Veena Sriram

Introduction: The current COVID-19 pandemic has emerged as the most urgent and challenging public health issue of our time. Public health decisions on how to curb infection rates have been required in the face of limited and sometimes contradictory evidence. There is currently limited understanding of how decision-makers use evidence in public health practice. This thesis aimed to 1) identify the types of evidence that public health decision-makers considered and 2) determine how evidence was weighed for the provincial decision to reopen K-12 public schools in British Columbia (BC) from March to June 2020. Methods: A qualitative, two-phase, multiple-methods study design was employed. Phase 1 included an organizational map, timeline of key events, and document analysis. Phase 1 informed the context and generated preliminary results. Phase 2 consisted of semi-structured key-informant interviews (n = 6) with senior public health and education decision-makers from BC to understand their perspectives on the use of evidence for the K-12 school reopening decision. Results: The organogram and timeline illustrated the nuanced relationships that existed between public health and education officials in addition to the small number of individuals with decision-making authority. The 62 documents included in the document analysis (12 official documents, 34 Twitter posts, and 16 newspaper/print media) found science and research to be the primary sources of evidence, with public needs and stakeholder engagement also being considered. Key-informant interviews reported reliance on practitioner expertise, observed and predictive epidemiological data locally and globally, and public needs (of children, parents, and teachers) for the reopening decision. The initial uncertainty of COVID-19 placed significant weight on scientific input. The context of BC and institutional trust were additional factors that influenced the reopening of K-12 public schools. Conclusion: This study highlighted that the initial uncertainty of COVID-19 made it challenging to make decisions based on evidence. This study concluded that scientific findings were the main source of input guiding the K-12 school reopening. However, public needs, experience and expertise, and contextual factors such as BC’s geography and institutional trust were all additional identified sources of evidence that was considered for the K-12 school reopening decision.

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This thesis is focused on characterizing differences in developmental outcomes among children born from intended and unintended pregnancies aged three to five. The Sustainable Development Goals have a specific target to “ensure that all girls and boys have access to quality early childhood development” by 2030. There is sparse literature regarding the impact of pregnancy intention (wantedness and timing) or planning on child development, and less so about differential impacts by ethnicity, income, or sex at birth.The research chapters of this thesis consist of two studies: First, we conducted a scoping review to summarize the evidence comparing the developmental outcomes of children from unwanted, unplanned, or mistimed (‘it happened too soon’ or ‘too late’) pregnancies to those of children from wanted or planned pregnancies. We identified 8 “cohorts” with information on approximately 39,000 children born mostly in developed countries. Overall, unwanted/unplanned pregnancies were associated with poorer child development when compared with wanted/planned pregnancies. Mistimed (sometimes classified as delayed) pregnancies correlated with weaker effects in the same direction.Second, we estimated the effect of unintended pregnancy on early childhood development in Ecuadorian children aged three to five, participating in the latest National Health and Nutrition Survey (2018) using a design-based regression model, stratified by ethnicity, sex at birth, and socioeconomic status. We also estimated to what extent eliminating unintended pregnancy would close the gap among the most privileged (i.e., high-income, white/mestizo, males) and other groups of each stratum. Among 6,687 observations representing 620,625 Ecuadorian children, unintended pregnancy was associated with 33% higher risk of inadequate development (RR: 1.33; 95% CI: 1.06; 1.64) after adjusting for available confounders. Black/montubio children were the most affected (RR: 2.78; 95% CI: 1.72; 3.85). These results suggest that these ethnic groups, along with low-income households, might benefit the most from interventions that support intended pregnancy. Together, the studies in this thesis underline the importance of policies that create environments supportive of wanted conception and access to safe abortion to reach the target for sustainable development goal 4, related to child development. In Ecuador, these interventions are particularly important for black/montubio and low-income populations.

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