In pursuit of 'safe' water: the burden of personal injury from water fetching in 21 low-income and middle-income countries.

INTRODUCTION: Water fetching for household needs can cause injury, but documentation of the burden of harm globally has been limited. We described the frequency, characteristics and correlates of water-fetching injuries in 24 sites in 21 low-income and middle-income countries in Asia, Africa and Latin America and the Caribbean. METHODS: In a survey of 6291 randomly selected households, respondents reported whether and how they had experienced water-fetching injuries. Responses were coded for injury type, mechanism, bodily location and physical context. We then identified correlates of injury using a multilevel, mixed-effects logistic regression model. RESULTS: Thirteen per cent of respondents reported at least one water-fetching injury. Of 879 injuries, fractures and dislocations were the most commonly specified type (29.2%), and falls were the most commonly specified mechanism (76.4%). Where specified, 61.1% of injuries occurred to the lower limbs, and dangerous terrain (69.4%) was the most frequently reported context. Significant correlates included being female (aOR=1.50, 95% CI 1.15 to 1.96); rural (aOR=4.80, 95% CI 2.83 to 8.15) or periurban residence (aOR=2.75, 95% CI 1.64 to 4.60); higher household water insecurity scores (aOR=1.09, 95% CI 1.07 to 1.10) and reliance on surface water (aOR=1.97, 95% CI 1.21 to 3.22) or off-premise water sources that required queueing (aOR=1.72, 95% CI 1.19 to 2.49). CONCLUSION: These data suggest that water-fetching injuries are an underappreciated and largely unmeasured public health challenge. We offer guidelines for comprehensive data collection on injuries to better capture the true burden of inadequate water access. Such data can guide the design of interventions to reduce injury risk and promote equitable water access solutions.

Knowledge, attitudes, intentions, and behavior related to green infrastructure for flood management: A systematic literature review.

Green infrastructure (GI), which mimics natural hydrological systems, is a promising solution for flood management at the intersection of urban built infrastructure and natural systems. However, it has not yet achieved widespread uptake, due in part to insufficient understanding of human dimensions of the broader socio-ecological-technical system. We therefore conducted a multidisciplinary systematic literature review to synthesize research on people's existing knowledge about flood risk and GI, and how that shapes their attitudes and motivation to adopt new solutions. We systematically screened 21,207 studies on GI for flood management; 85 met our inclusion criteria. We qualitatively analyzed these studies to extract results on knowledge, attitudes, intentions, and behavior relating to GI for flood management. Overall, knowledge of GI was low across the 44 studies in which it was evaluated. Seventy studies assessed attitudes about GI, including the functional, aesthetic, health and safety, recreational, conservation, financial, and cultural value of GI, albeit their measurement was inconsistent. Willingness to implement or pay for GI varied considerably across 55 studies in which it was measured. Twenty studies measured and documented behavior relating to GI use, and these found low rates of adoption. Few studies systematically assessed the role of demographic, socio-economic, or geographic characteristics that could influence individuals' knowledge, attitudes, intentions or behavior, and thereby the success of GI programs. We recommend that researchers should more systematically capture data on human dimensions of GI (i.e. knowledge, attitudes, intentions, and behavior) across diverse settings to improve program design and uptake, especially among vulnerable populations. Greater attention to the social component of the socio-ecological-technical system will help ensure that GI programs are equitable, inclusive, and sustainable.

A systematic review of the human health and social well-being outcomes of green infrastructure for stormwater and flood management.

BACKGROUND: The increase in frequency and intensity of urban flooding is a global challenge. Flooding directly impacts residents of industrialized cities with aging combined sewer systems, as well as cities with less centralized infrastructure to manage stormwater, fecal sludge, and wastewater. Green infrastructure is growing in popularity as a sustainable strategy to mimic nature-based flood management. Although its technical performance has been extensively studied, little is known about the effects of green stormwater infrastructure on human health and social well-being. METHODS: We conducted a multidisciplinary systematic review of peer-reviewed and gray literature on the effects of green infrastructure for stormwater and flood management on individuals', households', and communities' a) physical health; b) mental health; c) economic well-being; and d) flood resilience and social acceptance of green infrastructure. We systematically searched databases such as PubMed, Web of Science, and Scopus; the first 300 results in Google Scholar; and websites of key organizations including the United States Environmental Protection Agency. Study quality and strength of evidence was assessed for included studies, and descriptive data were extracted for a narrative summary. RESULTS: Out of 21,213 initial results, only 18 studies reported health or social well-being outcomes. Seven of these studies used primary data, and none allowed for causal inference. No studies connected green infrastructure for stormwater and flood management to mental or physical health outcomes. Thirteen studies were identified on economic outcomes, largely reporting a positive association between green infrastructure and property values. Five studies assessed changes in perceptions about green infrastructure, but with mixed results. Nearly half of all included studies were from Portland, Oregon. CONCLUSIONS: This global systematic review highlights the minimal evidence on human health and social well-being relating to green infrastructure for stormwater and flood management. To enable scale-up of this type of infrastructure to reduce flooding and improve ecological and human well-being, widespread acceptance of green infrastructure will be essential. Policymakers and planners need evidence on the full range of benefits from different contexts to enable financing and implementation of instfrastructure options, especially in highly urbanized, flood-prone settings around the world. Therefore, experts in social science, public health, and program evaluation must be integrated into interdisciplinary green infrastructure research to better relate infrastructure design to tangible human outcomes.

Community-Led Total Sanitation: A Mixed-Methods Systematic Review of Evidence and Its Quality.

BACKGROUND: Community-led total sanitation (CLTS) is a widely applied rural behavior change approach for ending open defecation. However, evidence of its impact is unclear. OBJECTIVES: We conducted a systematic review of journal-published and gray literature to a) assess evidence quality, b) summarize CLTS impacts, and c) identify factors affecting implementation and effectiveness. METHODS: Eligible studies were systematically screened and selected for analysis from searches of seven databases and 16 websites. We developed a framework to appraise literature quality. We qualitatively analyzed factors enabling or constraining CLTS, and summarized results from quantitative evaluations. DISCUSSION: We included 200 studies (14 quantitative evaluations, 29 qualitative studies, and 157 case studies). Journal-published literature was generally of higher quality than gray literature. Fourteen quantitative evaluations reported decreases in open defecation, but did not corroborate the widespread claims of open defecation-free (ODF) villages found in case studies. Over one-fourth of the literature overstated conclusions, attributing outcomes and impacts to interventions without an appropriate study design. We identified 43 implementation- and community-related factors reportedly affecting CLTS. This analysis revealed the importance of adaptability, structured posttriggering activities, appropriate community selection, and further research on combining and sequencing CLTS with other interventions. CONCLUSIONS: The evidence base on CLTS effectiveness available to practitioners, policy makers, and program managers to inform their actions is weak. Our results highlight the need for more rigorous research on CLTS impacts as well as applied research initiatives that bring researchers and practitioners together to address implementation challenges to improve rural sanitation efforts. https://doi.org/10.1289/EHP1965.

Identifying sources, pathways and risk drivers in ecosystems of Japanese Encephalitis in an epidemic-prone north Indian district.

Japanese Encephalitis (JE) has caused repeated outbreaks in endemic pockets of India. This study was conducted in Kushinagar, a highly endemic district, to understand the human-animal-ecosystem interactions, and the drivers that influence disease transmission. Utilizing the ecosystems approach, a cross-sectional, descriptive study, employing mixed methods design was employed. Four villages (two with pig-rearing and two without) were randomly selected from a high, a medium and a low burden (based on case counts) block of Kushinagar. Children, pigs and vectors were sampled from these villages. A qualitative arm was incorporated to explain the findings from the quantitative surveys. All human serum samples were screened for JE-specific IgM using MAC ELISA and negative samples for JE RNA by rRT-PCR in peripheral blood mononuclear cells. In pigs, IgG ELISA and rRT-PCR for viral RNA were used. Of the 242 children tested, 24 tested positive by either rRT-PCR or MAC ELISA; in pigs, 38 out of the 51 pigs were positive. Of the known vectors, Culex vishnui was most commonly isolated across all biotopes. Analysis of 15 blood meals revealed human blood in 10 samples. Univariable analysis showed that gender, religion, lack of indoor residual spraying of insecticides in the past year, indoor vector density (all species), and not being vaccinated against JE in children were significantly associated with JE positivity. In multivariate analysis, only male gender remained as a significant risk factor. Based on previous estimates of symptomatic: asymptomatic cases of JE, we estimate that there should have been 618 cases from Kushinagar, although only 139 were reported. Vaccination of children and vector control measures emerged as major control activities; they had very poor coverage in the studied villages. In addition, lack of awareness about the cause of JE, lack of faith in the conventional medical healthcare system and multiple referral levels causing delay in diagnosis and treatment emerged as factors likely to result in adverse clinical outcomes.

Building capacity for water, sanitation, and hygiene programming: Training evaluation theory applied to CLTS management training in Kenya.

Training and capacity building are long established critical components of global water, sanitation, and hygiene (WaSH) policies, strategies, and programs. Expanding capacity building support for WaSH in developing countries is one of the targets of the Sustainable Development Goals. There are many training evaluation methods and tools available. However, training evaluations in WaSH have been infrequent, have often not utilized these methods and tools, and have lacked rigor. We developed a conceptual framework for evaluating training in WaSH by reviewing and adapting concepts from literature. Our framework includes three target outcomes: learning, individual performance, and improved programming; and two sets of influences: trainee and context factors. We applied the framework to evaluate a seven-month community-led total sanitation (CLTS) management training program delivered to 42 government officials in Kenya from September 2013 to May 2014. Trainees were given a pre-training questionnaire and were interviewed at two weeks and seven months after initial training. We qualitatively analyzed the data using our conceptual framework. The training program resulted in trainees learning the CLTS process and new skills, and improving their individual performance through application of advocacy, partnership, and supervision soft skills. The link from trainees' performance to improved programming was constrained by resource limitations and pre-existing rigidity of trainees' organizations. Training-over-time enhanced outcomes and enabled trainees to overcome constraints in their work. Training in soft skills is relevant to managing public health programs beyond WaSH. We make recommendations on how training programs can be targeted and adapted to improve outcomes. Our conceptual framework can be used as a tool both for planning and evaluating training programs in WaSH.

Moving from rabies research to rabies control: lessons from India.

BACKGROUND: Despite the availability of effective interventions and public recognition of the severity of the problem, rabies continues to suffer neglect by programme planners in India and other low and middle income countries. We investigate whether this state of 'policy impasse' is due to, at least in part, the research community not catering to the information needs of the policy makers. METHODS #ENTITYSTARTX00026; FINDINGS: Our objective was to review the research output on rabies from India and examine its alignment with national policy priorities. A systematic literature review of all rabies research articles published from India between 2001 and 2011 was conducted. The distribution of conducted research was compared to the findings of an earlier research prioritization exercise. It was found that a total of 93 research articles were published from India since 2001, out of which 61% consisted of laboratory based studies focussing on rabies virus. Animals were the least studied group, comprising only 8% of the research output. One third of the articles were published in three journals focussing on vaccines and infectious disease epidemiology and the top 4 institutions (2 each from the animal and human health sectors) collectively produced 49% of the national research output. Biomedical research related to development of new interventions dominated the total output as opposed to the identified priority domains of socio-politic-economic research, basic epidemiological research and research to improve existing interventions. CONCLUSION: The paper highlights the gaps between rabies research and policy needs, and makes the case for developing a strategic research agenda that focusses on rabies control as an expected outcome.

Rabies control initiative in Tamil Nadu, India: A test case for the 'One Health' approach.

Although India accounts for nearly 50% of the global rabies mortality, there is no organised national rabies control programme. Rabies control is generally confined to small urban pockets, with minimal intersectoral co-ordination. Tamil Nadu is the first state in India to implement a state-wide, multisectoral rabies control initiative. The CDC Program Evaluation Framework guided the current assessment of this rabies prevention and control initiative in Tamil Nadu. Principle stakeholders were engaged through a series of interviews in order to document policy initiatives, to describe the programme and to understand their various roles. Surveillance data on dog bites were triangulated with vaccine consumption and dog population data to identify trends at the district level in the state. Findings and recommendations were shared at different levels. Rabies control activities in Tamil Nadu were conducted by separate departments linked by similar objectives. In addition to public health surveillance, animal census and implementation of dog licensing rules, other targeted interventions included waste management, animal birth control and anti-rabies vaccination, awareness campaigns, and widespread availability of anti-rabies vaccine at all public health facilities. In conclusion, this assessment suggests that it is possible to implement a successful 'One Health' programme in an environment of strong political will, evidence-based policy innovations, clearly defined roles and responsibilities of agencies, co-ordination mechanisms at all levels, and a culture of open information exchange.

The deubiquitinases USP33 and USP20 coordinate beta2 adrenergic receptor recycling and resensitization.

Agonist-induced ubiquitination of the beta(2) adrenergic receptor (beta(2)AR) functions as an important post-translational modification to sort internalized receptors to the lysosomes for degradation. We now show that this ubiquitination is reversed by two deubiquitinating enzymes, ubiquitin-specific proteases (USPs) 20 and 33, thus, inhibiting lysosomal trafficking when concomitantly promoting receptor recycling from the late-endosomal compartments as well as resensitization of recycled receptors at the cell surface. Dissociation of constitutively bound endogenously expressed USPs 20 and 33 from the beta(2)AR immediately after agonist stimulation and reassociation on prolonged agonist treatment allows receptors to first become ubiquitinated and then deubiquitinated, thus, providing a 'trip switch' between degradative and recycling pathways at the late-endosomal compartments. Thus, USPs 20 and 33 serve as novel regulators that dictate both post-endocytic sorting as well as the intensity and extent of beta(2)AR signalling from the cell surface.

Nedd4 mediates agonist-dependent ubiquitination, lysosomal targeting, and degradation of the beta2-adrenergic receptor.

Agonist-stimulated beta(2)-adrenergic receptor (beta(2)AR) ubiquitination is a major factor that governs both lysosomal trafficking and degradation of internalized receptors, but the identity of the E3 ubiquitin ligase regulating this process was unknown. Among the various catalytically inactive E3 ubiquitin ligase mutants that we tested, a dominant negative Nedd4 specifically inhibited isoproterenol-induced ubiquitination and degradation of the beta(2)AR in HEK-293 cells. Moreover, siRNA that down-regulates Nedd4 expression inhibited beta(2)AR ubiquitination and lysosomal degradation, whereas siRNA targeting the closely related E3 ligases Nedd4-2 or AIP4 did not. Interestingly, beta(2)AR as well as beta-arrestin2, the endocytic and signaling adaptor for the beta(2)AR, interact robustly with Nedd4 upon agonist stimulation. However, beta(2)AR-Nedd4 interaction is ablated when beta-arrestin2 expression is knocked down by siRNA transfection, implicating an essential E3 ubiquitin ligase adaptor role for beta-arrestin2 in mediating beta(2)AR ubiquitination. Notably, beta-arrestin2 interacts with two different E3 ubiquitin ligases, namely, Mdm2 and Nedd4 to regulate distinct steps in beta(2)AR trafficking. Collectively, our findings indicate that the degradative fate of the beta(2)AR in the lysosomal compartments is dependent upon beta-arrestin2-mediated recruitment of Nedd4 to the activated receptor and Nedd4-catalyzed ubiquitination.