Capstone Projects - Class of 2012 // Eck Institute for Global Health // University of Notre Dame

Eck Institute for Global Health

Capstone Projects - Class of 2012

Name: Husein Badani  MS '12
Degree and Year: Biology
University of California-Irvine, 2009

Capstone Project:   Spatio-temporal analysis of diarrheal diseases in Dar es Salaam, Tanzania


Abstract:  In order to understand the burden of diarrheal diseases in developing countries, it is important to determine the prevalence and causes of these illnesses. Through the Millennium Development Goals, the United Nations aims to increase access to potable water and improve basic sanitation, which both play roles in reducing diarrheal diseases. Diarrheal diseases rank fifth globally among the leading causes of death but predominantly afflict low to middle income countries. Here patient ward location, age, and gender information from 2006-2011 were analyzed from district reports of dispensaries, health centers, and hospitals throughout Dar es Salaam, Tanzania. Spatio-temporal analysis using SaTScan and R provided information on development of clusters. Monthly rainfall and land temperature data were analyzed to find a correlation between cases and weather events. Results depicted the diseases are highest in children under five years of age, but do not differentiate between genders. Multiple clusters were found, indicating the need to determine the causes of these hotspots. No significant correlation was found between weather patterns and cases. Taken together, clusters found from spatio-temporal analysis may be attributed to socioeconomic conditions and other possible spatial factors, and analysis of these assumptions should be investigated.

Name: Zoe Cross  MS '12
Degree and Year: Preprofessional Studies
University of Notre Dame, ‘12

Capstone Project:  Meta-analysis of helminth polyparasitism: Infection dynamics and morbidity


Abstract:  Polyparasitism is common in endemic areas and contributes to morbidity and mortality burdens. The objectives of this study were: to quantitatively evaluate the burden of polyparasitic infections, to assess whether synergistic interactions were at play, and to examine polyparasitic­induced morbidity. Helrninth-only and helrninth-protozoa interactions were considered as well as specific helminth-mixed infections: malaria. tuberculosis and HIV. These infections were selected because geographical endemicity overlaps extensively with helminth distribution. We conducted a systematic review of published prevalence and association studies within PubMed and Web of Science databases. A total of 71 studies were identified for review. We found significant interactions among the soil-transmitted helminthes. The species appear to interact synergistically within the host. Mixed co-infections were prevalent and exerted varying pressure on endemic helrninthiasis impact. Polyparasitism was found to be more prevalent than monoparasitism in endemic areas. Additionally, a positive correlation was seen between increasing endemic species and the mean number of host infections. Our results have important implications for understanding the ubiquity and impact of these diseases in order to develop promising initiatives for control.

Name: Molly Elston  MS '12
Degree and Year: Biology
Rockhurst University, 2011

Capstone Project:  How rural health promoters and participatory research models can help bridge healthcare barriers in the Napo Province in Ecuador


Abstract:  In 2000, the Ecuadorian Congress established a National Health Care System and passed health care reform measures. By 2007, however, access to healthcare services was still limited for many Ecuadorians, with nearly one-third of the population lacking regular access and two-thirds without health insurance or adequate resources to pay for health services. This lack of access to care is a serious issue that must be addressed if Ecuador is to continue to promote the development of its citizens. The goal of this research was to identify key health issues regarding health needs, practices, and access in three communities in Timmy Global Health's catchment areas in the Napo province of Ecuador in order to gauge how a rural health promoter program could address these key health issues and supplement Timmy's current medical brigade efforts in the area. First, a quantitative health survey was used to identify basic socio-demographics, sanitation practices, and the most commonly reported health concerns for Timmy’s adopted communities. Next, a more qualitative, participatory approach toward research in the form of individual interviews and focus groups was employed.  The surveys showed that the majority of questionnaire respondents have only completed up to primary school, make less than $50 per month, and do not have insurance. Information collected also displayed a great lack of basic health knowledge and problems with water sanitation in the communities. It is the hope of this project that findings of the this project and the recommendations created as a result of these findings can be utilized by Timmy Global Health in order to accomplish their goal of moving towards a Rural Health Promoter program empowers communities to take charge of their own health needs and promotes sustainable local knowledge in these same communities.

Name: Allie Herschel  MS '12
Degree and Year: Science-Business
University of Notre Dame, 2011

Capstone Project:  Examining the effects of health fair attendance on HIV testing rates among Latinos in Elkhart County, Indiana


Abstract:  Hispanics are unduly burdened by the HIV/AIDS epidemic in the United States. Although Latinos have a higher risk of contracting HIV than any other racial/ethnic minority group, they are less likely to get tested for the disease and more likely to test late in the course of their infection. Using response data from a registration form distributed at the Hispanic/Latino Health Coalition of Elkhart County’s annual health fairs in 2009, 2010, and 2011, we sought to determine whether or not previous health fair attendance led to higher HIV testing rates among Hispanics in Elkhart County, Indiana. Overall, our analysis shows that 25-44 year old female Latinos who attended a previous health fair are significantly more likely to have been screened for HIV at some point in their lives. Ultimately, our findings have valuable implications for the development of improved strategies to curb HIV transmission throughout the country, namely by increasing the testing rates in the Hispanic community of Elkhart County and beyond.

Name: Sarah Hurd  MS '12
Degree and Year: Kinesiology and Pre-Physical Therapy
Kansas State University, 2009

Capstone Project:  Determining the efficiency of government primary health care centers in Southern Karnataka, India


Abstract:  Data envelopment analysis (DEA) is a useful, practical method for evaluating the efficiency of decision-making units (DMUs) in comparison to the best practices of their peers. This method has been used extensively in healthcare around the world to evaluate the effectiveness of resource allocation and to ensure the conservation of limited resources. India’s government has recently made a commitment to contribute a larger portion of its gross domestic product (GDP) to the healthcare system, but this funding requires efficient and effective structures to make a significant impact. The objective of this study is to measure the technical efficiency (TE) and scale efficiency (SE) of several government-run primary healthcare centers (PHCs) to determine whether changes in structure might be indicated for more efficient resource allocation. This study uses DEA, and related methods to analyze the efficiency of 39 government PHCs in Southern Karnataka, India. Three inputs (clinical staff, non-clinical staff, and population coverage) and five outputs (outpatient visits, institutional deliveries, children immunized, antenatal care visits, and family planning visits) were used in the analysis. A Tobit censored regression model was conducted as a second-stage analysis. Fourteen (36%) of the 39 PHCs analyzed were found to be efficient assuming constant returns to scale (CRS), with an average efficiency of 84%. Twenty one (54%) of 39 were found to be technically efficient assuming variable returns to scale (VRS), with an average efficiency of 90%. Fifteen (38%) of the 39 PHCs displayed scale efficiency (SE), with an average SE of 93%. Stochastic Frontier Analysis (SFA) showed that the majority of the variance in the samples was due to inefficiency rather than noise in the data, and was highly correlated (.989) with the DEA model. Given these results, inefficient PHCs could hypothetically decrease their inputs by an average of 10% to achieve pure VRS technical efficiency and 7% to achieve scale efficiency. Because a large number of the PHCs are operating at increasing returns to scale, the additional financial resources slated for the public healthcare system would likely help the PHCs to become more efficient. This could increase quality and access to healthcare for many people of India. The authors suggest further study of additional PHCs in Karnataka to foster exploration of system- wide efficiencies and inefficiencies. Furthermore, implementation of a periodic monitoring of the PHCs over time as well as a qualitative evaluation of the health care system would provide additional insights.

Name: Luisa T. Krug  MS '12
Degree and Year: Chemistry and Molecular Biology
Oklahoma State University, 2011

Capstone Project:  Integration of human papilloma virus vaccine distribution into currently existing Notre Dame Haiti Program mass drug administration programs


Abstract:  Human papillomavirus (HPV) is the main causative agent of cervical cancer and can also cause other cancers in men and women such as vaginal, penile, and oropharyngeal cancers. Although the implementation of screening and vaccination programs has lowered the incidence and mortality in the developed world, a lack of these resources in the developing world has led to cervical cancer disproportionately affecting low and middle-income countries. Therefore, the WHO now recommends the addition of the human papillomavirus vaccine into routine national immunization schedules and organizations are advocating for increased prevention programs worldwide. This project discusses the feasibility of the integration of a Human papillomavirus vaccine distribution program into the Notre Dame Haiti Program’s existing mass drug administration program (MDA). The Notre Dame Haiti Program does an annual distribution of medications for Lymphatic filariasis, a mosquito borne disease that affects over 2 million Haitians. These medications are distributed free at posts set up within each community across the country. Feasibility was evaluated through community interviews and focus groups with participants from the following populations: parents, community members, and health workers and administrators. This research was focused in the Ca Ira community of the Leogane commune, but also took place in the communities of Diclo and Carrefour. Although initial knowledge of HPV and cervical cancer was low, participants were in favor of the implementation of this vaccine program within MDA, due to an acceptability of vaccines in general, and due to the respect that the MDA program has within these communities. In addition, interviews with health workers showed several logistical challenges but most employees agreed that good planning could create effective and feasible solutions for all of these challenges. After evaluating the evidence gathered, it is proposed that the HPV vaccine be distributed at MDA posts to boys and girls ages 10-13 in a pilot project in the Leogane commune. The second and third doses of the vaccine would be given at schools and local health centers within the communities targeted for the pilot project. This would be preceded by an extensive educational campaign that includes community seminars and HPV screening for women. Following the evaluation of the pilot project, an informed decision can be made about increasing the scope of this project.

Name: Charlotte Marous  MS '12
Degree and Year: Health and Exercise Science
Wake Forest University, 2011

Capstone Project:  Prevalence, risk factors, and clinical epidemiology of hepatitis C; an emerging infectious disease in the Alor Setar region of Kedah, Malaysia


Abstract:  Hepatitis C Virus (HCV), a chronic infectious disease caused by a small single-stranded RNA virus (family Flaviviridae) and major contributor to liver disease worldwide, is believed to be an emerging global threat. However, data on the prevalence, risk factors, and demographic epidemiology of the disease in the Kedah state of Malaysia are still limited. We carried out a hospital-based retrospective analysis of 707 confirmed cases extracted from a Hepatitis C Registry and past patient medical records set up from 2009 in Hospital Sultanah Bahiyah, Alor Setar, Kedah state, Malaysia, with the goal of providing a primary analytic description of the contemporary prevalence, risk factors, and clinical epidemiology of the disease in this potentially high risk region of the country.

The mean age of patients was 41.64 years (range: 1-104 years), with infection varying nonlinearly with age and gender. Males (88.0%) were the predominant gender affected by HCV and the majority of cases were Malays (79.5%). Intravenous drug use (64.2%) was the overwhelming prime risk factor associated with infected individuals, with incarceration(11.9%) and blood transfusions(8.6%) following in second and third, respectively. Diabetes mellitus (10.0%) and hypertension (9.1%) were the largest associated chronic diseases found in conjunction with HCV positive cases. Both HCV acute infection in addition to chronic liver cirrhosis and hepatocellular carcinoma seemed to follow a bell-curve prevalence pattern with respect to age; the largest prevalence topping off around age 40-50 years. This trend persisted when adjusted for gender as well. HCV appears to be strongly related with middle age, Malay ethnicity, and male gender, along with associated chronic diseases including diabetes mellitus and hypertension. Furthermore, intravenous drug use, incarceration, history of blood transfusion, and sexual promiscuity seemed to be the most common risk factors playing a role in infection rates. Incomplete medical records inhibited economic, treatment, and outcome of HCV to be evaluated in this particular study population so further investigation is necessary to estimate both current and future disease burdens in the state of Kedah. This data provides initial insight into the major demographic trends, populations sectors, and most common risk factors associated with HCV infections in this potentially risky area of Malaysia.

Name: Gabriela Moriel  MS '12
Degree and Year: Preprofessional Studies
University of Notre Dame, 2011

Capstone Project:  Empowering the Napo Province for a healthier future:  A partnership between Rural Health Promoters and Timmy Global Health


Abstract:  Timmy Global Health is an Indianapolis-based nonprofit organization with a hybrid mission: to expand access to healthcare both locally and internationally and to empower students and volunteers to tackle some of today’s most important global challenges. Over the past year Timmy has been working to increase access to healthcare in nine adopted communities in the Napo Province through primary care medical brigades that travel to each community every 2-3 months. Over the past year, August has been slowly developing the Rural Health Promoter program with 8 out of the 9 communities that Timmy currently resides. The research aims were to design training materials for the two rural health promoters in Napo. Surveys results showed the flu (83.02%), diarrhea (22.64%), and fever and body pains (15.09%) were most prevalent in the community. Each of these illnesses or symptoms are usually related to some underlying issue within the community and are rarely caused by more chronic infections such as HIV or TB. The goal was to use the rural health promoters as the key communication link between medical brigades and the community, by targeting health issues at their roots and preventing many of these preventable and commonly seen illnesses from occurring in the first place. Two resource cards were created to be distributed to rural health care providers in Napo Province. One card focused on hygiene and sanitation information and another on disease.

Name: Anna Nanigian  MS '12
Degree and Year: Preprofessional Studies and Sociology
University of Notre Dame, 2011

Capstone Project:  Does green always mean 'go'?: Assessing the extent to which India’s National Rural Health Mission traffic light monitoring and evaluation system accurately reflects the performance of Primary Health Centers in the state of Karnataka


Abstract:  In the state of Karnataka, an evaluation and planning initiative termed the Community Planning and Monitoring of Health Systems (CPMHS) has been formed to integrate constituent participation into health care reformation. In conducting CPMHS, representatives of each village, called Village Health and Sanitation Committee (VHSC) members assess the success of their Primary Health Centers (PHCs) by rating eleven different health parameters, such as maternal health, child health, disease surveillance, quality of care, and others, as red, yellow, or green, on a quarterly report card. An analysis of whether these traffic light evaluations accurately reflect the performance of PHCs, however, has not yet been undertaken. The goal of the research was to assess the extent to which traffic light scoring of PHCs is congruent with those PHCs’ ability to adequately service their constituents. In addition to performing quantitative analysis, the second aim of this research project was to analyze the social processes which take place to formulate traffic light rankings in community dialogue sessions. In my research, I found that from 2010 to 2011, the highest rated health parameters, those with the most villages reporting “green”, were Maternal Health Guarantees, Child Health, and Community Perceptions of ASHA. This identified the PHC goals, but did not relate them back to epidemiological data. Though a primary goal of this project was not achieved, in that I was unable to fully compare traffic light data to objective epidemiological data from PHC to PHC, the data I was able to collect, as well as the gaps in those data, shed light on the efficacy and benefits of the process of community monitoring, as well as the shortcomings which hamper it from being a truly effective method of accountability within the government health care system.

Name: Annette Ruth  MS '12
Degree and Year: Psychology and Biology
University of Notre Dame, 2011

Capstone Project:  Evaluating the efficacy of cholera prevention programming at changing PU BUC sanitation and hygiene behaviors in Haiti: Implications for control strategies, surveillance, and public policy


Abstract:  Evaluations of Catholic Relief Service's (CRS) post-earthquake cholera education programming in Haiti were conducted in June 2011 and March 2012 to evaluate the efficacy of their social marketing efforts for cholera prevention. A Knowledge, Attitudes, and Practices (KAP) survey implemented throughout Haiti collected data that was used to assess changes in beneficiaries' cholera prevention behaviors, their access to essential prevention and treatment materials, and time to seeking treatment. Thus, the purpose of the KAP was to determine the extent to which project beneficiaries have adopted improved hygiene and sanitation practices as a means of gauging the effectiveness of behavior change communication (BCC) and cholera messaging supported by the project. Furthermore, the KAP evaluation measured percent change in knowledge, behaviors, and practices between the 2011 evaluation results, serving as a partial baseline for the study, and the 2012 KAP survey to determine how well households adopted cholera prevention behavior. The main results of the study indicate that weaknesses in sanitation and hygiene practices and poor knowledge of cholera transmission have led to the persistence of cholera outbreak in Haiti. Comparing the results of the 2012 survey to the 2011 baseline found that the percentage of people who did not know how cholera was contracted increased by 22% (95% CI), comprising 59.5% of total respondents. Similarly, the percentage of people washing hands after using something touched by others, or potentially contaminated, decreased by 15% from the baseline, corresponding with poor knowledge of transmission via fomites. Open defecation decreased from 20% in 2011, though not significantly. However this data was likely confounded by the fact that a significant number of non-governmental organizations (NGOs) removed operations in Haiti, reducing handouts, resources, and informative, educational messaging given to the public. Considering that cholera spreads primarily via environmental contamination and not direct, person-to-person contact, the need for behavioral programming grows. Prevention strategies, such as behavior change programming, are necessary in countries like Haiti, where poverty, poor infrastructure, and a lack of sanitation facilities necessitate changes in routine behavior to prevent outbreak. Consistent surveillance and the implementation of environmental health assessments at outbreak sites can be used to create targeted, community-specific intervention programming.

Name: Noelle Tripp  MS '12
Degree and Year: BA Sociology and Preprofesional Studies
University of Notre Dame, 2011

Capstone Project:  Expanding preventative service delivery in Haiti


Abstract:  Currently, the country of Haiti is suffering from a two-year long cholera outbreak as well as mosquito-borne illness. Preventative measures such as the cholera vaccine and insecticide treated mosquito nets could help decrease the incidence of disease throughout the country. Existing programs that have the capacity to achieve national coverage, like the Notre Dame Haiti Program’s mass drug administration, could serve as the vehicle needed to deliver these two services. This study evaluates the feasibility and acceptability of carrying out such a project through interviews and focus groups with community members from Ca Ira, a semi urban community in Leogane, in addition to conversations with healthcare workers. Comparison studies were conducted in the rural village of Diclo and the urban borough of Carrefour. The data collected from these discussions demonstrates that community members would be receptive to incorporating additional services into the mass drug administration. However, contributions made by healthcare workers highlight that a number of logistical challenges must first be addressed. Through a proposed pilot study, the Notre Dame Haiti Program will be able to test the practicability of integrating new services into the existing structure of the mass drug administration program.

ame: Christopher Wynkoop  MS '12
Degree and Year: Chemistry
University of Notre Dame, 2011

Capstone Project:  Capturing cholera: Understanding disease dynamics and seasonal variations in Kolkata, India via a mathematical model


Abstract:  Understanding the complex dynamics of cholera can help to develop intervention strategies for current epidemics and predict and possibly prevent future outbreaks. In our research we developed a mathematical model that takes into account intrinsic disease dynamics, the presence of an aquatic reservoir of Vibrio cholerae, and external seasonal forcing factors for the Kolkata area in India.  We performed a stability analysis to determine an expression for the time-averaged expression of R0, the basic reproduction ratio, and find that it underestimates the true value of R0.  We also performed a sensitivity analysis and found several parameters that most influence the model output and, therefore, disease dynamics. We combined the aforementioned components of our model into one SIRS-type model to account for the intrinsic dynamics of a cholera outbreak determined by population-driven parameters and a seasonality component driven by external climate forcing factors. The parameter that has the strongest effect on disease dynamics is the recovery rate; there is a significant reduction in both the total size and severity of an epidemic when this rate is higher in a population.  We will continue this project with a resonance analysis and testing of the model to ensure it is ready for use with cholera and climate data in Kolkata.