"One country,two systems": Sociopolitical implications for female migrant sex workers in Hong Kong

Background

The burning of biomass fuels results in exposure to high levels of indoor air pollution, with consequent health effects. Possible interventions to reduce the exposure include changing cooking practices and introduction of smoke-free stoves supported by health education. Social, cultural and financial constraints are major challenges to implementation and success of interventions. The objective of this study is to determine awareness of women in Gondar, Ethiopia to the harmful health effects of cooking smoke and to assess their willingness to change cooking practices.

Methods

We used a single, administered questionnaire which included questions on household circumstances, general health, awareness of health impact of cooking smoke and willingness to change. We interviewed 15 women from each of rural, urban-traditional and middle class backgrounds.

Results

Eighty percent of rural women cooked indoors using biomass fuel with no ventilation. Rural women reported two to three times more respiratory disease in their children and in themselves compared to the other two groups. Although aware of the negative effect of smoke on their own health, only 20% of participants realised it caused problems in children, and 13% thought it was a cause for concern. Once aware of adverse effects, women were willing to change cooking practices but were unable to afford cleaner fuels or improved stoves.

Conclusion

Increasing the awareness of the health-effects of indoor biomass cooking smoke may be the first step in implementing a programme to reduce exposure.     

Control of household air pollution for child survival: estimates for intervention impacts

Background

Exposure to household air pollution (HAP) from cooking with solid fuels affects 2.8 billion people in developing countries, including children and pregnant women. The aim of this review is to propose intervention estimates for child survival outcomes linked to HAP.

Methods

Systematic reviews with meta-analysis were conducted for ages 0-59 months, for child pneumonia, adverse pregnancy outcomes, stunting and all-cause mortality. Evidence for each outcome was assessed against Bradford-Hill viewpoints, and GRADE used for certainty about intervention effect size for which all odds ratios (OR) are presented as protective effects.

Results

Reviews found evidence linking HAP exposure with child ALRI, low birth weight (LBW), stillbirth, preterm birth, stunting and all-cause mortality. Most studies were observational and rated low/very low in GRADE despite strong causal evidence for some outcomes; only one randomised trial was eligible.Intervention effect (OR) estimates of 0.64 (95% CI: 0.55, 0.75) for ALRI, 0.71 (0.65, 0.79) for LBW and 0.66 (0.54, 0.81) for stillbirth are proposed, specific outcomes for which causal evidence was sufficient. Exposure-response evidence suggests this is a conservative estimate for ALRI risk reduction expected with sustained, low exposure. Statistically significant protective ORs were also found for stunting [OR=0.79 (0.70, 0.89)], and in one study of pre-term birth [OR=0.70 (0.54, 0.90)], indicating these outcomes would also likely be reduced. Five studies of all-cause mortality had an OR of 0.79 (0.70, 0.89), but heterogenity precludes a reliable estimate for mortality impact. Although interventions including clean fuels and improved solid fuel stoves are available and can deliver low exposure levels, significant challenges remain in achieving sustained use at scale among low-income households.

Conclusions

Reducing exposure to HAP could substantially reduce the risk of several child survival outcomes, including fatal pneumonia, and the proposed effects could be achieved by interventions delivering low exposures. Larger impacts are anticipated if WHO air quality guidelines are met. To achieve these benefits, clean fuels should be adopted where possible, and for other households the most effective solid fuel stoves promoted. To strengthen evidence, new studies with thorough exposure assessment are required, along with evaluation of the longer-term acceptance and impacts of interventions.

     

Quantitative Guidance for Stove Usage and Performance to Achieve Health and Environmental Targets

Background

Displacing the use of polluting and inefficient cookstoves in developing countries is necessary to achieve the potential health and environmental benefits sought through clean cooking solutions. Yet little quantitative context has been provided on how much displacement of traditional technologies is needed to achieve targets for household air pollutant concentrations or fuel savings.

Objectives

This paper provides instructive guidance on the usage of cooking technologies required to achieve health and environmental improvements.

Methods

We evaluated different scenarios of displacement of traditional stoves with use of higher performing technologies. The air quality and fuel consumption impacts were estimated for these scenarios using a single-zone box model of indoor air quality and ratios of thermal efficiency.

Results

Stove performance and usage should be considered together, as lower performing stoves can result in similar or greater benefits than a higher performing stove if the lower performing stove has considerably higher displacement of the baseline stove. Based on the indoor air quality model, there are multiple performance–usage scenarios for achieving modest indoor air quality improvements. To meet World Health Organization guidance levels, however, three-stone fire and basic charcoal stove usage must be nearly eliminated to achieve the particulate matter target (< 1–3 hr/week), and substantially limited to meet the carbon monoxide guideline (< 7–9 hr/week).

Conclusions

Moderate health gains may be achieved with various performance–usage scenarios. The greatest benefits are estimated to be achieved by near-complete displacement of traditional stoves with clean technologies, emphasizing the need to shift in the long term to near exclusive use of clean fuels and stoves. The performance–usage scenarios are also provided as a tool to guide technology selection and prioritize behavior change opportunities to maximize impact.

Citation

Johnson MA, Chiang RA. 2015. Quantitative guidance for stove usage and performance to achieve health and environmental targets. Environ Health Perspect 123:820–826; http://dx.doi.org/10.1289/ehp.1408681     

Reaiming RE-AIM: Using the Model to Plan, Implement, and Evaluate the Effects of Environmental Change Approaches to Enhancing Population Health

The RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework, which provides a practical means of evaluating health interventions, has primarily been used in studies focused on changing individual behaviors. Given the importance of the built environment in promoting health, using RE-AIM to evaluate environmental approaches is logical. We discussed the benefits and challenges of applying RE-AIM to evaluate built environment strategies and recommended modest adaptations to the model. We then applied the revised model to 2 prototypical built environment strategies aimed at promoting healthful eating and active living. We offered recommendations for using RE-AIM to plan and implement strategies that maximize reach and sustainability, and provided summary measures that public health professionals, communities, and researchers can use in evaluating built environment interventions.The RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework¹ was developed to enhance the impact of health promotion interventions by evaluating the dimensions considered most relevant to real-world implementation, such as the capacity to reach underserved populations and to be adopted within diverse settings.^2,3 Briefly, the reach dimension of the framework refers to the percentage and characteristics of individuals receiving the intervention; effectiveness refers to the impact of the intervention, including anticipated as well as unanticipated outcomes; adoption concerns the percentage and representativeness of settings that adopt the intervention; implementation refers to the consistency and cost of delivering the intervention; and maintenance refers to long-term sustainability at both the setting and individual levels (see http://www.re-aim.org for more information about the framework.).^1,4,5The RE-AIM model was intended to guide planning and evaluation of evidence-based interventions^6,7 that address the different levels of the socioecological model, such as those that target individual health behavior change by increasing intrapersonal, organizational, and community resource support.⁸ It has been used to evaluate programmatic and policy⁹ interventions addressing a wide range of health conditions (e.g., diabetes, obesity, and hypertension)^10–12 and health behaviors (e.g., physical activity, dietary behaviors, and smoking).^13–15Despite RE-AIM''s efficacy as a public health planning and evaluation framework, it has not been formally applied to interventions targeting the social or built (i.e., manmade features of the environment that provide the settings for human activity)^16,17 environment. As public health continues to expand its focus beyond surveillance and epidemiology to address root factors affecting community health, we need models that help frame the planning and implementation of multilevel health interventions and guide comprehensive evaluations of the processes, effects, and outcomes¹⁸ associated with such interventions. Holistic evaluations of changes in public spaces (e.g., changes in transportation and land use) are critical given the complexity of such changes and their strong potential to positively affect social capital and cohesion or to exacerbate social and health inequities.Here we focus on applying RE-AIM to built environment interventions, although many of the issues and recommendations are also applicable to social environment interventions, and intended or unintended social consequences of interventions are included within the RE-AIM model. Our specific goals are to provide a rationale for using RE-AIM to plan and evaluate built environment changes that promote health behavior, discuss definitions and measures of the dimensions of RE-AIM and propose adaptations to them, illustrate applications of the dimensions through examples of built environment changes, and establish practical RE-AIM summary measures for built environment interventions.     

To Promote Adoption of Household Health Technologies,Think Beyond Health

Health risks from poor malaria control, unsafe water, and indoor air pollution are responsible for an important share of the global disease burden—and they can be addressed by efficacious household health technologies that have existed for decades. However, coverage rates of these products among populations at risk remain disappointingly low.We conducted a review of the medical and public health literatures and found that health considerations alone are rarely sufficient motivation for households to adopt and use these technologies.In light of these findings, we argue that health education and persuasion campaigns by themselves are unlikely to be adequate. Instead, health policymakers and professionals must understand what users value beyond health and possibly reengineer health technologies with these concerns in mind.HEALTH RISKS FROM POOR malaria control, unsafe water, and indoor air pollution are responsible for an important share of the global disease burden.1–3 These risks can be mitigated by efficacious household health technologies that have existed for decades. Insecticide-treated nets (ITNs) control malaria by protecting individuals sleeping under them from the bite of mosquitoes that carry the parasitic disease and by killing these mosquitoes directly.4,5 Water treatment processes, including boiling, solar disinfection, chemical disinfection (sometimes preceded by flocculation), and filtration, eliminate the microbial agents that cause diarrheal disease.6,7 Reengineered biomass cookstoves burn more efficiently and cleanly than traditional stoves, reducing concentrations of indoor air pollutants that cause cancers and respiratory infections.8,9However, these technologies have fallen short of their potential to improve health in developing countries, primarily because of low rates of adoption and use. Of the three, ITNs have seen relatively more progress in adoption and continued use among at-risk populations. The World Malaria Report 2011 of the World Health Organization (WHO) estimates that 50% of households in sub-Saharan Africa have at least one ITN (with about 96% of these currently in use), a substantial increase over the 3% household coverage estimated in 2000.4 The picture is more grim for water treatment and cooking technologies. Rosa and Clasen estimate that less than 30% of households in countries where unsafe drinking water can be a problem adequately treat their water at home (mainly through boiling), with significantly lower rates among African and rural households despite their being at higher risk of waterborne disease.10 A report sponsored by the United Nations Development Programme (UNDP) and WHO estimates that 27% of households that cook with solid fuels do so with some form of “improved” cookstove.11 A common problem, especially for improved cookstoves, is that usage rates also often decline after initial adoption.12     

Prevalence and determinants of the cleanliness of shared toilets in Kampala slums, Uganda

Aim

Keeping shared toilets clean is a key public health challenge household users face in urban slum settlements of most developing countries. This paper provides insights on the cleanliness of households’ shared toilets and the factors that influence their cleanliness, as well as influencing the inclination of the users to keep them clean.

Subjects and methods

This analysis is part of a cross-sectional study conducted in 50 randomly selected slums in Kampala, Uganda between October and November 2010. A total of 1,500 respondents were interviewed, using a semi-structured questionnaire.

Results

Out of 1,019 respondents using shared toilets, less than 12 % reported having very clean toilets. Some of the significant factors influencing the cleanliness of shared toilets are: the ease or difficulty in keeping shared toilets clean, the number of households sharing a toilet room, effortful cleaning behaviour and cleaning intention on the part of the users.

Conclusion

The findings show that most slum dwellers use toilets that are not hygienic.     

Effect of worldwide oil price fluctuations on biomass fuel use and child respiratory health: evidence from Guatemala

Objectives. We examined the effect of worldwide oil price fluctuations on household fuel use and child respiratory health in Guatemala.Methods. We regressed measures of household fuel use and child respiratory health on the average worldwide oil price and a rich set of covariates. We leveraged variation in oil prices over the 6-month period of the survey to identify associations between fuel prices, fuel choice, and child respiratory outcomes.Results. A $1 (3.4% point) increase in worldwide fuel prices was associated with a 2.8% point decrease in liquid propane gasoline use (P < .05), a 0.75% point increase in wood use (P < .05), and a 1.5% point increase in the likelihood of the child reporting a respiratory symptom (P < .1). The association between oil prices and the fuel choice indicators was largest for households in the middle of the income distribution.Conclusions. Fluctuations in worldwide fuel prices affected household fuel use and, consequently, child health. Policies to help households tide over fuel price shocks or reduce pollution from biomass sources would confer positive health benefits. Such policies would be most effective if they targeted both poor and middle-income households.Acute respiratory illnesses are the leading cause of death among children in the developing world and account for nearly 20% of child deaths.^1–4 Past research has found a strong association between respiratory health and household use of biomass fuels,^5–15 leading to the conclusion that exposure to indoor air pollution from cooking and heating with biomass fuels such as wood, dung, or crop residues causes at least one third of childhood respiratory illnesses.^3,4 These findings are supported by results from studies that used quasi-experimental conditions to more rigorously establish causality.^16–18The design of effective policies to reduce indoor air pollution requires an understanding of how families choose fuels. Certainly, socioeconomic status is important: poorer households are more likely to use biomass fuels, with high start-up costs and lack of access preventing adoption of cleaner alternatives.^2-4,7 The relative price of clean fuels, such as liquid propane gasoline, vis-à-vis dirty fuels could also affect fuel choice.^19,20 The price of liquid propane gasoline is determined not only by local supply and demand but also by the worldwide market price of crude oil, which is used to produce liquid propane gasoline. Anecdotal evidence indicates that increases in worldwide crude oil prices may cause families to substitute away from cleaner alternatives, particularly in the short run.²¹ However, no research has explored the effect of fluctuations in worldwide crude oil price on fuel use and health outcomes.The great variation in household fuel use in Guatemala—around 60% of households use wood, 40% use liquid propane gasoline, 35% use some combination of the two, and 8% use other types of fuels, such as kerosene, coal, or electricity²²—makes it an ideal setting to study the impact of price changes on fuel choice. As with other developing countries, previous research on Guatemala has suggested that education, socioeconomic position, and clean fuel availability play a large role in driving liquid propane gasoline adoption. The effect of price fluctuations, however, has not been well elucidated.²³ Therefore, we addressed this gap by using a rich data set from Guatemala to examine the association between fluctuations in the worldwide crude oil price, household fuel choice, and childhood respiratory illness.     

Household costs for personal protection against mosquitoes: secondary outcomes from a randomised controlled trial of dengue prevention in Guerrero state,Mexico

Background

Dengue is a serious public health issue that affects households in endemic areas in terms of health and also economically, imposing costs for prevention and treatment of cases. The Camino Verde cluster-randomised controlled trial in Mexico and Nicaragua assessed the impact of evidence-based community engagement in dengue prevention. The Mexican arm of the trial was conducted in 90 randomly selected communities in three coastal regions of Guerrero State. This study reports an analysis of a secondary outcome of the trial: household use of and expenditure on anti-mosquito products. We examined whether the education and mobilisation activities of the trial motivated people to spend less on anti-mosquito products.

Methods

We carried out a household questionnaire survey in the trial communities in 2010 (12,312 households) and 2012 (5349 households in intervention clusters, 5142 households in control clusters), including questions about socio-economic status, self-reported dengue illness, and purchase of and expenditure on insecticide anti-mosquito products in the previous month. We examined expenditures on anti-mosquito products at baseline in relation to social vulnerability and we compared use of and expenditures on these products between intervention and control clusters in 2012.

Results

In 2010, 44.2% of 12,312 households reported using anti-mosquito products, with a mean expenditure of USD4.61 per month among those who used them. Socially vulnerable households spent less on the products. In 2012, after the intervention, the proportion of households who purchased anti-mosquito products in the last month was significantly lower in intervention clusters (47.8%; 2503/5293) than in control clusters (53.3%; 2707/5079) (difference ? 0.05, 95% CIca ?0.100 to ?0.010). The mean expenditure on the products, among those households who bought them, was USD6.43; 30.4% in the intervention clusters and 36.7% in the control clusters spent more than this (difference ? 0.06, 95% CIca ?0.12 to ?0.01). These expenditures on anti-mosquito products represent 3.3% and 3.8% respectively of monthly household income for the poorest 10% of the population in 2012.

Conclusions

The Camino Verde community mobilisation intervention, as well as being effective in reducing dengue infections, was effective in reducing household use of and expenditure on insecticide anti-mosquito products.

Trial registration

(ISRCTN27581154).

     

Sustained Effects of the Communities That Care System on Prevention Service System Transformation

Objectives. We examined whether the Communities That Care (CTC) system sustained effects 1.5 years after study funding ended on prevention system constructs expected to be important for community-level reductions in drug use and antisocial behaviors among youths.Methods. Data were from a community trial of 24 towns in the United States randomized to either the CTC intervention or control conditions. Participants were 928 community key leaders interviewed at 1 to 4 waves from 2001 to 2009. Intervention activities, including training and technical assistance, were conducted between 2003 and 2008 in the CTC communities.Results. Leaders from CTC communities reported higher levels of adoption of a science-based approach to prevention and a higher percentage of funding desired for prevention activities in 2009 than did leaders in control communities. CTC communities showed a higher increase over time in community norms against adolescent drug use as well as adoption of a science-based approach compared with control communities.Conclusions. These findings indicated that CTC implementation produced enduring transformation of important prevention system constructs in intervention communities, which might, in turn, produce long-term reductions in youth problem behaviors.Despite evidence for effectiveness of preventive interventions to reduce the occurrence of drug use and delinquent behaviors among youths,1,2 few communities have implemented such interventions as part of community-wide strategies. Approaches that address prevention of youth problem behaviors through community system-level changes have the potential for significant public health impact.3–5 Consistent with this, the federal government identified systems thinking and evidence-based practices, research, and evaluation as 2 priorities for public health improvement for the next decade.6A recent review identified that a common feature of successful strategies for reducing alcohol use or availability of alcohol to adolescents is reliance on local coalitions to develop and implement prevention plans.5 For example, Communities Mobilizing for Change on Alcohol (a program using coalition-based efforts to change community policies, practices, and norms related to underage alcohol use) showed a reduction of alcohol provision to minors and arrests for drunk driving among 18- to 20-year-old drivers.7,8 The Midwestern Prevention Project, which combined coalition-led strategies with school-based prevention activities, demonstrated reductions in past-month cigarette and alcohol use among middle school students.9 Not all coalition-based efforts have proven successful, however. For example, the Fighting Back10 and Community Partnership11 initiatives did not yield reductions in youth alcohol use. Insufficient guidance on implementing prevention strategies and reliance on locally created prevention programs not tested for effectiveness likely played roles in the lack of effects.A coalition-based community strategy that showed significant effects on youth outcomes is Communities That Care (CTC).12,13 CTC is a manualized system to mobilize communities to develop and transform their prevention systems to address elevated risk and depressed protective factors for youth problem behaviors through the appropriate selection, installation, and monitoring of tested and effective preventive interventions.14,15 According to the CTC theory of change, CTC implementation leads to reduced problem behavior and positive development among youths through activating and reinforcing 5 prevention system constructs:

1. adoption of a science-based approach to prevention,16
2. community support for prevention,17,18
3. community norms against adolescent drug use,19
4. collaboration across community service sectors for prevention,20,21 and
5. use of the social development strategy.22

Although each construct is theorized to be important,23–26 adoption of a science-based approach to prevention, which refers to community leaders’ understanding and use of a prevention science framework to plan and implement programs to prevent youth problem behaviors,16 is the primary mechanism through which CTC is expected to produce positive changes in outcomes.27Findings from the Community Youth Development Study (CYDS), a community-randomized controlled trial designed to test the efficacy of CTC,12,13 were consistent with this theory of change. Previous studies found positive effects of CTC on prevention system constructs. Earlier CYDS findings showed that CTC compared with control community leaders reported higher levels of adoption of a science-based approach to prevention in 2004 and 2007, 1.5 and 4.5 years after initial CTC implementation, respectively.28,29 Also, at 4.5 years after implementation, leaders from CTC compared with control communities reported a higher percentage of funding desired for prevention activities and, among communities with higher proportions of residents in poverty, higher levels of community norms against adolescent drug use.As CTC communities transformed their prevention systems, risk factors for problem behaviors that were selected by CTC communities to be targeted for intervention were also affected.30,31 Using data from a sample of youths followed longitudinally from fifth through eighth grades over a corresponding time period (2004–2007) from the same randomized CYDS communities, studies demonstrated a slower growth of levels of targeted risk factors among youths from CTC compared with control communities.30,31 Finally, data from these longitudinal studies showed that positive youth outcomes were achieved. Compared with those from control communities, CTC youths were less likely to initiate delinquent behavior and use of alcohol, cigarettes, and smokeless tobacco; were less likely to use alcohol and smokeless tobacco in the past month and to binge drink in the past 2 weeks; and reported fewer past-year delinquent behaviors.30,31Recent research from the CYDS longitudinal sample assessed during 10th grade, 1 year after the removal of study funding and resources for intervention to CTC communities, showed that youths from CTC compared with youths from control communities continued to have a reduced risk of initiation of alcohol and cigarette use and delinquent behavior, lower prevalence of current smoking and past-year delinquent behavior, and lower levels of risk factors targeted by communities.32 These findings indicated that the effects of interventions implemented through CTC during the study period were sustained for a year beyond funding.An important next question was whether CTC’s effects on prevention systems were also sustained. Data from previous CYDS analyses of prevention system characteristics were collected while CTC communities were receiving study-funded intervention resources. The time shortly after removal of funding was an important period in the long-term viability of this intervention. Because of challenges with competing demands and sustaining momentum, interventions often cease after withdrawal of study funding.33,34 Without study resources, will CTC communities abandon the use of science to guide prevention strategies or decrease their commitment to prevention efforts? Is an initial round of CTC training and implementation sufficient to generate sustained system-wide changes in prevention systems that have potential for continued long-term reductions in youth problem behaviors?As a follow-up to previous studies and as part of the ongoing CYDS, this study examined whether CTC’s effects on prevention system constructs were sustained through 2009—approximately 6.5 years after initial implementation, 2 years after the previous data collection, and 1.5 years after study resources for CTC implementation were withdrawn. This study also examined whether effects of CTC on prevention system constructs differed by community-level characteristics, including percentage of residents living in poverty, percentage of non-White residents, and population size.     

Assessment of unmet needs to address noncompliant households during polio supplemental immunization activities in Kaduna state, 2014–2016

Background

Despite concerted global efforts being made to eradicate poliomyelitis, the wild poliovirus still circulates in three countries, including Nigeria. In addition, Nigeria experiences occasional outbreaks of the circulating vaccine-derived poliovirus type 2 (cVDPV2). Vaccine rejection by caregivers persists in some parts of northern Nigeria, which compromises the quality of supplemental immunization activities (SIAs). In 2013, the Expert Review Committee (ERC) on polio recommended innovative interventions in all high-risk northern states to improve the quality of SIA rounds through innovative interventions. The study assessed the impact of using unmet needs data to develop effective strategies to address noncompliant households in 13 high-risk Local government areas (LGAs) in Kaduna state, Nigeria.

Methods

A retrospective study was conducted in noncompliant communities using unmet needs data collated from 2014 to 2016. Household-based noncompliance data collated from tally sheets between 2013 and 2016 was also analyzed to assess the impact of unmet needs data in addressing noncompliance households in high-risk communities in Kaduna state. A structured interview was used to interview caregivers by the application of an unmet needs questionnaire, a quantitative study that assesses caregiver perception on immunization and other unmet needs which, if the gaps were addressed, would allow them to accept immunization services. Interventions include siting of temporary health camps in noncompliant communities to provide free medical consultations, treatment of minor ailments, provision of free antimalaria drugs and other essential drugs, and also referral of serious cases; intervention of religious and traditional leaders, youth against polio intervention, and the use of attractive bonuses (sweets, balloons, milk) during SIAs were all innovations applied to reduce noncompliance in households in affected communities as the need for eradication of polio was declared as a state of emergency. Outcomes from the analyses of unmet needs data were used to direct specific interventions to certain areas where they will be more effective in reducing the number of noncompliant households recorded on the tally sheet in each SIA round. Hence, seven immunization parameters were assessed from the unmet needs data.

Results

Overall, 54% of the noncompliant caregivers interviewed were ready to support immunization services in their communities. The majority of caregivers were also willing to vaccinate their children publicly following unmet needs interventions that were conducted in noncompliant communities. The trend of noncompliant households decreased by 79% from 16,331 in September 2013 to 3394 in May 2016.

Conclusions

Unmet needs interventions were effective in reducing the number of noncompliant households recorded during SIA rounds in Kaduna State. Hence, unmet needs intervention could be adapted at all levels to address challenges faced in other primary healthcare programs in Nigeria.

     

Living in Mosul during the time of ISIS and the military liberation: results from a 40-cluster household survey

Background

In June 2014, an estimated 1500 fighters of the Islamic State of Iraq and Syria (ISIS) seized control of Mosul, Iraq’s second city. Although many residents fled, others stayed behind, enduring the restrictive civil and social policies of ISIS. In December 2016, the military activity, known as the liberation campaign, began in east Mosul, concluding in west Mosul in June 2017.

Methods

To assess life in Mosul under ISIS, and the consequences of the military campaign to retake Mosul we conducted a 40 cluster-30 household survey in Mosul, starting in March 2017. All households included were present in Mosul throughout the entire time of ISIS control and military action.

Results

In June 2014, 915 of 1139 school-age children (80.3%) had been in school, but only 28 (2.2%) attended at least some school after ISIS seized control. This represented a decision of families. Injuries to women resulting from intimate partner violence were reported in 415 (34.5%) households. In the surveyed households, 819 marriages had occurred; 688 (84.0%) among women. Of these women, 89 (12.9%) were aged 15 years and less, and 253 (49.7%) were aged under 18 at the time of marriage. With Mosul economically damaged by ISIS control and physically during the Iraqi military action, there was little employment at the time of the survey, and few persons were bringing cash into households. The liberation of Mosul in 2017 caused extensive damage to dwellings. Overall only a quarter of dwellings had not sustained some damage. In west Mosul, only 21.7% of houses had little or no damage from the conflict, with 98 (21.7%) households reporting their house had been destroyed, forcing its occupants to move. No houses had regular electricity and there was limited piped water. Inadequate fuel for cooking was reported by 996 (82.9%) households.

Conclusion

The physical, and social damage occurring during ISIS occupation of Mosul and during the subsequent military action (liberation) was substantial and its impact is unlikely to be erased soon.

     

Informed community mobilization for dengue prevention in households with and without a regular water supply: Secondary analysis from the Camino Verde trial in Nicaragua

Background

Studies in different countries have identified irregular water supply as a risk factor for dengue virus transmission. In 2013, Camino Verde, a cluster-randomised controlled trial in Managua, Nicaragua, and Mexico’s Guerrero State, demonstrated impact of evidence-based community mobilisation on recent dengue infection and entomological indexes of infestation by Aedes aegypti mosquitoes. This secondary analysis of data from the trial impact survey asks: (1) what is the importance of regular water supply in neighbourhoods with and without the trial intervention and (2) can community interventions like Camino Verde reasonably exclude households with adequate water supply?

Methods

Entomological data collected in the dry season of 2013 in intervention and control communities allow contrasts between households with regular and irregular water supplies. Indicators of entomological risk included the House Index and pupa positive household index. Generalised linear mixed models with cluster as a random effect compared households with and without regular water, and households in intervention and control communities.

Results

For the House Index, regular water supply was associated with a protection in both intervention households (OR 0.7, 95%CI 0.6–0.9) and control households (OR 0.6, 95%CI 0.5–0.8). For the pupa positive household index, we found a similar protection from regular water supply in intervention households (OR 0.6, 95%CI 0.4–0.8) and control households (OR 0.7, 95%CI 0.5–0.9). The Camino Verde intervention had a similar impact on House Index in households with regular water supply (OR 0.7, 95%CI 0.5–1.0) and irregular water supply (OR 0.6, 95%CI 0.4–0.8); for the pupa positive household index, the effect of the intervention was very similar in households with regular (OR0.5, 95%CI 0.3–0.8) and irregular (OR 0.5, 95%CI 0.3–0.9) water supply.

Conclusion

While Aedes aegypti control efforts based on informed community mobilisation had a strong impact on households without a regular water supply, this intervention also impacted entomological indices in households with a regular water supply. These households should not be excluded from community mobilisation efforts to reduce the Aedes aegypti vector.

Trial registration

ISRCTN27581154.

     

Relationship between Economic Security and Self-Rated Health in Elderly Japanese Residents Living Alone

Objectives

The purpose of this study was to assess the relationship between economic security and self-rated health for elderly Japanese residents living alone.

Design

A secondary analysis of a cross-sectional study.

Setting

N City, H. Prefecture, Japan.

Participants

Survey questionnaires were distributed to 2,985 elderly residents living alone, aged ≥70 years, of which, 1,939 (65.0%) were returned and treated as valid responses.

Measurements

The survey included questions about gender, age, number of years spent in N City, self-rated health, economic security, number of years spent living alone, reason for living alone, life satisfaction, cooking frequency, frequency of seeing a doctor, long-term care service usage, as well as whether they enjoyed their lives, participated in social organizations.

Results

Of the respondents, 1,563 (80.6%) reported that they were economically secure, and 376 (19.4%) responded that they were insecure. The odds ratio predicting poor self-rated health for the economically insecure participants was significantly high (odds ratio: 3.19, 95%, Confidence Interval (CI): 2.53?4.02, and P < 0.001). Similarly, the adjusted odds ratio for poor self-rated health was significantly high for the economically insecure participants in multivariate analyses controlling for factors such as age, gender, cooking frequency, and social participation (adjusted odds ratio: 2.21, 95%, CI: 1.70?2.88, and P < 0.001). Furthermore, a similar trend was observed in stratified analyses based on gender and age groups.

Conclusion

Economic security predicted self-rated health independently of confounders, including social participation and cooking frequency, among the elderly Japanese living alone in communities.

     

Access to and perceptions towards water,sanitation and hygiene: a case of HIV/AIDS affected and non-affected households in rural Uganda

Aim

To explore the water, sanitation and hygiene (WASH) access and perceptions among households with people living with HIV/AIDS (affected households) as compared to households without people living with HIV/AIDS (non-affected households).

Methods

This was a cross-sectional study that was conducted in the rural districts of Mpigi and Gomba. The study used a sample of 450 respondents with 222 from HIV/AIDS affected and 228 from HIV/AIDS non-affected households.

Results

Majority of respondents had improved water sources although most of these sources were beyond 2 km from households. Respondents from HIV/AIDS-affected households were four times more likely to have ever used a chemical water disinfectant locally known as “water guard”. Additionally, affected households were twice more likely to mention having clean containers for storing drinking water and twice more likely to report boiling water for drinking. No significant differences in presence of latrines for affected and non-affected households were reported. Households with a perception that fetching water takes a lot of time were more likely to buy water from vendors.

Conclusions

Access to improved water sources in short distances with a round trip water collection time of 30 min as recommended by WHO/UNICEF is still a challenge in this region. Good water practices were reported more in HIV/AIDS-affected households. A perception that fetching water takes a lot of time is significantly associated with buying water from vendors. Sleeping in own house is significantly associated with household presence of latrines.     

Prevalence,care-seeking,and health service utilization for non-communicable diseases among Syrian refugees and host communities in Lebanon

Background

Given the large burden of non-communicable diseases (NCDs) among both Syrian refugees and the host communities within which they are settled, humanitarian actors and the government of Lebanon face immense challenges in addressing health needs. This study assessed health status, unmet needs, and utilization of health services among Syrian refugees and host communities in Lebanon.

Methods

A cross-sectional survey of Syrian refugees and host communities in Lebanon was conducted using a two-stage cluster survey design with probability proportional to size sampling. To obtain information on chronic NCDs, respondents were asked a series of questions about hypertension, cardiovascular disease, diabetes, chronic respiratory disease, and arthritis. Differences in household characteristics by care-seeking for these conditions were examined using chi-square, t-test, and adjusted logistic regression methods.

Results

Over half (50.4 %) of refugee and host community households (60.2 %) reported a member with one of the five NCDs. Host community prevalence rates were significantly higher than refugees for all conditions except chronic respiratory diseases (p?=?0.08). Care-seeking for NCDs among refugees and host community households was high across all conditions with 82.9 and 97.8 %, respectively, having sought care in Lebanon for their condition. Refugees utilized primary health care centers (PHCC) (57.7 %) most often while host communities sought care most in private clinics (62.4 %). Overall, 69.7 % of refugees and 82.7 % of host community members reported an out-of-pocket consultation payment (p?=?0.041) with an average payment of US$15 among refugees and US$42 for the host community (p <0.001).

Conclusions

Given the protracted nature of the Syrian crisis and the burden on the Lebanese health system, implications for both individuals with NCDs and Lebanon’s health system are immense. The burden of out of pocket expenses on persons with NCDs are also substantial, especially given the tenuous economic status of many refugees and the less affluent segments of the Lebanese population. Greater investment in the public sector health system could benefit all parties. Efforts to improve quality of care for NCDs at the primary care level are also a critical component of preventing adverse outcomes and lowering the overall cost of care for NCDs.

     

Assessing and improving organizational readiness to implement substance use disorder treatment in primary care: findings from the SUMMIT study

Background

Millions of people with substance use disorders (SUDs) need, but do not receive, treatment. Delivering SUD treatment in primary care settings could increase access to treatment because most people visit their primary care doctors at least once a year, but evidence-based SUD treatments are underutilized in primary care settings. We used an organizational readiness intervention comprised of a cluster of implementation strategies to prepare a federally qualified health center to deliver SUD screening and evidence-based treatments (extended-release injectable naltrexone (XR-NTX) for alcohol use disorders, buprenorphine/naloxone (BUP/NX) for opioid use disorders and a brief motivational interviewing/cognitive behavioral –based psychotherapy for both disorders). This article reports the effects of the intervention on key implementation outcomes.

Methods

To assess changes in organizational readiness we conducted pre- and post-intervention surveys with prescribing medical providers, behavioral health providers and general clinic staff (N?=?69). We report on changes in implementation outcomes: acceptability, perceptions of appropriateness and feasibility, and intention to adopt the evidence-based treatments. We used Wilcoxon signed rank tests to analyze pre- to post-intervention changes.

Results

After 18 months, prescribing medical providers agreed more that XR-NTX was easier to use for patients with alcohol use disorders than before the intervention, but their opinions about the effectiveness and ease of use of BUP/NX for patients with opioid use disorders did not improve. Prescribing medical providers also felt more strongly after the intervention that XR-NTX for alcohol use disorders was compatible with current practices. Opinions of general clinic staff about the appropriateness of SUD treatment in primary care improved significantly.

Conclusions

Consistent with implementation theory, we found that an organizational readiness implementation intervention enhanced perceptions in some domains of practice acceptability and appropriateness. Further research will assess whether these factors, which focus on individual staff readiness, change over time and ultimately predict adoption of SUD treatments in primary care.

     

Community cost-benefit discussions that launched the Camino Verde intervention in Nicaragua

Background

Recent literature on community intervention research stresses system change as a condition for durable impact. This involves highly participatory social processes leading to behavioural change.

Methods

Before launching the intervention in the Nicaraguan arm of Camino Verde, a cluster-randomised controlled trial to show that pesticide-free community mobilisation adds effectiveness to conventional dengue controls, we held structured discussions with leaders of intervention communities on costs of dengue illness and dengue control measures taken by both government and households. These discussions were the first step in an effort at Socialising Evidence for Participatory Action (SEPA), a community mobilisation method used successfully in other contexts. Theoretical grounding came from community psychology and behavioural economics.

Results

The leaders expressed surprise at how large and unexpected an economic burden dengue places on households. They also acknowledged that large investments of household and government resources to combat dengue have not had the expected results. Many were not ready to see community preventive measures as a substitute for chemical controls but all the leaders approved the formation of “brigades” to promote chemical-free household control efforts in their own communities.

Conclusions

Discussions centred on household budget decisions provide a good entry point for researchers to engage with communities, especially when the evidence showed that current expenditures were providing a poor return. People became motivated not only to search for ways to reduce their costs but also to question the current response to the problem in question. This in turn helped create conditions favourable to community mobilisation for change.

Trial registration

ISRCTN27581154.

     

Chronic non-communicable diseases and the challenge of universal health coverage: insights from community-based cardiovascular disease research in urban poor communities in Accra,Ghana

Background

The rising burden of chronic non-communicable diseases in low and middle income countries has major implications on the ability of these countries to achieve universal health coverage. In this paper we discuss the impact of cardiovascular diseases (CVD) on primary healthcare services in urban poor communities in Accra, Ghana.

Methods

We review the evidence on the evolution of universal health coverage in Ghana and the central role of the community-based health planning services (CHPS) programme and the National Health Insurance Scheme in primary health care. We present preliminary findings from a study on community CVD knowledge, experiences, responses and access to services.

Results

The rising burden of NCDs in Ghana will affect the achievement of universal health coverage, particularly in urban areas. There is a significant unmet need for CVD care in the study communities. The provision of primary healthcare services for CVD is not accessible, equitable or responsive to the needs of target communities.

Conclusions

We consider these findings in the context of the primary healthcare system and discuss the challenges and opportunities for strengthening health systems in low and middle-income countries.

     

Coverage and beliefs about temephos application for control of dengue vectors and impact of a community-based prevention intervention: secondary analysis from the Camino Verde trial in Mexico

Background

Temephos in domestic water containers remains a mainstay of Latin American government programmes for control of Aedes aegypti and associated illnesses, including dengue. There is little published evidence about coverage of routine temephos programmes. A cluster randomised controlled trial of community mobilisation in Mexico and Nicaragua reduced vector indices, dengue infection, and clinical dengue cases. Secondary analysis from the Mexican arm of the trial examined temephos coverage and beliefs, and the impact of the trial on these outcomes.

Methods

The trial impact survey in December 2012, in 10,491 households in 45 intervention and 45 control clusters, asked about visits from the temephos programme, retention of applied temephos, and views about temephos and mosquito control. Fieldworkers noted if temephos was present in water containers.

Results

Some 42.4% of rural and 20.7% of urban households reported no temephos programme visits within the last 12 months. Overall, 42.0% reported they had temephos placed in their water containers less than 3 months previously. Fieldworkers observed temephos in at least one container in 21.1% of households. Recent temephos application and observed temephos were both significantly more common in urban households, when other household variables were taken into account; in rural areas, smaller households were more likely to have temephos present.Most households (74.4%) did not think bathing with water containing temephos carried any health risk. Half (51%) believed drinking or cooking with such water could be harmful and 17.6% were unsure.Significantly fewer households in intervention sites (16.5%) than in control sites (26.0%) (Risk Difference ? 0.095, 95% confidence interval ? 0.182 to ?0.009) had temephos observed in their water; more households in intervention clusters (41.8%) than in control clusters (31.6%) removed the applied temephos quickly. Although fewer households in intervention sites (82.7%) compared with control sites (86.7%) (RD -0.04, 95% CI -0.067 to ?0.013) agreed temephos and fumigation was the best way to avoid mosquitoes, the proportion believing this remained very high.

Conclusion

Coverage with the government temephos programme was low, especially in rural areas. Despite an intervention encouraging non-chemical mosquito control, most households continued to believe that chemicals are the best control method.

Trial registration

ISRCTN:27581154.