Shiga Toxin-Producing Escherichia coli O157:H7 Illness Outbreak Associated with Untreated, Pressurized, Municipal Irrigation Water - Utah, 2023.

During July-September 2023, an outbreak of Shiga toxin-producing Escherichia coli O157:H7 illness among children in city A, Utah, caused 13 confirmed illnesses; seven patients were hospitalized, including two with hemolytic uremic syndrome. Local, state, and federal public health partners investigating the outbreak linked the illnesses to untreated, pressurized, municipal irrigation water (UPMIW) exposure in city A; 12 of 13 ill children reported playing in or drinking UPMIW. Clinical isolates were genetically highly related to one another and to environmental isolates from multiple locations within city A's UPMIW system. Microbial source tracking, a method to indicate possible contamination sources, identified birds and ruminants as potential sources of fecal contamination of UPMIW. Public health and city A officials issued multiple press releases regarding the outbreak reminding residents that UPMIW is not intended for drinking or recreation. Public education and UPMIW management and operations interventions, including assessing and mitigating potential contamination sources, covering UPMIW sources and reservoirs, indicating UPMIW lines and spigots with a designated color, and providing conspicuous signage to communicate risk and intended use might help prevent future UPMIW-associated illnesses.

Dental loss, stress fractures, and musculoskeletal pain in a 48-year-old woman.

We report a 48-year-old female patient with various stress fractures of extremities, musculoskeletal pain, and tooth loss. Hypophosphatasia was diagnosed based on clinical and laboratory findings and ALPL genetic results. This case highlights the importance of early diagnosis of hypophosphatasia in adults and appropriate treatment to prevent further complications.

Evaluation of a comprehensive maternal newborn health intervention in rural Tanzania: single-arm pre-post coverage survey results.

BACKGROUND: In Tanzania, maternal and newborn deaths can be prevented via quality facility-based antenatal care (ANC), delivery, and postnatal care (PNC). Scalable, integrated, and comprehensive interventions addressing demand and service-side care-seeking barriers are needed. OBJECTIVE: Assess coverage survey indicators before and after a comprehensive maternal newborn health (MNH) intervention in Misungwi District, Tanzania. METHODS: A prospective, single-arm, pre- (2016) and post-(2019) coverage survey (ClinicalTrials.gov #NCT02506413) was used to assess key maternal and newborn health (MNH) outcomes. The Mama na Mtoto intervention included district activities (planning, leadership training, supportive supervision), health facility activities (training, equipment, infrastructure upgrades), and plus community health worker mobilization. Implementation change strategies, a process model, and a motivational framework incorporated best practices from a similar Ugandan intervention. Cluster sampling randomized hamlets then used 'wedge sampling' protocol as an alternative to full household enumeration. Key outcomes included: four or more ANC visits (ANC4+); skilled birth attendant (SBA); PNC for mother within 48 hours (PNC-woman); health facility delivery (HFD); and PNC for newborn within 48 hours (PNC-baby). Trained interviewers administered the 'Real Accountability: Data Analysis for Results Coverage Survey to women 15-49 years old. Descriptive statistics incorporated design effect; the Lives Saved Tool estimated deaths averted based on ANC4+/HFD. RESULTS: Between baseline (n = 2,431) and endline (n = 2,070), surveys revealed significant absolute percentage increases for ANC4+ (+11.6, 95% CI [5.4, 17.7], p < 0.001), SBA (+16.6, 95% CI [11.1, 22.0], p < 0.001), PNC-woman (+9.2, 95% CI [3.2, 15.2], p = 0.002), and HFD (+17.2%, 95% CI [11.3, 23.1], p < 0.001). A PNC-baby increase (+6.1%, 95% CI [-0.5, 12.8], p = 0.07) was not statistically significant. An estimated 121 neonatal and 20 maternal lives were saved between 2016 and 2019. CONCLUSIONS: Full-district scale-up of a comprehensive MNH package embedded government health system was successfully implemented over a short time and associated with significant maternal care-seeking improvements and potential for lives saved.

Cluster of Norovirus Genogroup IX Outbreaks in Long-Term Care Facilities, Utah, USA, 2021.

We report 5 clustered acute gastroenteritis outbreaks in long-term care facilities in Utah, USA, that were linked to healthcare employees working at multiple facilities. Four outbreaks were caused by norovirus genotype GIX. We recommend continued norovirus surveillance and genotyping to determine contributions of this genotype to norovirus outbreaks.

Late initiation and low utilization of postnatal care services among women in the rural setting in Northwest Tanzania: a community-based study using a mixed method approach.

BACKGROUND: Maternal and newborn mortality is high immediately after childbirth and up to 42 days postnatally despite the availability of interventions. Postnatal care is crucial in preventing mortality and improving the health of women and newborns. This prospective cohort study investigated the initiation and utilization of postnatal care at health facilities and explored users' and providers' perspectives on utilization of postnatal care services. METHODS: A sequential explanatory mixed method was used involving women who were followed from the 3rd trimester of pregnancy to 3-4 months postnatally in Northwest, Tanzania. From January to December 2018, a door-to-door survey was conducted 3-4 months postnatally among 1385 of these women. A convenience sample of women and community health workers participated in focus group discussions, and traditional birth attendants and nurses participated in key informant interviews to complement quantitative data. Data analyses were conducted using STATA version 13 and NVIVO version 12. STUDY FINDINGS: Approximately, one half of participants attended postnatal care within 42 days after delivery. Postnatal care seeking within 48 h after delivery was reported by 14.6 % of the participants. Women who attended antenatal care at least four times, delivered at health facilities or experienced delivery-related complications were more likely to seek postnatal care. Limited knowledge on the postnatal care services and obstetric complications after childbirth, and not being scheduled for postnatal care by health providers negatively influenced services uptake. Overwhelming workload and shortages of supplies were reported to hinder the provision of postnatal care services. CONCLUSIONS: Utilization of postnatal care services remains low in this setting as a result of a number of disparate and complex factors that influence women's choices. Provision of effective postnatal care is hindered by lack of supplies, staffing, and inadequate infrastructure. To ensure accessibility and availability of quality services in this setting, both demand and supply sides factors need to be addressed.

Soil transmitted helminth infection in primary school children varies with ecozone in the Ngorongoro Conservation Area, Tanzania.

BACKGROUND: Soil-transmitted helminthiasis is a neglected tropical disease, thriving in environments of poverty and disadvantage. Our objective was to determine the prevalence and intensity of four soil transmitted helminths (STH) among primary school children in the Ngorongoro Conservation Area (NCA), Tanzania. METHODS: A cross-sectional study was performed between May 15th and June 2nd, 2014. Six of 20 primary schools were chosen, based on elevation, designated low elevation ecozone (LEE) or high elevation ecozone (HEE). A total of 340 children from standards one to four were recruited. Height and weight of each child was determined and body mass index (BMI) was calculated. Stool samples were analyzed using the Kato-Katz, Wisconsin, and Baermann techniques to detect STH eggs and larvae. An interviewer-administered questionnaire on socio-demographic variables was used to capture information from the school's headmaster and a checklist was used to assess sanitation facilities. RESULTS: STHs identified included Ascaris (presumably lumbricoides), Trichuris (presumably trichiura), hookworms (presumably Ancylostoma duodenale and/or Necator americanus), and Strongyloides (presumably stercoralis). The overall prevalence of STH infection was 29.0% in LEE and 34.0% in HEE. Prevalence was 34.3% and 28.2% in males versus females, respectively. Ascaris sp. were only identified in HEE, prevalence of Trichuris sp. and hookworms were significantly higher in HEE compared to LEE, and Strongyloides spp. prevalence was lower in HEE. Intensity of Trichuris sp. was significantly higher in HEE and lower for hookworms. We did not detect a significant relationship between BMI and helminth intensity; however, BMI was lower in lower elevations and in males vs. females. Sanitation practices are taught at the schools, but challenges were identified when implementing. Latrine facilities were available and latrine-cleaning routines were practiced; however, hand washing practices were challenging due to restricted water availability. CONCLUSIONS: Significant differences in prevalence in HEE and LEE exist, and STH infections are still very common among school children suggesting that anthelminthic intervention and education may be necessary in this region. Based on this outcome, the study area in the NCA would be classified as a medium risk area, where periodic treatment recommendations should be based on prevalence estimations in the different ecozones. TRIAL REGISTRATION: Ethics approval was obtained from the Catholic University of Health and Allied Sciences (CUHAS; Lake Zone Institutional Review Board MR/53/100/307)); the Conjoint Health Research Ethics Board (CHREB) at the University of Calgary in Canada (Study ID REB14-0127); the National Institute of Medical Research (NIMR) of Tanzania; and the Tanzania Commission for Science and Technology (COSTEC).

Neutral effect of exenatide on serum testosterone in men with type 2 diabetes mellitus: A prospective cohort.

BACKGROUND: Endogenous testosterone increases with weight loss from diet, exercise, and bariatric surgery. However, little is known about testosterone levels after weight loss from medication. OBJECTIVES: Uncover the effects of Glucagon-Like Peptide-1 receptor agonist (GLP-1 RA) therapy on serum testosterone. MATERIAL AND METHODS: Prospective cohort study of men starting GLP-1 RA therapy for type 2 diabetes mellitus. RESULTS: 51 men lost 2.27 kg (p = 0.00162) and their HbA1c values improved by 0.7% (p = 0.000503) after 6 months of GLP-1 RA therapy. There was no significant change in testosterone for the group as a whole. However, in subgroup analyses, there was a significant difference in total testosterone change between men starting with baseline total testosterone <320 ng/dL (238.5 ± 56.5 ng/dL to 272.2 ± 82.3 ng/dL) compared to higher values (438 ± 98.2 ng/dL to 412 ± 141.2 ng/dL) (p = 0.0172);free testosterone increased if the baseline total testosterone was <320 ng/dL (55.2 ± 12.8 pg/mL to 57.2 ± 17.6 pg/mL) and decreased if >320 ng/dL (74.7 ± 16.3 pg/mL to 64.2 ± 17.7 pg/mL) (p = 0.00807). Additionally, there were significant differences in testosterone change between men with HbA1c improvements ≥1% (351.6 ± 123.9 ng/dL to 394.4 ± 136.5 ng/dL) compared to men with HbA1c changes <1% (331.8 ± 128.6 ng/dL to 316.1 ± 126.2 ng/dL) (p = 0.0413). CONCLUSION: GLP-1 RA therapy improves weight and HbA1c without adverse effects on testosterone. Those starting with lower testosterone values or attaining greater improvement in HbA1c may see additional benefits.

Effects of prenatal exposure and co-exposure to metallic or metalloid elements on early infant neurodevelopmental outcomes in areas with small-scale gold mining activities in Northern Tanzania.

BACKGROUND: Artisanal and small-scale gold mining (ASGM) is associated with release of neurotoxic metallic or metalloid chemical elements including lead (Pb), mercury (Hg), cadmium (Cd) and arsenic (As). OBJECTIVE: To examine associations between prenatal exposure and co-exposure to total lead (T-Pb), total mercury (T-Hg), total cadmium (T-Cd) and total arsenic (T-As) and infant neurodevelopment at 6 to 12 months of age in areas with ASGM activities in Tanzania. METHODS: Women in their second trimester of pregnancy who resided in ASGM areas were enrolled from 2015 to 2017 (n = 883). At 6 to 12 months of age, children were assessed with the Malawi Developmental Assessment Tool (MDAT) (n = 439). We measured T-Pb, T-Hg, and T-Cd in maternal dried blood spots and T-As in maternal urines. Poisson regression was used to examine associations between prenatal concentrations of these elements and neurodevelopmental outcomes. RESULTS: Prenatal T-Hg concentration was associated with global neurodevelopment status (aPR 1.03, CI:1.01-1.04; p < 0.001) and language impairment (aPR 1.05, CI:1.03-1.07; p < 0.001) on the MDAT. When prenatal T-Hg and T-As values were at or above the human biomonitoring reference values (≥95%) of the German Environmental Survey for Human Biomonitoring, that is 0.80 µg/L and 15 µg/L, respectively, the prevalence ratio of global neurodevelopmental impairment was two times higher (aPR 2.1, CI:1.0-4.3; p = 0.034). There was a 40% increase in the prevalence ratio of global neurodevelopmental impairment (aPR 1.4, CI:0.90-2.10, p = 0.027), when prenatal T-Hg was at or above the reference value of 0.80 µg/L and T-Pb was at or above the reference value of 35 µg/L. When prenatal T-Hg was at or above the reference value of 0.80 µg/L and T-As was at or above the reference value of 15 µg/L, the prevalence ratio of global neurodevelopmental impairment was two times higher (aPR 2.1, CI:1.0-4.3; p < 0.034). DISCUSSION: Infants born to women in areas with ASGM activities are at significant risk for neurodevelopmental impairment and this is associated with exposure to higher concentrations of Hg prenatally. Co-exposure to high concentrations of Hg and Pb, or Hg and As appeared to have negative potentiated effects on infants' neurodevelopment.

Is it home delivery or health facility? Community perceptions on place of childbirth in rural Northwest Tanzania using a qualitative approach.

BACKGROUND: In low and middle-income countries, pregnancy and delivery complications may deprive women and their newborns of life or the realization of their full potential. Provision of quality obstetric emergency and childbirth care can reduce maternal and newborn deaths. Underutilization of maternal and childbirth services remains a public health concern in Tanzania. The aim of this study was to explore elements of the local social, cultural, economic, and health systems that influenced the use of health facilities for delivery in a rural setting in Northwest Tanzania. METHODS: A qualitative approach was used to explore community perceptions of issues related to low utilization of health facilities for childbirth. Between September and December 2017, 11 focus group discussions were conducted with women (n = 33), men (n = 5) and community health workers (CHWs; n = 28); key informant interviews were conducted with traditional birth attendants (TBAs; n = 2). Coding, identification, indexing, charting, and mapping of these interviews was done using NVIVO 12 after manual familiarization of the data. Data saturation was used to determine when no further interviews or discussions were required. RESULTS: Four themes emerge; self-perceived obstetric risk, socio-cultural issues, economic concerns and health facility related factors. Health facility delivery was perceived to be crucial for complicated labor. However, the idea that childbirth was a "normal" process and lack of social and cultural acceptability of facility services, made home delivery appealing to many women and their families. In addition, out of pocket payments for suboptimal quality of health care was reported to hinder facility delivery. CONCLUSION: Home delivery persists in rural settings due to economic and social issues, and the cultural meanings attached to childbirth. Accessibility to and affordability of respectful and culturally acceptable childbirth services remain challenging in this setting. Addressing barriers on both the demand and supply side could result in improved maternal and child outcomes during labor and delivery.

Global health electives: Ethical engagement in building global health capacity.

Purpose: Little is known about the impact medical trainees undertaking global health electives (GHEs) have on host institutions and their communities in low-and middle-income countries. The goal of this study was to explore the relationship dynamics associated with GHEs as perceived by host stakeholders at three sites in sub-Saharan Africa.Method: This case-based interpretive phenomenological study examined stakeholder perspectives in Mwanza, Tanzania, and Mbarara and Rugazi, Uganda, where the University of Calgary, Alberta, Canada has long-standing institutional collaborations. Between September and November 2017, 33 host stakeholders participated in semi-structured interviews and 28 host stakeholders participated in focus group discussions. Participant experiences were analyzed using interpretive phenomenological techniques.Results: The findings revealed that, although GHEs are well-established and a common experience for host stakeholders, their perceptions about who visiting medical trainees (VMTs) are remains indistinct. Participants acknowledged that there are a variety of benefits to GHEs, but overall VMTs appear to benefit the most from this unique learning opportunity. Host stakeholders described significant challenges and burdens of GHEs and recommended ways in which GHEs could be improved.Conclusions: GHEs need to be designed to better embrace ethical engagement and reciprocity with host stakeholders to ensure equity in benefits and responsibilities.

Maternal exposure to arsenic and mercury and associated risk of adverse birth outcomes in small-scale gold mining communities in Northern Tanzania.

BACKGROUND: Exposure to arsenic and mercury in artisanal and small-scale gold mining (ASGM) communities is an issue that predominantly affects low and middle-income countries. Large epidemiology studies in these communities are rare, and the impact of such exposures on reproductive outcomes are not well understood. OBJECTIVE: To examine associations between prenatal maternal arsenic and mercury exposure and birth outcomes in both ASGM and non-ASGM communities in Northern Tanzania. METHODS: This longitudinal prospective study included 961 women (ASGM = 788, non-ASGM = 173) of the original cohort of 1056 who were followed until a pregnancy outcome was registered. Maternal spot urine samples and dried blood spots were used to measure total arsenic (T-As) and total mercury (T-Hg) in the second trimester of pregnancy. Data on adverse birth outcomes were collected in 5 categories: spontaneous abortion, stillbirth, preterm birth, low birth weight, and visible congenital anomalies. Mann-Whitney U-tests were used to test for differences between median T-As and T-Hg by area of residence. Logistic regression models were used to estimate the odds of stillbirth and visible congenital anomalies given maternal T-As and T-Hg levels. Modified Poisson regressions were used to estimate relative risk ratios between maternal T-As and T-Hg levels and composite adverse birth outcome, spontaneous abortion, low birth weight, and preterm birth. RESULTS: Statistically significant differences were found in median T-As (9.6 vs. 6.3 µg/L, Mann-Whitney U-tests, Z = -3.50, p < 0.001) and median T-Hg blood concentrations (1.2 vs. 0.70 µg/L, Z = -9.88, p-value < 0.001) between women living in ASGM and non-ASGM areas respectively. In ASGM areas, the adjusted relative risk (aRR) of a composite adverse birth outcome increased with increasing T-As (aRR 1.23, 95%CI: 1.14-1.33, p < 0.0001) and T-Hg (aRR 1.17, 95%CI: 1.1-1.25, p < 0.0001) exposure. Spontaneous abortion (aRR 1.53, 95%CI: 1.28-1.83), stillbirth (adjusted odds ratio (aOR) 1.97, 95%CI: 1.45-2.66) and preterm birth (1.17, 95%CI: 1.01-1.36) were significantly associated with elevated T-As, whereas elevated T-Hg was significantly associated with stillbirth (aOR 2.49, 95%CI: 1.88-3.29) and visible congenital anomalies (aOR 2.24, 95%CI: 1.3-3.87). CONCLUSION: Over half (54.7%) of women in ASGM areas of Northern Tanzania had adverse birth outcomes and the risk of adverse birth outcomes was significantly associated with increased prenatal exposure to arsenic and mercury.

Maternal exposure to arsenic and mercury in small-scale gold mining areas of Northern Tanzania.

Artisanal and small-scale gold mining (ASGM) in Tanzania results in occupational exposures and environmental contamination to toxic chemical elements such as arsenic and mercury. Populations living in such areas may be exposed by various routes, and prenatal exposure to arsenic and mercury has been associated with adverse birth outcomes and developmental delays. The aim of this study was to determine if levels of arsenic and mercury differed among pregnant women living in areas with and without ASGM activities in Northern Tanzania. This cross-sectional study is part of the ongoing Mining and Health prospective longitudinal study. Spot urine samples and dried blood spots were collected at the antenatal health clinics from pregnant women (n = 1056) at 16-27 weeks gestation. Urine samples were analyzed for total arsenic (T-As) and dried blood spots were analyzed for total mercury (T-Hg). Women in the ASGM cohort had median T-As levels (9.4 µg/L; IQR: 4.9-15.1) and T-Hg levels (1.2 µg/L; IQR: 0.8-1.86) that were significantly higher than the median T-As levels (6.28 µg/L; IQR: 3.7-14.1) and T-Hg levels (0.66 µg/L; IQR: 0.3-1.2) of women in the non-ASGM cohort (Mann-Whitney U test, T-As: z = -9.881, p = 0.0005; T-Hg: z = -3.502, p < 0.0001). Among pregnant women from ASGM areas, 25% had urinary T-As and 75% had blood T-Hg above the established human biomonitoring reference values of 15 and 0.80 µg/L. In the ASGM cohort, lower maternal education and low socioeconomic status increased the odds of higher T-As levels by 20% (p < 0.05) and 10% (p < 0.05), respectively. Women involved in mining activities and those of low socioeconomic status had increased odds of higher T-Hg by 70% (p < 0.001) and 10% (p < 0.05), respectively. Arsenic and mercury concentrations among women in non-ASGM areas suggest exposure sources beyond ASGM activities that need to be identified. Arsenic and mercury levels in women in Tanzania are of public health concern and their association with adverse birth and child developmental outcomes will be examined in future studies on this cohort.

Validation of Dried Blood Spots for Maternal Biomonitoring of Nonessential Elements in an Artisanal and Small-Scale Gold Mining Area of Tanzania.

Biomonitoring studies of vulnerable populations in low- and middle-income countries are limited because traditional sampling methods are challenging to implement in low-resource settings. The present study examined the feasibility, precision, and accuracy of dried blood spots (DBS) for human biomonitoring of nonessential elements (cadmium [Cd], mercury [Hg], and lead [Pb]) in an area of northern Tanzania with artisanal and small-scale gold mining activities. Pregnant women (n = 44) were recruited in Geita during antenatal clinic visits, and DBS from capillary blood were collected on filter paper. As a gold-standard comparison, venous blood was sampled from the same participants and compared with the DBS. Venous blood, DBS, and quality control samples were analyzed for chemical elements by inductively coupled plasma mass spectrometry. Field blanks were very clean for most elements, generally only twice as high as corresponding laboratory filter blanks. No significant differences were found between duplicate DBS samples taken from the same participants, with near perfect intraclass correlation coefficients (0.99) for Cd, Hg, and Pb, indicating excellent reliability. Moreover, correlation was strong (r2 > 0.9) and significant (p < 0.0001) between DBS and the quantitative venous blood, with regression line slopes close to 1.0 (0.847, 0.976, and 0.969 for Cd, Hg, and Pb, respectively), indicating high accuracy of the DBS method compared with the gold-standard approach. The DBS method is minimally invasive and was a feasible, precise, and accurate means of measuring exposure to Cd, Hg, and Pb in pregnant women in a low-resource setting. Environ Toxicol Chem 2019;38:1285-1293. © 2019 SETAC.

Missed opportunities in antenatal care for improving the health of pregnant women and newborns in Geita district, Northwest Tanzania.

BACKGROUND: Despite the significant benefits of early detection and management of pregnancy related complications during antenatal care (ANC) visits, not all pregnant women in Tanzania initiate ANC in a timely manner. The primary objectives of this research study in rural communities of Geita district, Northwest Tanzania were: 1) to conduct a population-based study that examined the utilization and availability of ANC services; and 2) to explore the challenges faced by women who visited ANC clinics and barriers to utilization of ANC among pregnant women. METHODS: A sequential explanatory mixed method design was utilized. Household surveys that examined antenatal service utilization and availability were conducted in 11 randomly selected wards in Geita district. One thousand, seven hundred and nineteen pregnant women in their 3rd trimester participated in household surveys. It was followed by focus group discussions with community health workers and pregnant women that examined challenges and barriers to ANC. RESULTS: Of the pregnant women who participated, 86.74% attended an ANC clinic at least once; 3.62% initiated ANC in the first trimester; 13.26% had not initiated ANC when they were interviewed in their 3rd trimester. Of the women who had attended ANC at least once, the majority (82.96%) had been checked for HIV status, less than a half (48.36%) were checked for hemoglobin level, and only a minority had been screened for syphilis (6.51%). Among women offered laboratory testing, the prevalence of HIV was 3.88%, syphilis, 18.57%, and anemia, 54.09%. In terms of other preventive measures, 91.01% received a tetanus toxoid vaccination, 76.32%, antimalarial drugs, 65.13%, antihelminthic drugs, and 76.12%, iron supplements at least once. Significant challenges identified by women who visited ANC clinics included lack of male partner involvement, informal regulations imposed by health care providers, perceived poor quality of care, and health care system related factors. Socio-cultural beliefs, fear of HIV testing, poverty and distance from health clinics were reported as barriers to early ANC utilization. CONCLUSION: Access to effective ANC remains a challenge among women in Geita district. Notably, most women initiated ANC late and early initiation did not guarantee care that could contribute to better pregnancy outcomes.

Promoting equitable global health research: a policy analysis of the Canadian funding landscape.

BACKGROUND: Recognising radical shifts in the global health research (GHR) environment, participants in a 2013 deliberative dialogue called for careful consideration of equity-centred principles that should inform Canadian funding polices. This study examined the existing funding structures and policies of Canadian and international funders to inform the future design of a responsive GHR funding landscape. METHODS: We used a three-pronged analytical framework to review the ideas, interests and institutions implicated in publically accessible documents relevant to GHR funding. These data included published literature and organisational documents (e.g. strategic plans, progress reports, granting policies) from Canadian and other comparator funders. We then used a deliberative approach to develop recommendations with the research team, advisors, industry informants and low- and middle-income country (LMIC) partners. RESULTS: In Canada, major GHR funders invest an estimated CA$90 M per annum; however, the post-2008 re-organization of funding structures and policies resulted in an uncoordinated and inefficient Canadian strategy. Australia, Denmark, the European Union, Norway, Sweden, the United Kingdom and the United States of America invest proportionately more in GHR than Canada. Each of these countries has a national strategic plan for global health, some of which have dedicated benchmarks for GHR funding and policy to allow funds to be held by partners outside of Canada. Key constraints to equitable GHR funding included (1) funding policies that restrict financial and cost burden aspects of partnering for GHR in LMICs; and (2) challenges associated with the development of effective governance mechanisms. There were, however, some Canadian innovations in funding research that demonstrated both unconventional and equitable approaches to supporting GHR in Canada and abroad. Among the most promising were found in the International Development Research Centre and the (no longer active) Global Health Research Initiative. CONCLUSION: Promoting equitable GHR funding policies and practices in Canada requires cooperation and actions by multiple stakeholders, including government, funding agencies, academic institutions and researchers. Greater cooperation and collaboration among these stakeholders in the context of recent political shifts present important opportunities for advancing funding policies that enable and encourage more equitable investments in GHR.

Participatory science and innovation for improved sanitation and hygiene: process and outcome evaluation of project SHINE, a school-based intervention in Rural Tanzania.

BACKGROUND: Diarrheal disease is a major cause of mortality and morbidity in low and middle income countries with children being disproportionately affected. Project SHINE (Sanitation & Hygiene INnovation in Education) is a grassroots participatory science education and social entrepreneurship model to engage youth and the wider community in the development of sustainable strategies to improve sanitation and hygiene. METHODS: Based in rural and remote Tanzania, this pilot study engaged pastoralist high-school students and communities in the development and evaluation of culturally and contextually relevant strategies to improve sanitation and hygiene. Using a train-the-trainer approach, key activities included teacher workshops, school-based lessons, extra-curricular activities, community events and a One Health sanitation science fair which showcased projects related to water, sanitation and hygiene in relation to human and animal health. The process and outcome of the study were evaluated through qualitative interviews and focus group discussions with diverse project participants, as well as pre- and post- questionnaires completed by students on knowledge, attitudes and practices concerning sanitation and hygiene. RESULTS: The questionnaire results at baseline and follow-up showed statistically significant improvements on key measures including a decrease in unhygienic behaviors, an increase in the perceived importance of handwashing and intention to use the toilet, and increased communication in the social network about the importance of clean water and improved sanitation and hygiene practices, however there were no significant changes in sanitation related knowledge. Qualitative data highlighted strong leadership emerging from youth and enthusiasm from teachers and students concerning the overall approach in the project, including the use of participatory methods. There was a high degree of community engagement with hundreds of community members participating in school-based events. Sanitation science fair projects addressed a range of pastoralist questions and concerns regarding the relationship between water, sanitation and hygiene. Several projects, such as making soap from local materials, demonstrate potential as a sustainable strategy to improve health and livelihoods in the long-term. CONCLUSIONS: The Project SHINE model shows promise as an innovative capacity building approach and as an engagement and empowerment strategy for youth and communities to develop locally sustainable strategies to improve sanitation and hygiene.

Adapting the capacities and vulnerabilities approach: a gender analysis tool.

Gender analysis methodology is increasingly being considered as essential to health research because 'women's social, economic and political status undermine their ability to protect and promote their own physical, emotional and mental health, including their effective use of health information and services' {World Health Organization [Gender Analysis in Health: a review of selected tools. 2003; www.who.int/gender/documents/en/Gender. ANALYSIS: pdf (20 February 2008, date last accessed)]}. By examining gendered roles, responsibilities and norms through the lens of gender analysis, we can develop an in-depth understanding of social power differentials, and be better able to address gender inequalities and inequities within institutions and between men and women. When conducting gender analysis, tools and frameworks may help to aid community engagement and to provide a framework to ensure that relevant gendered nuances are assessed. The capacities and vulnerabilities approach (CVA) is one such gender analysis framework that critically considers gender and its associated roles, responsibilities and power dynamics in a particular community and seeks to meet a social need of that particular community. Although the original intent of the CVA was to guide humanitarian intervention and disaster preparedness, we adapted this framework to a different context, which focuses on identifying and addressing emerging problems and social issues in a particular community or area that affect their specific needs, such as an infectious disease outbreak or difficulty accessing health information and resources. We provide an example of our CVA adaptation, which served to facilitate a better understanding of how health-related disparities affect Maasai women in a remote, resource-poor setting in Northern Tanzania.

Developing a Pictorial Sisterhood Method in collaboration with illiterate Maasai traditional birth attendants in northern Tanzania.

OBJECTIVE: To study whether data on maternal mortality can be gathered while maintaining local ownership of data in a pastoralist setting where a scarcity of data sources and a culture of silence around maternal death amplifies limited awareness of the magnitude of maternal mortality. METHODS: As part of a participatory action research project, investigators and illiterate traditional birth attendants (TBAs) collaboratively developed a quantitative participatory tool-the Pictorial Sisterhood Method-that was pilot-tested between March 12 and May 30, 2011, by researchers and TBAs in a cross-sectional study. RESULTS: Fourteen TBAs interviewed 496 women (sample), which led to 2241 sister units of risk and a maternal mortality ratio of 689 deaths per 100000 live births (95% confidence interval 419-959). Researchers interviewed 474 women (sample), leading to 1487 sister units of risk and a maternal mortality ratio of 484 (95% confidence interval 172-795). CONCLUSION: The Pictorial Sisterhood Method is an innovative application that might increase the participation of illiterate individuals in maternal health research and advocacy. It offers interesting opportunities to increase maternal mortality data ownership and awareness, and warrants further study and validation.