda Bureau of Statistics 2016). Currently, family planning employs a facilities-based approach, requiring women to go to a clinic or hospital to obtain or continue using most family planning methods (Schecter, Ciraldo, and Paccione 2016). Moving forward, VHTs may be able to play a practical and vital role in helping overcome the gap between interest and unmet need for family planning methods.

2017 General Aims

  1. Describe family planning knowledge and interest in a sample of current mothers.
  2. Investigate the effect of side effects and social factors on attitudes towards family planning and reproductive outcomes.


Both the Duke University Institutional Review Board and Uganda’s Mityana District Health Officer, Dr. Fred Lwasampijja, approved this study and the following methodology.  Participants were consented and ethical procedures were followed as specified both by Duke IRB and DGHI faculty mentors.

Study Setting

Data collection began in June 2017 and concluded in August 2017. The location was a rural parish of fourteen villages located about 50 miles from the capital city, Kampala, in Mityana District, Central Region 2, Uganda. The number of households in each village ranges from 54 to 247, with an average of 105 households per village.


In the summer of 2013, 69 women who were either pregnant or had recently delivered were recruited to participate in this now 5-year study. The women were either recruited through a village register or through an annual community health fair. Every year since, as many of these women have been re-recruited, as well as new participant mothers. The new mothers were women who had recently delivered and were recruited by their village health workers to be interviewed. In 2017, 59 mothers who had previously participated in this study were recruited, as well as 17 new mothers for a total sample of n=76.

Table 4. 2017 Demographics of Mothers (N=76)

In the summer of 2017, the mothers answered questions on their use of family planning and cell phones. No blood or stool samples were collected from the mothers in 2017.



A trained translator read and explained the approved consent form in Luganda, the local language, to participating mothers. Written consent was obtained from the mother at the place of survey, either her home or common space selected by their village health worker.

Survey Tool

A trained translator administered the survey by asking the questions in Luganda, the local language, and translating the mother’s response directly to English after every utterance. The responses were recorded in a notebook and later coded. The surveys were administered at either the mother’s home or at a central location in the village. Each survey took approximately 30 minutes per participant.


The survey contained demographic questions, various questions about family planning use, experience, attitudes, and reproductive outcomes, and questions regarding the mothers’ use of cell phones. The researchers developed the survey questions after reviewing relevant literature and consulting with research mentors, including a Ugandan physician. The translators were consulted regarding the wording of questions prior to finalizing and administering the survey. The survey was printed in English but administered in Luganda, the local language.


Of the 76 women surveyed in 2017 (ages 18-45 years), 81.6% (62/76) were married, and 18.4% (14/76) were single at the time of the survey. The median age at first pregnancy was 18 years, whereas the average age at first pregnancy was 18.49 years. This average age of first pregnancy is comparable but slightly higher than the Central 2 region average of 18.3 years (DHS, 2011).

The average number of pregnancies for women in our sample was 4.12. Of the women in our sample with 2 or more children, 91.2% (62/68) felt that they had waited long enough between the births of any of their children, whereas 18.8% (6/68) felt that they had not waited long enough between births. However, when asked about the intentionality of their previous or current pregnancy, 78.9% (60/76) of women wanted to be pregnant then, 19.7% (15/76) wanted to be pregnant later, and 1.3% (1/76) did not want to be pregnant at all. This can be seen in Figure 4 below.

Figure 4. Pregnancy Intentionality, N=76

All 76 women who participated in the survey were asked questions on family planning use and perceptions. When asked about family planning usage, 47.4% (36/76) reported that they were currently using a contraceptive method, 40.8% (31/76) said that they have used contraceptive methods in the past but not currently, and 11.8% (9/76) indicated that they have never used a contraceptive method. This can be seen in Figure 5 below.

Figure 5. Mother’s Contraceptive Use, N=76

Of the 67 mothers in our sample who currently or previously used a contraceptive method, the most common methods were injections and implants. Some women used multiple types of contraception, resulting in a total response number of 78 contraceptive types. 62.8% (49/78) used or currently use an injection, and 25.6% (20/78) used or currently use some form of implant. This breakdown can be seen in Figure 6 below.

Figure 6. Types of Contraception Used by Mothers, N=78

While 25% 1 of the 4 women in our sample who were currently pregnant had unintentional pregnancies, overall: 28% (21/76) had experienced at least one unplanned pregnancy at some point. Of those women reporting an unplanned pregnancy, 52.4% (11/21) reported that the pregnancy was due to unprotected sex, 14.3% (3/21) mentioned contraceptive failure, 23.8% (5/21) stated that they were still breastfeeding when they became pregnant, 4.8% (1/21) reported that she did not need family planning, and 4.8% (1/21) said that she was not aware of family planning at the time of the pregnancy.

Figure 7. Unplanned Pregnancy, N=76

Higher than the reported number in our sample, 43.7% of births in Uganda were wanted at a later time or not at all (DHS, 2011). Given that the number of unintentional pregnancies remains high, various factors were explored, including the age at first birth and age at the start of contraceptive use. As previously stated, the median age at first pregnancy was 18 years, whereas the average age at first pregnancy was 18.49 years. The median age at the start of contraceptive use was 22 years, whereas the average age was 22.32 years. Statistical analysis comparing the age at which women report their first pregnancy and initiating contraceptive use shows that there is a significant difference between the age at which women are first pregnant and when they begin family planning methods. Therefore, women are starting family planning methods after their first pregnancy.

Figure 8. Comparison of age at first birth and age at the start of contraceptive use, N=67

As stated earlier, 41% of mothers in our sample previously used at least one form of contraception in the past but do not currently use any family planning method. Of these 31 women, 45.2% (14/31) wanted another child, and 32.3% (10/31) stopped use due to side effects.

Figure 9. Reasons for Stopping Contraception, N=31

Based on our data and recommendations from 2016, we took a closer look at women who stopped contraception due to side effects. We analyzed whether or not women who stopped contraception due to side effects report significantly greater levels of side effect severity when compared to women who stopped contraception due to any other reason. We found that women in our sample who stopped contraceptive use due to side effects reported significantly more severe side effects (t=2.3208, df=20.543, p=0.03068). Figure 10 below visualizes the difference in reported side effect severity between the two groups of women, one indicating that they halted contraceptive use due to side effects and the other stopping use due to any other reason.

Figure 10. Comparison of women who stopped contraceptive use, N=31

From the 2011 Ugandan Demographic Health Survey, 56% of current contraceptive users were given information about potential side effects or complications that may be associated with the contraceptive method that they use. 53% of women were told what steps to take if they experienced these side effects, and 59% obtained information about one or more alternative contraceptive method. As side effects were a significant reason for halting contraceptive use, the severity of side effects based on whether or not information was provided to the patient was analyzed.

We analyzed whether or not provider information made a difference in the painfulness of side effects reported due to contraceptive use. To do so, we grouped participants into two groups. One group reported that they had received any information at all about family planning methods, which was not limited to information about side effects associated with the contraceptive method the participant was using. Women in our sample were asked to rank the severity of the side effects the experienced on a scale from 1 to 10, with 1 being not a bother and 10 being so painful that the participant had to immediately discontinue use of her contraceptive method. For the group of women who received information from their provider, the median painfulness of side effects reported was 6, with an average score of 5.8. For the group of women who did not receive information from their provider, the median painfulness of side effects reported was 7, with an average score of 7.2. Statistical analysis revealed a trending towards significant difference between the two groups, indicating that women who did not receive information from their provider may report more severe side effects associated with contraceptive use.

Figure 11. Painfulness of Side Effects, N=47

To further assess whether or not there are mitigating factors for side effect severity, we analyzed the social support women received from female friends. Contrary to what we would expect, in terms of friends, women with more supportive friends have a median side effect severity score of 8, with an average score of 7.2. Women with unsupportive friends have a median side effect severity score of 6, with an average score of 6. While this trend is opposite of what we would expect, it is not statistically different indicating that the support of friends may not act as a mitigating factor for side effect severity associated with contraceptive use.

Another assessment of social support exists in the form of support from female family members. Therefore, we analyzed this type of social support participants have to investigate whether or not having supportive female family members may mitigate the severity of side effects associated with contraceptive use. Women with supportive female family members had a median reported side effect severity of 7, with an average score of 6.3. Women with unsupportive female family members had a median reported side effect severity of 10, with an average score of 8.6. Statistical analysis showed that there was a significant difference between the two groups of women, indicating that women with more supportive female family members report significantly less severe side effects associated with contraceptive use.

Figure 12. Reported Side Effect Severity Grouped by Family Support, N=28

One final measure of social support that we explored was partner’s perception of contraceptive use. We asked women in our sample how she thinks her partner feels about contraceptive methods. Of women in our sample with a partner, 55.9% (38/68) reported that their partner supports contraceptive methods, 19.1% (13/68) said that their partner does not support contraceptive use, 16.2% (11/68) responded that they do not know how their partner feels, and 8.8% (6/68) stated that their partner does not know that they currently or previously used a contraceptive method. This breakdown can be seen in Figure 13 below. Note that some women gave multiple answers to this question.

Figure 13. Partner Perception of Contraceptive Methods, N=68


The women in our sample show a high level of contraceptive use. However, almost 1 in 3 mothers have experienced an unplanned pregnancy. This remains the case even though women mostly report that the primary use for contraception seems to be family spacing as opposed to individual reproductive control. In Uganda, contraceptives are free and available in local clinics, but the problems of transportation, service availability, and social support are still prevalent. The largest barrier to access for women who want to use contraceptive methods may be side effects. Many women in our sample reported that they had experienced side effects and discontinued use of their contraceptive method due to these side effects. Furthermore, the lack of information by providers is concerning, particularly as it may be a factor that may mitigate the severity of side effects women associate with contraceptive use. When discussing patient education with health workers in a few of the local clinics in Naama, we were informed that it is required for them to provide information about the contraceptive method the patient desires, along with side effects associated with that family planning method and general information about other available methods.

Boosting family planning education for patients serves as a promising prospect for a policy piece in the future. Policies should aim to mitigate misperceptions about the types and effects of contraception, which are potentially due to social networks perpetuating more information than health systems. As women with more supportive family networks report lower side effect severity, this idea has some degree of support. Therefore, a policy piece that aims to boost education provided at the point of procurement of family planning services as well as a community-based model that incorporates VHTs perpetuating information about family planning methods and associated side effects may be the best way to move forward.


There are several limitations to our analysis of family planning perceptions and method use. Firstly, our survey relied on self-report method. It is very possible that women have forgotten the age at which they began contraceptive use along with the timeline of other questions. Furthermore, self-report measures for side effect severity may be skewed with time. If women have experienced these side effects more recently, they may be perceived as more severe. On the other hand, women who experienced side effects many years ago may not remember exactly what side effects they had and time may make those they do remember feel less severe. Secondly, we attempted to understand differences between the numbers of actual versus desired children for mothers in Naama. However, our sample only consisted of women who were still of childbearing age. We could not accurately draw conclusions from this sample because they may have more children in the future. A sample that included women beyond childbearing years should have been included to assess actual versus desired numbers of children. Broadening the sample would also allow for some degree of assessment in terms of a generational shift, determining whether or not a trend exists in the number of children desired by age group. Thirdly, we wanted to analyze birth spacing over time for mothers to see if there was a change as time went on or if the start of family planning methods increased birth spacing. However, we did not ask about the birthdays of all children, which prevented us from assessing these measures. Lastly, we did not separate or ask questions about modern versus traditional contraceptive methods. Many women in our sample mentioned that they had an unplanned pregnancy while they were still breastfeeding. Additional analysis would have been helpful to understand perceptions of modern versus traditional family planning methods.


Bachou, H., and Demetre Labadarios. 2002. “The Nutrition Situation in Uganda.” Nutrition 18 (4):356–58.

Brooker, S., A. C. A. Clements, and D. A. P. Bundy. 2006. “Global Epidemiology, Ecology and Control of Soil-Transmitted Helminth Infections.” In Advances in Parasitology, edited by Simon I. Hay, Alastair Graham, and David J. Rogers, 62:221–61. Global Mapping of Infectious Diseases: Methods, Examples and Emerging Applications. Academic Press.

Hotez, Peter J., and Aruna Kamath. 2009. “Neglected Tropical Diseases in Sub-Saharan Africa: Review of Their Prevalence, Distribution, and Disease Burden.” PLOS Neglected Tropical Diseases 3 (8):e412.

Mbonye, Anthony K., Ib Bygbjerg, and Pascal Magnussen. 2008. “Intermittent Preventive Treatment of Malaria in Pregnancy: A Community-Based Delivery System and Its Effect on Parasitemia, Anemia and Low Birth Weight in Uganda.” International Journal of Infectious Diseases 12 (1):22–29.

Pelletier, D. L., E. A. Frongillo, D. G. Schroeder, and J. P. Habicht. 1995. “The Effects of Malnutrition on Child Mortality in Developing Countries.” Bulletin of the World Health Organization 73 (4):443–48.

Schecter, A., K. Ciraldo, and G. Paccione. 2016. “Meeting Unmet Need for Family Planning in Rural Uganda through Village Health Worker Distribution of Emergency Contraception: Assessing Attitudes and Use.” Annals of Global Health 82 (3):499.

Shapiro, Adrienne E., Edridah M. Tukahebwa, Jennifer Kasten, Siân E. Clarke, Pascal Magnussen, Annette Olsen, Narcis B. Kabatereine, Richard Ndyomugyenyi, and Simon Brooker. 2005. “Epidemiology of Helminth Infections and Their Relationship to Clinical Malaria in Southwest Uganda.” Transactions of the Royal Society of Tropical Medicine and Hygiene 99 (1):18–24.

Uganda Bureau of Statistics. 2016. “Uganda Demographic Health Survey 2016.” 2016.

“United Nations Millennium Development Goals.” 2017. 2017.

WHO. 2011. “Haemoglobin Concentrations for the Diagnosis of Anaemia and Assessment of Severity.” 2011.

“WHO | Malaria.” 2017. WHO. 2017.

“WHO | Soil-Transmitted Helminth Infections.” 2017. WHO. 2017.

Engaging with the modern stigma of the ancient disease of leprosy

Sonali Biswas

March 20, 2017

I left for Ecuador thinking two months would be enough to make an impact in a community with leprosy. With centuries of stigma, leprosy proved to be not only a physical disease, but also a social disease that could only begin to be understood in eight weeks time.

Overwhelmed by the unanticipated hours of traffic that lay in front of me and dehydrated from the Ecuadorian sun on a crowded bus, I quickly began to doubt my own preparedness for DukeEngage. Through my service project, I would be working with people in the urban city of Guayaquil who had had leprosy, and were now suffering from the symptoms. Prior to departure, I spent weeks researching leprosy, preferably known as Hansen’s Disease to avoid the stigma traditionally associated with the disease. I even read up on Ecuadorian culture, ambitiously trying to pinpoint how my goals could be accomplished in the 8 weeks we had there. Unbeknownst to me at the time, this initial impediment would be the first of many experiences that challenged my perspective on how short-term service projects can grapple with the complex social determinants of disease.

As I walked through the gates of the Damien House foundation on that first day, my fellow volunteering partner and I were welcomed by the residents of the clinic with open embraces and wide smiles. Walking through the foundation, seeing the patients making hammocks for sale, or painting canvases to decorate their rooms, I was surprised to find the thriving community within the foundation’s concrete walls. Even though all residents suffered from the same disease, each possessed their own unique history and personality. As I spent more time with each resident, the service goals I had developed before getting to know this community suddenly seemed narrow-minded and inflexible in the face of the diversity of this population. My initial planning unintentionally imposed my own objectives on this community, considering them as merely victims of a disease; after observing the multidimensional complexity of their world from within, I sought to better understand how I could integrate into their existing lifestyles

While I knew I still wanted to have some kind of impact, I found myself without any clear path forward to what that impact could be and how I could achieve it. Not wanting to interrupt the already-busy staff, my partner and I began to investigate the clinical experiences of both the resident inpatients and the outpatients, the latter being those who have not lost their independence due to the disease. From the outpatients, I first began to understand how my clinical understanding of Hansen’s Disease from journals was significantly different from these people’s experiences in society. I previously understood Hansen’s Disease from a scientific perspective as a neglected tropical disease, meaning it disproportionately affects those in low-resource communities who have extended exposure to the bacteria Myobacterium leprae. These patients, however, perceived their experience entirely in the social context of how their communities perceived them. To them, Hansen’s Disease was a curse with ancient biblical ties. In their highly religious communities, their familial and professional relationships were affected by how “lepers”, as they were called, historically had to ring a bell when they entered public spaces, so that the community could hide from contagion. Abandoned by their communities, only after coming to the Damien House did the outpatients realize that their affliction could be easily combatted physically.

Curing the patients of the bacteria, however, did not cure them of the burden of the disease. Physically, the sequelae left patients with significant scarring, reduced nerve sensitivity, and amputated limbs. Financially, the bus ride they took to the clinic each day, rarely more than five dollars, was expensive because they were no longer able to work, and physically difficult to navigate with their condition, factors that I in my privilege never had to consider on the same bus ride each day. Those not from Guayaquil struggled even more travelling from rural communities, where treatment was unavailable despite the highest disease burden. I assumed that the lives of the permanent residents would be significantly better than those of the outpatients due to access to 24/7 care, daily meals, religious services, and the freedom to pursue hobbies such as sewing and making hammocks to sell to the community. The relationships I fostered, however, revealed their desire for someone to talk to—a willing ear, an outside friend, or even a psychologist. Others wanted events to break the monotony of their schedules that did not extend past the walls of the center. Unable to work, many simply desired to regain their independence. While these people were extremely optimistic about their situation, citing their faith as their main motivator and coping mechanism, I felt increasingly helpless and frustrated. This was the first and certainly not the last time that I realized that the issues that were most relevant in these patients’ lives were the ones I was incapable of solving, especially in our short two months time.

Given my time restraints and ability as an undergraduate student, I believe that the most important role I could play was that of a companion. Unlike how I had initially anticipated, my academic knowledge and my research experience were insufficient to truly connect with this community. Together, the patients and I played dominoes, watched telenovelas, and painted canvases. My partner and I eventually began a daily exercise class to help patients regain their independence, and created a guide for future volunteers to sustain our work. We painted a mural on a blank wall with the patients in a popular socializing spot. Most of all, we prioritized validating the individuality of each patient through one-on-one conversation, games, and activities.

As I spent each day experiencing the wealth of diversity among the residents while volunteering throughout the two months, I became frustrated by those who visited the center for days at a time. Often, these groups had come to the center to perform a day of service but often ended up nervously observing and taking photos of the patients as if the patients were exhibits. To me, these visitors lacked the time needed to see past the disease in each patient and to the commonalities they shared. However, as my time came to an end, I began to see myself as I saw those tour groups. Like them, I arrived at the clinic with the same well-meaning desire to make a positive impact. Like them, however, I was leaving the clinic behind, unaccountable for the repercussions of my absence. I felt pain at suddenly leaving the relationships from which I had learned so much. I felt helpless that I could not directly help these patients much after I left. While students would be returning to the foundation the following year from Duke, I struggled to find my own role in sustainability. I felt guilt at my privilege of being able to escape the reaches of this disease and return to my own life, while the patients never had a similar option. I felt frustrated by my own naiveté of thinking of two months as a sufficient time to make a meaningful impact.

Most of all, I felt grateful that these people allowed me into their lives as an outsider to accompany them during their meals, church services, and craft-making that constituted their daily lives. From this experience, I have come to greatly appreciate the WHO’s definition of health, where health is “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” In the eyes and spirits of the patients with one of the most stigmatized diseases of the world, I learned how to see humanity and the power of hope. With the stories I heard from patients, I discovered firsthand how people’s social environments are as relevant as and often determine their physical wellbeing. Above all, I learned that eight weeks with even the best intentions could never remedy a problem that has spanned centuries. Nevertheless, having the privilege of any amount of time and resources should motivate oneself to mindfully take the first steps to making an impact.

Making a true two-way global health partnership in Tanzania

Jackie Xu and Judy Riviere

March 20, 2017

Global health partnerships are often fraught with donor-recipient power dynamics. In Tanzania, Americans are perceived to have “big money, big personalities, and data obsession.” Fighting against these stereotypes, we strove to build an authentic two-way partnership while working with the SHED Foundation during summer 2016.


In 2016, The Lancet published the first systematic analysis of the geographical distribution of university global health partnerships (GHPs). The rising popularity of global health as a field has led universities and NGOs to establish GHPs in developing nations.This partnership model stresses open communication and listening, allowing each partner to voice their needs and eliminate the hierarchical structure present in current global health work. Professor Johnanna Crane of The Lancet notes “true partnership is especially challenging in global health, in which institutions must forge collaborations across sometimes staggering inequalities” (1). In these words lies the main goal of GlobeMed: to overcome global health inequities through effective partnerships.

Currently, GlobeMed at Duke is partnered with the Shirati Health, Education, and Development (SHED) Foundation in Tanzania. During the summer of 2016, we three Duke undergraduates, Jackie, Judy, and Alexa, lived in Shirati for nine weeks, sponsored by a DukeEngage Independent Project grant. As interns for SHED and advocates for GlobeMed at Duke, we worked to strengthen our organizational relationship via three projects: 1) build a school desk carpentry program to promote self-sustainability for SHED, 2) provide schistosomiasis and hygiene education to SHED schoolchildren, and 3) perform project evaluation on the Ministry of Health’s mass drug administration work.

While the foundation of the collaborative global health partnership model is strong in theory, we found that achieving its goals is much easier said than done. Work in the global health field remains plagued by its deep imperialistic past. Too often, donor-driven cultures within non-profit organizations impede meaningful discussions on community needs. Stereotypes about well-to-do foreigners result in prejudices that hinder progress and communication. Such was our experience with SHED, yet through our time engaging with community members, we learned how to overcome these limitations and achieve our project goals.

A New Foundation for Education

Initially, we planned to work on a schistosomiasis mass drug administration (MDA) campaign with SHED. However, a few days before leaving home, we received an email from SHED informing us that the Ministry of Health had initiated a schistosomiasis and worms MDA for all primary schools in the Rorya district of Tanzania, essentially eliminating the need for us to conduct our planned summer work. In the chaos of our 48-hour flight and arrival in Shirati, we scrambled to plan a new project. Throughout our research, we discovered a common theme through stories of global health fieldwork: a lack of school desks in primary schools. Thus, we were catapulted into our newest project.

A lack of school desks in Tanzanian primary schools began when the President of Tanzania, John Magafuli, created a policy for free primary school education. Consequently, school attendance skyrocketed, causing overcrowding in primary schools. To illustrate this issue, television advertisements frequently streamed short films of five to six school children squeezed together on a single bench meant for three. In response, Magafuli spearheaded a school desk construction campaign to provide for the new influx of students, after which, nearly every school within the Mara region had proper desks. Overall, Magafuli’s rapid mobilization of primary schools amazed us, inspiring us to aid in this cause.

The main primary school that we worked with, Shirati Primary, was a two minute walk from our SHED complex. The first time we visited the school, we initially discovered an empty schoolyard. We retreated embarrassed, but not before a few students inside spotted us and whispered to their peers in amazement, “mzungu!”, Swahili for “foreigner!” Suddenly, a river of children dressed in identical uniforms rushed towards us. Despite their excitement, they remained at a distance, forming an invisible circle around us. Following closely, the headmaster walked out to greet us as well. Although we apologized profusely, the headmaster seemed unfazed by our intrusive entry. He promptly gave us a tour of the school, dismissed the children from class, and showed us a classroom filled with broken wooden desks. Dilapidated pieces of wood had been stamped with the phrase “DONATED BY NMB.” The marking signified that these desks had been donated by a Parliamentary member. Shaking his head in contempt, the headmaster explained that the donation was merely a political strategy to increase the Parliament member’s chances of re-election. However, the cheap materials and woodworking had rendered much of the original donation useless. Furthermore, the potholes that riddled the concrete floors of the Shirati Primary classrooms rapidly aged the poorly constructed desks.

Despite our initial belief that the Tanzanian government had truly altruistic motives for providing school desks, we found that most officials only provided desks in hopes that citizens would favor them in the upcoming elections. In this respect, the desk donation reflected a donor-driven culture, one that promotes giving as a means to an end. To combat this issue, we researched how to create the optimal desk design: we aimed to find desks with the highest quality that were able to withstand the uneven floors, but at the lowest cost. GlobeMed at Duke was the sole funder of this project, as SHED lacked its own source of income.

Determined to avoid instances of pseudo-donation and develop a lasting and meaningful product for Shirati Primary, we planned meetings with Shirati Primary to review every grueling detail necessary to construct high-quality desks. For these meetings, our American notions of professionalism included scheduling ahead of time, communicating consistently, and using organizational spreadsheets. Yet we soon found that these notions were inconsistent with Tanzanian culture. In Tanzania, meetings would spontaneously relocate from SHED to Shirati Primary and often were haphazard in organization. At first, we attempted to force the planning process our way, wrongfully exercising our power as the funders. However, we quickly realized that we were reinforcing Tanzanian stereotypes about American donors of “big money, big personalities, and data obsession.” Thus, partnership with SHED required that we adapt to their organizational culture.

Through these meetings, we determined that our main goal was to build the foundations for a carpentry business owned by SHED that could serve as a potential source of income for this non-profit. Thus, our global health summer internship transformed into lessons in wood planing (the process of smoothing wood surfaces) and metal welding. Despite our feelings of disconnect from healthcare, we came to understand the importance of our work as one of the many faces global health work.

Since Shirati Primary is a public school, our work needed to be approved by the government. As such, government officials oversaw the our project. SHED, concerned that these officials would attempt to take credit for the handiwork (funded, researched, and executed by GlobeMed with SHED), encouraged us to paint the words “DONATED BY GLOBEMED/SHED” on the side of the desks. We shied away from this idea, feeling that such a message reinforced ideas of charity as an achievement. Additionally, we dreamt of attracting the attention of the District government as potential customers to expand our impact, which fortunately came true. One day, a District official visited Shirati Primary to see our work in progress, hearing the gossip that mzungus had been working with Shirati Primary on school desks. This small visit ultimately increased the Tanzanian government’s support our project goals, and thus, laid the foundation for future collaborations.

Carpenters are sitting at the desks they built at SHED for Shirati Primary School.

The Challenges of Collaboration

Living in Shirati for 9 weeks endowed us with a new perspective on global health prejudices and donor driven culture. Often, it is easy to criticize Tanzania’s concept of time: it slows processes down, it drags work out, and it is less organized and reliable. Yet incidentally, we discovered the benefits of actually taking time to process and focus, something Americans too often forget to do. During meetings, we always had everyone’s full attention, without any distracting smartphone notifications. Carpenters would stay after meetings to discuss their plans with us, and children voluntarily stayed at school after class to hear more of our lessons. Our previous presumptions about how time should be managed exemplifies the “assumed values” that foreigners bring into global health work. Therefore, global health partners need to adapt to working within the local culture, as opposed to “fixing” their partners, or getting stuck on logistical challenges.

Working closely with a partner organization in an unfamiliar community was, at times, a true challenge. From small complications like a malfunctioning printer to larger issues like absentee taxi drivers, we accumulated an unnerving number of obstacles. However, we realized that pushing against these problems did not resolve them. Rather, we had to understand and adapt to community dynamics and in order to contribute towards the existing work of local organizations like SHED. Working through the partnership model, we strove to dismantle the traditional power dynamic of donor and recipient that often interferes with global health work.

However, in a sense, power dynamics were inevitable. On one hand, we needed SHED’s knowledge of the local community and communication tools to carry out projects, allowing the organization executives to have the final say on major project decisions. On the other hand, we were perceived as “rich” investors by certain Tanzanians. Therefore we were often granted excessive liberty to do whatever we wanted at the primary schools, which in fact made our work more difficult, as the school headmasters avoided expressing their needs clearly. We had to navigate these power dynamics with grace—at times raising our voices, and at others encouraging our partners to take the lead.


SHED played a crucial role in our partnership: they provided essential knowledge, cultural capability, and technical expertise. They knew which of the local carpenters were hard-working and which cheated on business deals. They provided guidance on more minute details such as  the cost of lumber and how much we should compensate carpenters for their work. Our role in the partnership was to provide an outsider perspective to promote the growth of new ideas, such as creating classroom instruction materials or establishing more partnerships between SHED and other local non-profits.

A partnership favors the voices of many. Talking and understanding to meet in the middle is the road to progress. Building respectful and constructive relationships to give a platform for all takes time and cooperation. Global health partnerships present a unique opportunity to revolutionize how we address global health—as an act of listening, deep community engagement, collaboration, and above all, a balance of power to provide a multiperspective approach to service.


  1. Crane J. Scrambling for Africa? Universities and global health. The Lancet. 2011 Apr 23;377(9775):1388-90.

Introducing the Duke Student Global Health Review

Peter J Hotez MD PhD1

1Professor of Pediatrics and Molecular Virology, Texas Children’s Hospital Endowed Chair of Tropical Pediatrics, Director of the Sabin Vaccine Institute and Texas Children’s Hospital Center for Vaccine Development, and Dean of the National School of Tropical Medicine, Baylor College of Medicine, Houston, Texas

A decade ago, the Duke Global Health Institute was launched as an overarching organization to channel global health activities across the University and to bridge Duke’s campus with additional university faculties in Durham, North Carolina, as well as those in Singapore, Africa, Brazil, and elsewhere. Under the visionary leadership of Dr. Michael Merson, by almost every measure the Duke Global Health Institute has been a resounding success, helping to elevate Duke University to its current stature as one of the very important institutions working to address health disparities in the world’s low- and middle-income countries.

Since its beginning, the Duke Global Health Institute has emphasized undergraduate education and the need to introduce university undergraduates of diverse backgrounds to the complexities of international development and health. By fostering this environment, the Duke undergraduates have now responded by establishing a global health journal wholly independent of the Institute itself: the new student-run Duke Student Global Health Review, which will emphasize essays, global health projects, and other writings.

The timing of this year’s launch is perfect, given that 2016 marks the start of the new United Nations Sustainable Development Goals (SDGs). A hallmark of the SDGs is to reaffirm the importance of health in its links to international development, but also to emphasize how these goals go beyond traditional health norms, including diverse elements such as the environment, water, climate change, urbanization human migrations, and conflict. The SDGs highlight how global health is intertwined with these various Anthropocene forces, so that solving complex global problems will require the full commitment – by students especially – of a large and comprehensive university, such as Duke. In this way, the Duke Student Global Health Review can serve as important clearinghouse for students to tackle health disparities in the context of sustainable development.

The Duke Student Global Health Review will emphasize HIV/AIDS, tuberculosis, malaria, the now 18 neglected tropical diseases (with the latest inclusion of mycetoma), important vaccine preventable diseases of childhood, and key non-communicable diseases, such as cancer, diabetes, cardiovascular diseases and chronic pulmonary diseases. It will address the scourges of unipolar depression and other global mental health disparities. But in the spirit of the SDGs this new journal will also provide an opportunity to comprehensively evaluate health disparities in multiple dimensions, and of course with the recent recruitment of Dr. Gavin Yamey to Duke the Review can serve as an important sounding board for global convergence in the coming decades. I congratulate the students who founded this new important Duke Student Global Health Review as well as the faculty and leadership of the Duke University Global Health Institute for keeping these issues front and center on the University agenda!