Where are the links? Using a causal loop diagram to assess interactions in healthcare coordination for youth experiencing homelessness in Toronto, Canada.

BACKGROUND: Youth experiencing homelessness (YEH) suffer from poorer physical and mental health outcomes than stably housed youth. Additionally, YEH are forced to navigate fragmented health and social service systems on their own, where they often get lost between systems when transitioning or post-discharge. Inevitably, YEH require support with health system navigation and healthcare coordination. The aim of this study is to understand interactions within and between the emergency youth shelter (EYS) and health systems that affect healthcare coordination for YEH in Toronto, Canada, and how these interactions can be targeted to improve healthcare coordination for YEH. METHODS: This study is part of a larger qualitative case study informed by the framework for transformative systems change. To understand interactions in healthcare coordination for YEH within and between the EYS and health systems, we developed a causal loop diagram (CLD) using in-depth interview data from 24 key informants at various levels of both systems. Open and focused codes developed during analysis using Charmaz's constructivist grounded theory methodology were re-analysed to identify key variables, and links between them to create the CLD. The CLD was then validated by six stakeholders through a stakeholder forum. RESULTS: The CLD illustrates six balancing and one reinforcing feedback loop in current healthcare coordination efforts within the EYS and health systems, respectively. Increasing EYS funding, building human resource capacity, strengthening inter and intra-systemic communication channels, and establishing strategic partnerships and formal referral pathways were identified among several other variables to be targeted to spiral positive change in healthcare coordination for YEH both within and between the EYS and health systems. CONCLUSIONS: The CLD provides a conceptual overview of the independent and integrated systems through which decision-makers can prioritize and guide interventions to strengthen healthcare coordination within and between the EYS and health systems. Overall, our research findings suggest that key variables such as streamlining communication and improving staff-youth relationships be prioritized, as each of these acts interdependently and influences YEH's access, quality and coordination of healthcare.

Where's the Disconnect? Exploring Pathways to Healthcare Coordinated for Youth Experiencing Homelessness in Toronto, Canada, Using Grounded Theory Methodology.

About 900 youth experiencing homelessness (YEH) reside at an emergency youth shelter (EYS) in Toronto on any given night. Several EYSs offer access to healthcare based on youths' needs, including access to primary care, and mental health and addictions support. However, youth also require healthcare from the broader health system, which is often challenging to navigate and access. Currently, little is known about healthcare coordination efforts between the EYS and health systems for YEH. Using grounded theory methodology, we interviewed 24 stakeholders and concurrently analyzed and compared data to explore pathways to healthcare coordinated for youth who reside at an EYS in Toronto. We also investigated fundamental parts (i.e., norms, resources, regulations, and operations) within the EYS and health systems that influence these pathways to healthcare using thematic analysis. A significant healthcare coordination gap was found between these two systems, typically when youth experience crises, often resulting in a recurring loop of transition and discharge between EYSs and hospitals. Several parts within each system act interdependently in hindering adequate healthcare coordination between the EYS and health systems. Incorporating training for system staff on how to effectively coordinate healthcare and work with homeless populations who have complex health needs, and rethinking information-sharing policies within circles of care are examples of how system parts can be targeted to improve healthcare coordination for YEH. Establishing multidisciplinary healthcare teams specialized to serve the complex needs of YEH may also improve healthcare coordination between systems, and access and quality of healthcare for this population.

Foregrounding women and household dynamics to inform Article 17: a qualitative description analysis of tobacco farming households in Mozambique.

PURPOSE: This paper examines the intrahousehold dynamics between women and men present in tobacco farming households in Mozambique. Attention to the experiences and realities of the smallholder farmers is crucial for understanding approaches to alternative livelihoods. Intrahousehold dynamics can provide important insights into how these households and their members view tobacco production and engage with the political economy of tobacco farming, how they make decisions, and the rationale and values behind these decisions. METHODS: Data were collected through single-gender focus group discussions (n=8) with 108 participants (men=57, women=51). Analysis was informed by a qualitative description methodology. This research presents a gender-based analysis examining the perspectives, roles, decision-making processes and desires of female and male tobacco farmers in four key tobacco-growing districts in Mozambique. FINDINGS: Throughout this paper, women are found to hold leverage and influence in tobacco farming households, and this leverage is in part gained via the necessity of women's unpaid labour in achieving profitability in tobacco farming. Both women and men are also found to strongly desire and pursue the well-being of the household. CONCLUSION: Women hold agency within tobacco-growing households and participate in decision-making processes regarding tobacco agriculture. Women should be included in future tobacco control policies and programmes pertaining to Article 17.

Policies to prevent zoonotic spillover: a systematic scoping review of evaluative evidence.

BACKGROUND: Emerging infectious diseases of zoonotic origin present a critical threat to global population health. As accelerating globalisation makes epidemics and pandemics more difficult to contain, there is a need for effective preventive interventions that reduce the risk of zoonotic spillover events. Public policies can play a key role in preventing spillover events. The aim of this review is to identify and describe evaluations of public policies that target the determinants of zoonotic spillover. Our approach is informed by a One Health perspective, acknowledging the inter-connectedness of human, animal and environmental health. METHODS: In this systematic scoping review, we searched Medline, SCOPUS, Web of Science and Global Health in May 2021 using search terms combining animal health and the animal-human interface, public policy, prevention and zoonoses. We screened titles and abstracts, extracted data and reported our process in line with PRISMA-ScR guidelines. We also searched relevant organisations' websites for evaluations published in the grey literature. All evaluations of public policies aiming to prevent zoonotic spillover events were eligible for inclusion. We summarised key data from each study, mapping policies along the spillover pathway. RESULTS: Our review found 95 publications evaluating 111 policies. We identified 27 unique policy options including habitat protection; trade regulations; border control and quarantine procedures; farm and market biosecurity measures; public information campaigns; and vaccination programmes, as well as multi-component programmes. These were implemented by many sectors, highlighting the cross-sectoral nature of zoonotic spillover prevention. Reports emphasised the importance of surveillance data in both guiding prevention efforts and enabling policy evaluation, as well as the importance of industry and private sector actors in implementing many of these policies. Thoughtful engagement with stakeholders ranging from subsistence hunters and farmers to industrial animal agriculture operations is key for policy success in this area. CONCLUSION: This review outlines the state of the evaluative evidence around policies to prevent zoonotic spillover in order to guide policy decision-making and focus research efforts. Since we found that most of the existing policy evaluations target 'downstream' determinants, additional research could focus on evaluating policies targeting 'upstream' determinants of zoonotic spillover, such as land use change, and policies impacting infection intensity and pathogen shedding in animal populations, such as those targeting animal welfare.

Editorial: Whither globalization and health in an era of geopolitical uncertainty?

Globalization has been declared dead or dying for many years, although recently, the number of voices declaring it 'over' has swelled [1]. As editors of a journal interrogating how globalization affects health, we confront the question: Have the COVID-19 pandemic, Russia's war against Ukraine, a breakdown in multilateralism, and the risk of a return to the stagflation of the 1970s finally sounded a death knell for the research and scholarship we have been publishing in the journal's 20-year history? We think not and argue below why, in our post-pandemic fractured and fractious era, it is vitally important to retain a focus on this messy construct short-handed as 'globalization.'

A pandemic treaty, revised international health regulations, or both?

BACKGROUND: A special session of the World Health Assembly (WHA) will be convened in late 2021 to consider developing a WHO convention, agreement or other international instrument on pandemic preparedness and response - a so-called 'Pandemic Treaty'. Consideration is given to this treaty as well as to reform of the International Health Regulations (IHR) as our principal governing instrument to prevent and mitigate future pandemics. MAIN BODY: Reasons exist to continue to work with the IHR as our principal governing instrument to prevent and mitigate future pandemics. All WHO member states are party to it. It gives the WHO the authority to oversee the collection of surveillance data and to issue recommendations on trade and travel advisories to control the spread of infectious diseases, among other things. However, the limitations of the IHR in addressing the deep prevention of future pandemics also must be recognized. These include a lack of a regulatory framework to prevent zoonotic spillovers. More advanced multi-sectoral measures are also needed. At the same time, a pandemic treaty would have potential benefits and drawbacks as well. It would be a means of addressing the gross inequity in global vaccine distribution and other gaps in the IHR, but it would also need more involvement at the negotiation table of countries in the Global South, significant funding, and likely many years to adopt. CONCLUSIONS: Reform of the IHR should be undertaken while engaging with WHO member states (and notably those from the Global South) in discussions on the possible benefits, drawbacks and scope of a new pandemic treaty. Both options are not mutually exclusive.

Global health diplomacy in Mexico: insights from key actors in the field.

BACKGROUND: Global health diplomacy (GHD) focuses on the actions taken by diverse stakeholders from different nations -governments, multilateral agents, and civil society- to phenomena that can affect population health and its determinants beyond national borders. Although the literature on conceptual advancements of GHD exists, empirical studies about how health becomes an issue of relevance for foreign policy are scarce. We present an analysis of the entry processes of health into the foreign policy and diplomatic domains in Mexico from the perspective of key informants of three different sectors. METHODS: A purposive sample of high-rank representatives of three sectors involved in GHD was designed: Two from Health Sector (HS), four from Foreign Affairs Sector (FAS), and three from Non-governmental organizations (NGOs). Nine semi-structured interviews were conducted exploring the topics of: (1) Health concerns entering diplomatic and foreign policy; (2) Processes that allow actors to influence foreign policy and negotiation and; (3) Impact of multilateral negotiations on decision-making at the national level. RESULTS: Our analysis suggests that GHD in Mexico is hierarchically driven by the FAS and health concerns only enter foreign policy when they are relevant to national priorities (such as trade or security). HS possesses a lesser degree of influence in GHD, serving as an instance of consultation for the FAS when deciding on health-related issues at global meetings (i.e., World Health Assembly). NGOs resort to lobbying, advocacy, networking, and coalition-working practices with other sectors (academy, think-tanks) to prevent harmful impacts on local health from multilateral decisions and as a mean to compensate its power asymmetry for influencing GHD processes in relation to the government. CONCLUSIONS: GHD in Mexico occurs in a context of asymmetric power relationships where government actors have the strongest influence. However, NGOs' experience in raising awareness of health risks needs to be weighted by government decision-makers. This situation calls for capacity building on intersectoral communication and coordination to create formal mechanisms of GHD practices, including the professionalization and training on GHD among government agencies.

A survey of International Health Regulations National Focal Points experiences in carrying out their functions.

BACKGROUND: The 2005 International Health Regulations (IHR (2005)) require States Parties to establish National Focal Points (NFPs) responsible for notifying the World Health Organization (WHO) of potential events that might constitute public health emergencies of international concern (PHEICs), such as outbreaks of novel infectious diseases. Given the critical role of NFPs in the global surveillance and response system supported by the IHR, we sought to assess their experiences in carrying out their functions. METHODS: In collaboration with WHO officials, we administered a voluntary online survey to all 196 States Parties to the IHR (2005) in Africa, Asia, Europe, and South and North America, from October to November 2019. The survey was available in six languages via a secure internet-based system. RESULTS: In total, 121 NFP representatives answered the 56-question survey; 105 in full, and an additional 16 in part, resulting in a response rate of 62% (121 responses to 196 invitations to participate). The majority of NFPs knew how to notify the WHO of a potential PHEIC, and believed they have the content expertise to carry out their functions. Respondents found training workshops organized by WHO Regional Offices helpful on how to report PHEICs. NFPs experienced challenges in four critical areas: 1) insufficient intersectoral collaboration within their countries, including limited access to, or a lack of cooperation from, key relevant ministries; 2) inadequate communications, such as deficient information technology systems in place to carry out their functions in a timely fashion; 3) lack of authority to report potential PHEICs; and 4) inadequacies in some resources made available by the WHO, including a key tool - the NFP Guide. Finally, many NFP representatives expressed concern about how WHO uses the information they receive from NFPs. CONCLUSION: Our study, conducted just prior to the COVID-19 pandemic, illustrates key challenges experienced by NFPs that can affect States Parties and WHO performance when outbreaks occur. In order for NFPs to be able to rapidly and successfully communicate potential PHEICs such as COVID-19 in the future, continued measures need to be taken by both WHO and States Parties to ensure NFPs have the necessary authority, capacity, training, and resources to effectively carry out their functions as described in the IHR.

The contribution of group work to the goals of comprehensive primary health care.

ISSUE ADDRESSED: Group work, such as peer support and health promotion is an important strategy available to comprehensive primary health care. However, group work and how it contributes to the goals of comprehensive primary health care has been under-researched and under-theorised. METHODS: In this 5-year study, we partnered with seven Australian primary health care services, and drew on service reports, two rounds of staff interviews (2009-2010 and 2013, N = 68 and 55), 10 community assessment workshops (N = 65), a client survey (N = 315) and case tracking of clients with diabetes (N = 184, plus interviews with 35 clients, and five practitioners) and clients with depression (N = 95, plus interviews with 21 clients, and 11 practitioners). We conducted a rapid literature review of existing research on group work, and developed a model showing a group work reinforcing cycle. We examined the nature of the groups run, and the benefits staff and clients perceived. RESULTS: Benefits were grouped into four main themes: (a) social support, including for clients of the Aboriginal services, opportunities to celebrate their cultural identity, (b) improving skills and knowledge, (c) increasing access to services and (d) empowerment and solidarity. CONCLUSIONS: The perceived collective and individual benefits aligned with a comprehensive primary health care vision. However, the individualism stressed by neoliberal-driven health policy threatened the provision of group work and its potential collectivist benefits. SO WHAT: There are multiple benefits of group work in primary health care that cannot be achieved through individual work, highlighting the importance of policy and organisational support for group work.

Global health activists' lessons on building social movements for Health for All.

BACKGROUND: The People's Health Movement (PHM) was formed in 2000 and drew inspiration from the Alma Ata Declaration on Primary Health Care's 'Health for All' (1978). Since then PHM has been an active part of a global counter-hegemonic social movement. This study aimed to gain insights on social movement building, drawing on the successes and failures reported by activists over their experiences of working in the Health for All social movement to improve health, justice and equity. METHODS: Qualitative research methods were employed in this study to capture complex and historical narratives of individual activists, through semi-structured interviews and subsequent thematic analysis of transcripts. The research design and analysis were informed by social movement theory and literature on health activism as a pathway for social change. In this study we examine the semi-structured interviews of 15 health activists who are part of the PHM, with the aim of deriving lessons for strengthening movements for Health for All. RESULTS: This study locates the activists' narratives within a socio-political analysis of the global trends of late modern individualism and capitalist neoliberalism. This highlights the challenges faced by civil society groups mobilising collective action and building social movements for Health for All. The study found that within the constraints of the neoliberal socio-political and economic conditions which have caused the rise in social and health inequities, this group of long-term health activists have been nurturing alternative approaches to structuring society and building collective agency to improve health. CONCLUSION: The practical long-term experiences of the PHM activists examined in this study contribute to a better understanding of the processes and motivations that lead to and sustain health activism, and the dilemmas, strategies, impacts and achievements of such activism.

Explaining Why Farmers Grow Tobacco: Evidence From Malawi, Kenya, and Zambia.

INTRODUCTION: Tobacco production continues to increase in low- and middle-income countries creating complications for tobacco control efforts. There is the need to understand and address the global tobacco leaf supply as a means of decreasing tobacco consumption and improving farmers livelihoods in line with Article 17 of the WHO Framework Convention on Tobacco Control. This study aims to understand the reasons why farmers grow tobacco and identify factors that influence these reasons. METHODS: Primary survey data (N = 1770) collected in Kenya, Malawi, and Zambia in the 2013-2014 farming season. Data analysis uses both descriptive and multinomial logistical regression methods. RESULTS: Majority of farmers started and are currently growing tobacco because they believed it was the only economically viable crop. Compared with Malawi, farmers in Kenya and Zambia have a 0.2 and 0.4 lower probability of growing tobacco, respectively because they perceive it as the only economically viable crop, but a 0.04 and 0.2 higher probability of growing tobacco, respectively because they believe it is highly lucrative. There are district/county differences in the reasons provided with some districts having a majority of the farmers citing the existence of a ready market or incentives from the tobacco industry. Statistically significant factors influencing these reasons are the educational level and age of the household head, land allocated to tobacco and debts. CONCLUSION: There is the need to address the unique features of each district to increase successful uptake of alternative livelihoods. One consistent finding is that farmers' perceived economic viability contributes to tobacco growing. IMPLICATIONS: This study finds that perceived economic viability of tobacco is the dominant factor in the decisions to grow tobacco by smallholder farmers in Malawi, Kenya, and Zambia. There is the need to more deeply understand what contributes to farmers' perceived viability of a crop. Understanding and addressing these factors may increase the successful uptake of alternative livelihoods to tobacco. Furthermore, this study demonstrates that a one-size fits all alternative livelihood intervention is less likely to be effective as each district has unique features affecting farmers' decisions on growing tobacco.

USMCA 2.0: a few improvements but far from a 'healthy' trade treaty.

The USMCA (NAFTA 2.0), although signed over a year ago, went through several months of renegotiation of certain of its new rules that the Democrat-controlled US Congress wanted altered or strengthened. In December a 'Protocol of Amendment' was agreed upon and signed by the three Parties (the USA, Mexico, and Canada). A number of tough, new measures governing pharmaceuticals were revised or deleted, making it potentially easier for generic competition and lower drug costs in all three countries. Rules on protection of labour rights were also strengthened, lowering the threshold at which a complaint of unfair labour practices could be initiated. Procedures for investigating such a complaint or resolving a formal dispute were also improved. Similar procedural improvements were made on measures affecting environmental protection. These Protocol agreements are more health-positive than health-negative, and in the case of pharmaceuticals are of significant impact. Overall, however, these amendments are simply a political fine-tuning of the agreement. Concerns raised in our earlier health impact assessment of the USMCA, notably how the agreement's regulatory reforms reduce public health policy flexibilities, remain. The agreement continues to subordinate known or potential health costs of many of its measures to dubious claims of aggregate economic gains. Moreover, these gains, if materialized, are likely to accrue to those atop the income/wealth hierarchies in all three nations.

Globalisation in the time of COVID-19: repositioning Africa to meet the immediate and remote challenges.

The COVID-19 pandemic has ushered in a new climate of uncertainty which is fuelling protectionism and playing into nationalist narratives. Globalisation is under significant threat as governments scramble to reduce their vulnerability to the virus by limiting global trade and flows of people. With the imposition of border closures and strict migration measures, there have been major disruptions in Africa's global supply chains with adverse impacts on employment and poverty. The African economies overly reliant on single export-orientated industries, such as oil and gas, are expected to be severely hit. This situation is further aggravated by tumbling oil prices and a lowered global demand for African non-oil products. The agricultural sector, which should buffer these shocks, is also being affected by the enforcement of lockdowns which threaten people's livelihoods and food security. Lockdowns may not be the answer in Africa and the issue of public health pandemic response will need to be addressed by enacting context-specific policies which should be implemented in a humane way. In addressing the socioeconomic impact of COVID-19 on African nations, we argue that governments should prioritize social protection programmes to provide people with resources to maintain economic productivity while limiting job losses. International funders are committing assistance to Africa for this purpose, but generally as loans (adding to debt burdens) rather than as grants. G20 agreement so suspend debt payments for a year will help, but is insufficient to fiscal need. Maintaining cross-border trade and cooperation to continue generating public revenues is desirable. New strategies for diversifying African economies and limiting their dependence on external funding by promoting trade with a more regionalised (continental) focus as promoted by the African Continental Free Trade Agreement, while not without limitations, should be explored. While it is premature to judge the final economic and death toll of COVID-19, African leaders' response to the pandemic, and the support they receive from wealthier nations, will determine its eventual outcomes.

Health intersectoralism in the Sustainable Development Goal era: from theory to practice.

In 2015, the United Nations' (UN) Member States adopted a bold and holistic agenda of the Sustainable Development Goals (SDGs), integrating a vision of peace and prosperity for people and planet. Extensive work within, between, across sectors is required for this bold and holistic agenda to be implemented. It is in this context that this special article collection showcases multisectoral approaches to achieving SDG 3-Good Health and Well-Being-which, though focused explicitly on health, is connected to almost all other goals. A confluence of social and health inequities, within a context of widespread environmental degradation demands systems thinking and intersectoral action. Articles in this issue focus on the SDGs as a stimulus for renewed multisectoral action: processes, policies, and programs primarily outside the health sector, that have health implications through social, commercial, economic, environmental, and political determinants of health. Case studies offer critical lessons on effectively engaging other sectors to enhance their health outputs, identifying co-benefits and 'win-wins' that enhance human health.

Increasing the public health voice in global decision-making on nutrition labelling.

To respond to the global noncommunicable disease (NCD) crisis, the Codex Alimentarius Commission (Codex), a multilateral United Nations body responsible for work on food standards, is developing global guidance for front of pack (FoP) nutrition labelling. Guidance from Codex regarding FoP nutrition labelling at the global level will almost certainly influence national policy making. This shift in Codex's activities towards standards to address NCDs presents new risks for achievement of public health goals, as a result of the high level of industry involvement in this forum; there is a potential commercial conflict of interest held by manufacturers of products whose consumption could be discouraged by such guidance. In this Commentary, we examine the implications of Codex processes for developing robust global guidance on FoP nutrition labelling and identify opportunities to increase consideration of public health objectives. To date, there has been significantly higher representation of food industry compared to public health actors in Codex discussions on FoP nutrition labelling. Without a strong public health voice in Codex, the industry voice could dominate discussions on FoP nutrition labelling, such that subsequent global guidance prioritises future trade and profits over potential risks to public health. There is currently a critical window of opportunity for public health interests to be prioritised in this multisectoral international forum. The key public health priority for global guidance on FoP nutrition labelling is to ensure protection of policy space for national governments to implement strong and effective regulation, and allow scope for innovation. Public health actors can engage directly with Codex processes, at both the national and global level, and also need to raise awareness among domestic policy makers - including with Ministries of Agriculture and Industry, which often represent countries at Codex - regarding the importance and effectiveness of FoP labelling in NCD prevention. Increased engagement with Codex processes represents a tangible new opportunity to strengthen global governance for public health, and move towards improved coherence between trade policy and health protection goals.

Effectiveness of upgraded maternity waiting homes and local leader training on improving institutional births: a cluster-randomized controlled trial in Jimma, Ethiopia.

BACKGROUND: Maternity waiting homes (MWHs), residential spaces for pregnant women close to obstetric care facilities, are being used to tackle physical barriers to access. However, their effectiveness has not been rigorously assessed. The objective of this cluster randomized trial was to evaluate the effectiveness of functional MWHs combined with community mobilization by trained local leaders in improving institutional births in Jimma Zone, Ethiopia. METHODS: A pragmatic, parallel arm cluster-randomized trial was conducted in three districts. Twenty-four primary health care units (PHCUs) were randomly assigned to either (i) upgraded MWHs combined with local leader training on safe motherhood strategies, (ii) local leader training only, or (iii) usual care. Data were collected using repeat cross-sectional surveys at baseline and 21 months after intervention to assess the effect of intervention on the primary outcome, defined as institutional births, at the individual level. Women who had a pregnancy outcome (livebirth, stillbirth or abortion) 12 months prior to being surveyed were eligible for interview. Random effects logistic regression was used to evaluate the effect of the interventions. RESULTS: Data from 24 PHCUs and 7593 women were analysed using intention-to-treat. The proportion of institutional births was comparable at baseline between the three arms. At endline, institutional births were slightly higher in the MWH + training (54% [n = 671/1239]) and training only arms (65% [n = 821/1263]) compared to usual care (51% [n = 646/1271]). MWH use at baseline was 6.7% (n = 256/3784) and 5.8% at endline (n = 219/3809). Both intervention groups exhibited a non-statistically significant higher odds of institutional births compared to usual care (MWH+ & leader training odds ratio [OR] = 1.09, 97.5% confidence interval [CI] 0.67 to 1.75; leader training OR = 1.37, 97.5% CI 0.85 to 2.22). CONCLUSIONS: Both the combined MWH+ & leader training and the leader training alone intervention led to a small but non-significant increase in institutional births when compared to usual care. Implementation challenges and short intervention duration may have hindered intervention effectiveness. Nevertheless, the observed increases suggest the interventions have potential to improve women's use of maternal healthcare services. Optimal distances at which MWHs are most beneficial to women need to be investigated. TRIAL REGISTRATION: The trial was retrospectively registered on the Clinical Trials website ( https://clinicaltrials.gov ) on 3rd October 2017. The trial identifier is NCT03299491 .

Uncovering spatial variation in maternal healthcare service use at subnational level in Jimma Zone, Ethiopia.

BACKGROUND: Analysis of disaggregated national data suggest uneven access to essential maternal healthcare services within countries. This is of concern as it hinders equitable progress in health outcomes. Mounting an effective response requires identification of subnational areas that may be lagging behind. This paper aims to explore spatial variation in maternal healthcare service use at health centre catchment, village and household levels. Spatial correlations of service use with household wealth and women's education levels were also assessed. METHODS: Using survey data from 3758 households enrolled in a cluster randomized trial geographical variation in the use of maternity waiting homes (MWH), antenatal care (ANC), delivery care and postnatal care (PNC) was investigated in three districts in Jimma Zone. Correlations of service use with education and wealth levels were also explored among 24 health centre catchment areas using choropleth maps. Global spatial autocorrelation was assessed using Moran's I. Cluster analyses were performed at village and household levels using Getis Ord Gi* and Kulldorf spatial scan statistics to identify cluster locations. RESULTS: Significant global spatial autocorrelation was present in ANC use (Moran's I = 0.15, p value = 0.025), delivery care (Moran's I = 0.17, p value = 0.01) and PNC use (Moran's I = 0.31, p value < 0.01), but not MWH use (Moran's I = -0.005, p value = 0.94) suggesting clustering of villages with similarly high (hot spots) and/or low (cold spots) service use. Hot spots were detected in health centre catchments in Gomma district while Kersa district had cold spots. High poverty or low education catchments generally had low levels of service use, but there were exceptions. At village level, hot and cold spots were detected for ANC, delivery care and PNC use. Household-level analyses revealed a primary cluster of elevated MWH-use not detected previously. Further investigation of spatial heterogeneity is warranted. CONCLUSIONS: Sub-national variation in maternal healthcare services exists in Jimma Zone. There was relatively higher poverty and lower education in areas where service use cold spots were identified. Re-directing resources to vulnerable sub-groups and locations lagging behind will be necessary to ensure equitable progress in maternal health.

"Everything Is Perfect, and We Have No Problems": Detecting and Limiting Social Desirability Bias in Qualitative Research.

Many qualitative research studies acknowledge the possibility of social desirability bias (a tendency to present reality to align with what is perceived to be socially acceptable) as a limitation that creates complexities in interpreting findings. Drawing on experiences conducting interviews and focus groups in rural Ethiopia, this article provides an empirical account of how one research team developed and employed strategies to detect and limit social desirability bias. Data collectors identified common cues for social desirability tendencies, relating to the nature of the responses given and word choice patterns. Strategies to avoid or limit bias included techniques for introducing the study, establishing rapport, and asking questions. Pre-fieldwork training with data collectors, regular debriefing sessions, and research team meetings provided opportunities to discuss social desirability tendencies and refine approaches to account for them throughout the research. Although social desirability bias in qualitative research may be intractable, it can be minimized.

The Economic Geography of Kenyan Tobacco Farmers' Livelihood Decisions.

INTRODUCTION: The narrative of prosperous economic livelihood of tobacco farmers in Kenya as alleged by the tobacco industry deserves challenge as evidence increasingly suggests that smallholder tobacco farmers are making little or no profits. Article 17 of the World Health Organization Framework Convention on Tobacco Control encourages viable alternative livelihoods for tobacco farmers. There is little evidence, however, on how tobacco farmers make livelihood choice decisions. METHODS: A total of 527 purposefully selected smallholder tobacco farmers in Kenya from three main tobacco-growing regions participated in a 2017 economic livelihood survey. Geo-economic data were matched to surveyed farmers' Global Positioning System coordinates to estimate each farmer's access to nearby economic centers. Ownership of cell phones or radios was also used to estimate farmers' virtual access to nearby economic activities to understand better the role of information. Multivariate logistic regressions were used to control socioeconomic status and self-reported activity in nearby economic centers. RESULTS: Tobacco farmers rarely live within 10 km of an economic center. Results suggest that the further away farmers live from economic centers, the less likely they are to grow tobacco, but more likely to grow tobacco under contract. Also, farmers owning a cell phone or radio are not only less likely to grow tobacco, but also to not engage in farming under contract if they do grow tobacco. CONCLUSIONS: Physical and virtual access to nearby economic activities is significantly associated with tobacco farmers' livelihood choice decision and should be taken into consideration by decision makers while developing interventions for FCTC Article 17. IMPLICATIONS: Smallholder tobacco farmers in lower-income countries are making little or no profits, but few studies have been conducted to illuminate what perpetuates tobacco production, with such studies urgently needed to support governments to develop viable alternative livelihoods for tobacco farmers. This study suggests that geographic and technological factors that shape farmers' economic decisions can help policy makers tailor alternative livelihood policies to different regional contexts and should be a focus of future research in this area.

Costs, contracts and the narrative of prosperity: an economic analysis of smallholder tobacco farming livelihoods in Kenya.

BACKGROUND: The tobacco industry has used the alleged negative impacts on economic livelihoods for tobacco farmers as a narrative to oppose tobacco control measures in low/middle-income countries. However, rigorous empirical evidence to support or refute this claim remains scarce. Accordingly, we assess how much money households earn from selling tobacco, and the costs they incur to produce the crop, including labour inputs. We also evaluate farmers' decision to operate under contract directly with tobacco manufacturers and tobacco leaf-buying companies or to operate as independent farmers. METHODS: A stratified random sampling method was used to implement a nationally representative household-level economic survey of 585 farmers across the three main tobacco growing regions in Kenya. The survey was augmented with focus group discussions in all three regions to refine and enrich the context of the findings. RESULTS: Both contract and independent farmers experience small profit margins per acre, with contract farmers operating at a loss. Even when family labour is excluded from the calculation, income levels remain low, particularly considering the typically large households. Generally, tobacco farmers enter into contracts with tobacco companies because they have a 'guaranteed' buyer for their tobacco leaf and receive the necessary agricultural inputs (fertiliser, seeds, herbicides and so on) without paying cash up-front. CONCLUSIONS: Tobacco farming households enter into contract with tobacco companies to realise perceived economic benefits. The narrative that tobacco farming is a lucrative economic undertaking for smallholder farmers, however, is inaccurate in the context of Kenya.