Emergence and Spread of Basal Lineages of Yersinia pestis during the Neolithic Decline.

Between 5,000 and 6,000 years ago, many Neolithic societies declined throughout western Eurasia due to a combination of factors that are still largely debated. Here, we report the discovery and genome reconstruction of Yersinia pestis, the etiological agent of plague, in Neolithic farmers in Sweden, pre-dating and basal to all modern and ancient known strains of this pathogen. We investigated the history of this strain by combining phylogenetic and molecular clock analyses of the bacterial genome, detailed archaeological information, and genomic analyses from infected individuals and hundreds of ancient human samples across Eurasia. These analyses revealed that multiple and independent lineages of Y. pestis branched and expanded across Eurasia during the Neolithic decline, spreading most likely through early trade networks rather than massive human migrations. Our results are consistent with the existence of a prehistoric plague pandemic that likely contributed to the decay of Neolithic populations in Europe.

Negotiating discord in sustainability transformations.

Policy action for sustainability transformation faces inherent and ever-present sources of conflict, pushback, and resistance (i.e., discord). However, conceptual frameworks and policy prescriptions for sustainability transformations often reflect an undue image of accord. This involves simplified assumptions about consensus, steering, friction, discreteness, and additiveness of policy action, conferring an unrealistic view of the potential to deliberately realize transformation. Instead, negotiating discord through continuously finding partial political settlements among divided actors needs to become a key focus of policy action for sustainability transformations. Doing so can help to navigate deeply political settings through imperfect but workable steps that loosen deadlock, generate momentum for further policy action, and avoid complete derailment of transformation agendas when discord arises.

Refugee settlements are highly exposed to extreme weather conditions.

Involuntary displacement from conflict and other causes leads to clustering of refugees and internally displaced people, often in long-term settlements. Within refugee-hosting countries, refugee settlements are frequently located in isolated and remote areas, characterized by poor-quality land and harsh climatic conditions. Yet, the exposure of refugee settlements to climatic events is underresearched. In this article, we study the exposure of the 20 largest refugee settlements worldwide to extreme variations in climatic conditions. The analysis integrates exposure of camp locations compared to the national trends for both slow- and rapid-onset events and includes descriptive statistics, signal-to-noise analyses, and trend analyses. Our findings show that most refugee settlements included face relatively high exposure to slow-onset events, including high temperatures (for settlements in Kenya, Ethiopia, Rwanda, Sudan, and Uganda), low temperatures (in the case of Jordan and Pakistan), and low levels of rainfall (in Ethiopia, Rwanda, Kenya, and Uganda) compared to national averages. Our findings for rapid-onset events-heatwaves, coldwaves, and extreme rainfall-are less conclusive compared to country trends, although we find relatively high exposure to extreme rainfall in Cox's Bazar, Bangladesh. Our analyses confirm that refugee populations are exposed to extreme weather conditions postdisplacement, which, in combination with their sociopolitical exclusion, poses a threat to well-being and increased marginalization. Our findings call for an inclusive and integrated approach, including refugees and their host communities, in designing climate adaptation and sustainable development policies, in order to promote equitable sustainable development pathways in refugee-hosting countries.

Association Between Household Deprivation and Living in Informal Settlements and Incidence of Diarrhea in Children Under 5 in Eleven Latin American Cities.

Diarrhea is a leading cause of death in children globally, mostly due to inadequate sanitary conditions and overcrowding. Poor housing quality and lack of tenure security that characterize informal settlements are key underlying contributors to these risk factors for childhood diarrhea deaths. The objective of this study is to better understand the physical attributes of informal settlement households in Latin American cities that are associated with childhood diarrhea. We used data from a household survey (Encuesta CAF) conducted by the Corporación Andina de Fomento (CAF), using responses from sampled individuals in eleven cities. We created a household deprivation score based on household water and sewage infrastructure, overcrowding, flooring and wall material, and security of tenure. We fitted a multivariable logistic regression model to estimate odds ratios (OR) and 95% confidence intervals (95% CI) to test the association between the deprivation score and its individual components and childhood diarrhea during the prior 2 weeks. We included a total of 4732 households with children, out of which 12.2% had diarrhea in the 2-week period prior to completing the survey. After adjusting for respondent age, gender, and city, we found a higher risk of diarrhea associated with higher household deprivation scores. Specifically, we found that the odds of diarrhea for children living in a mild and severe deprived household were 1.04 (95% CI 0.84-1.28) and 3.19 times (95% CI 1.80-5.63) higher, respectively, in comparison to households with no deprivation. These results highlight the connections between childhood health and deprived living conditions common in informal settlements.

Trends and Inequalities in Maternal and Newborn Health Services for Unplanned Settlements of Lusaka City, Zambia.

Living conditions and other factors in urban unplanned settlements present unique challenges for improving maternal and newborn health (MNH), yet MNH inequalities associated with such challenges are not well understood. This study examined trends and inequalities in coverage of MNH services in the last 20 years in unplanned and planned settlements of Lusaka City, Zambia. Geospatial information was used to map Lusaka's settlements and health facilities. Zambia Demographic Health Surveys (ZDHS 2001, 2007, 2013/2014, and 2018) were used to compare antenatal care (ANC), institutional delivery, and Cesarean section (C-section) coverage, and neonatal mortality rates between the poorer 60% and richer 40% households. Health Management Information System (HMIS) data from 2018 to 2021 were used to compute service volumes and coverage rates for ANC1 and ANC4, and institutional delivery and C-sections by facility level and type in planned and unplanned settlements. Although the correlation is not exact, our data analysis showed close alignment; and thus, we opted to use the 60% poorer and 40% richer groups as a proxy for households in unplanned versus planned settlements. Unplanned settlements were serviced by primary centers or first-level hospitals. ZDHS findings show that by 2018, at least one ANC visit and institutional delivery became nearly universal throughout Lusaka, but early and four or more ANC visits, C-sections, and neonatal mortality rates remained worse among poorer than richer women in ZDHS. In HMIS, ANC and institutional delivery volumes were highest in public facilities, especially in unplanned settlements. The volume of C-sections was much greater within facilities in planned than unplanned settlements. Our study exposed persistent gaps in timing and use of ANC and emergency obstetric care between unplanned and planned communities. Closing such gaps requires strengthening outreach early and consistently in pregnancy and increasing emergency obstetric care capacities and referrals to improve access to important MNH services for women and newborns in Lusaka's unplanned settlements.

Exploring the implementation of an SMS-based digital health tool on maternal and infant health in informal settlements.

BACKGROUND: The rapid urbanization of Kenya has led to an increase in the growth of informal settlements. There are challenges with access to maternal, newborn, and child health (MNCH) services and higher maternal mortality rates in settlements. The Kuboresha Afya Mitaani (KAM) study aimed to improve access to MNCH services. We evaluate one component of the KAM study, PROMPTS (Promoting Mothers through Pregnancy and Postpartum), an innovative digital health intervention aimed at improving MNCH outcomes. PROMPTS is a two-way AI-enabled SMS-based platform that sends messages to pregnant and postnatal mothers based on pregnancy stage, and connects mothers with a clinical help desk to respond and refer urgent cases in minutes. METHODS: PROMPTS was rolled out in informal settlements in Mathare and Kawangware in Nairobi County. The study adopted a pre-post intervention design, comparing baseline and endline population outcomes (1,416 participants, Baseline = 678, Endline = 738). To further explore PROMPTS's effect, outcomes were compared between endline participants enrolled and not enrolled in PROMPTS (738 participants). Outcomes related to antenatal (ANC) and postnatal (PNC) service uptake and knowledge were assessed using univariate and multivariate linear and logistic regression. RESULTS: Between baseline and enldine, mothers were 1.85 times more likely to report their babies and 1.88 times more likely to report themselves being checked by a provider post-delivery. There were improvements in moms and babies receiving care on time. 45% of the 738 endline participants were enrolled in the PROMPTS program, with 87% of these participants sending at least one message to the system. Enrolled mothers were 2.28 times more likely to report completing four or more ANC visits relative to unenrolled mothers. Similarly, enrolled mothers were 4.20 times more likely to report their babies and 1.52 times more likely to report themselves being checked by a provider post-delivery compared to unenrolled mothers. CONCLUSIONS: This research demonstrates that a digital health tool can be used to improve care-seeking and knowledge levels among pregnant and postnatal women in informal settlements. Additional research is needed to refine and target solutions amongst those that were less likely to enroll in PROMPTS and to further drive improved MNCH outcomes amongst this population.

Examining the efficacy of the legal framework governing the management of greywater in South Africa's informal settlements.

The management of greywater and sanitation in South Africa's urban informal settlements is a pressing concern. This review critically examines the legal framework that governs greywater management in South Africa's informal settlements, aiming to shed light on the existing regulations, gaps, and opportunities for sustainable greywater reuse. By scrutinizing the legal framework, the review identifies gaps and challenges in the regulatory environment, including inconsistencies, lack of clarity, and limited enforcement mechanisms. It explores the potential for international best practices to inform possible amendments to the existing legal framework. This was a quantitative research design utilizing a cross sectional survey model. Questionnaires were administered electronically to a sample of 17 municipal leaders from the City of Tshwane, City of Johannesburg and Buffalo City municipalities whose responsibilities were on water management. Descriptive statistics were employed in analysis of the data. Outcomes were reviewed against the alignment or the lack thereof with the SANS 1732:201x standards. This paper underscores the critical need for a coherent and robust legal framework to support responsible greywater management in South Africa's informal settlements. The paper's insights contribute to the ongoing discourse on water governance, shedding light on the pathways toward a more equitable water future.

The nexus between household water insecurity, mother's handwashing practices, and diarrheal diseases among under-five children.

This study aimed to examine the association between household water insecurity (HWIS), mother's handwashing practices, and childhood diarrhea in the peri-urban and informal settlements of Hosanna town. A community-based cross-sectional study involving 424 mothers was carried out in Hosanna town, and the data were collected using a pretested structured questionnaire, HWISE Scale, and an observational checklist. Bivariate and multivariable logistic regression models were used to analyze the data. The study revealed that the prevalence of HWIS and diarrhea among under-five children was 68.6% and 16%, respectively. Only 42.2% of the mothers had good handwashing practices. Good knowledge of handwashing, positive attitudes toward handwashing, household water security (HWS), and the presence of handwashing facilities were significantly associated with good handwashing practices. Children aged 6-11 months, HWIS, uncovered and wide-mouthed water storage containers, unsafe child's stool disposal practices, and hands not washed with soap after defecation, before preparing food, and feeding a child were significantly associated with the occurrence of diarrhea. The prevalence of diarrhea and HWIS was very high. The majority of the mothers had poor handwashing practices. Therefore, findings suggest interventions to improve HWS and mother's handwashing practices, which could reduce the risk of diarrheal diseases.

Overcoming the constraints of competitive clientelism? Explaining the success of Ghana's poorest region in reducing maternal mortality.

Maternal mortality remains a health challenge that many developing countries struggle to address. Drawing on 64 key informant interviews, this article shows how Ghana's most impoverished administrative region, the Upper East, emerged as a bureaucratic 'pocket of effectiveness' in reducing maternal mortality in a context where national political settlement dynamics are undermining progress in improving maternal health. At the national level, Ghana's progress in reducing maternal mortality has been disappointing because public investments are disproportionately directed to reforms that contribute to the short-term political survival of ruling elites. Competitive electoral pressures have contributed to greater elite commitment towards health sector investments with visual impact, while weakening elite incentives for dedicating resources to interventions that are necessary for enhancing the quality of health. The relatively better performance of the Upper East Region in reducing maternal mortality has been driven by a hybrid form of accountability that combines top-down pressures from the regional health directorate with horizontal forms of accountability that result in a competitive spirit among health workers. These findings show that even in contexts where resources are limited, the capacity of sub-national leaders in devising local solutions to local problems can lead to improved performance of health systems at the sub-national level. The findings also suggest the need for academic debates to go beyond the binary distinctions regarding the usefulness of top-down versus bottom-up accountability measures and focus on building effective and legitimate forms of accountability that run both top-down and bottom-up when seeking to improve health service delivery.

Local ecological knowledge and perception as a strategy in the management of ecosystem services.

In designing and implementing initiatives to conserve biodiversity and ensure the flow of ecosystem services, it is crucial to understand the perspectives of communities living near protected areas. Improving conservation efforts may depend on analyzing socio-ecological factors and their impact on Local Ecological Knowledge (LEK) and perceptions of ecosystem services. We employed participatory methodologies with 80 farmers from agrarian settlements adjacent to protected areas in the Cerrado biome, Brazil, we quantified LEK and assessed perceptions of ecosystem services using an adaptation of the Q-methodology. We collected data on thirteen socio-ecological variables, including age, gender, farm size, education, engagement with conservation initiatives, and interactions with protected areas and Legal Reserves. Using artificial intelligence in a Random Forest (RF) modelling approach, we identified the most influential variables on LEK and perceptions. Our findings demonstrate that engagement in nature conservation and restoration initiatives, along with the use of native areas (protected and managed areas) significantly influence LEK levels within the farmers' communities. Farmers with full participation, from conception to implementation and evaluation of the initiatives, had a significantly higher LEK level (28.5 ± 13.0) compared to farmers without participation in those initiatives (11.4 ± 5.9). Farmers who used the cerrado for leisure and education (28.2 ± 21.2) had significantly higher LEK levels compared to farmers who do not attend or use the cerrado areas (13.5 ± 8.9) and those using areas of native vegetation for cattle raising (12.8 ± 6.8). These results highlight that, in addition to farmers' participation in conservation and restoration initiatives, the sustainable use of natural areas is fundamental to strengthen their local knowledge of ecosystem functioning. Furthermore, we found that the type of agroecosystem present on farms strongly? shapes farmers' perceptions of ecosystem services. Farmers perceive different ecosystem services depending on land use, indicating the need for tailored interventions for the planning and management of conservation areas. Farmers practicing soybean monoculture had significantly lower perception scores on ecosystem services (-5.1 ± 3.8) than to the other four evaluated groups. Overall, the study highlights the critical role of incorporating local knowledge and perceptions for the design of effective management strategies to increase ecosystem services provision and biodiversity conservation in areas adjacent to protected areas.

"People are now working together for a common good": The effect on social capital of participatory design for community-level sanitation infrastructure in urban informal settlements.

Communities with higher levels of social capital perform better than communities with lower social capital in community-level water and sanitation interventions and have better health outcomes. Although research recommends bolstering social capital to improve intervention outcomes, few studies provide empirical evidence on the effect of intervention activities on social capital. This study aimed to evaluate the effect of participatory design and community engagement activities on social capital among urban informal settlements in Suva, Fiji and Makassar, Indonesia enrolled in the Revitalizing Informal Settlements and their Environments trial using the Short Adapted Social Capital Assessment Tool. We performed confirmatory factor analyses (CFA) to test tool performance and built structural equation models to assess intervention effect on CFA-informed, sub-scale scores for cognitive and structural social capital. Qualitative in-depth interviews in Fiji and Indonesia and focus group discussions in Fiji provided nuanced understanding of intervention effects on social capital from residents' perspectives. Results confirmed the hypothesized two-factor solution but revealed differences by country and by gender in Indonesia. The intervention appeared positively related to cognitive social capital among men and women in Indonesia and negatively related to cognitive and structural social capital among men and women in Fiji. While effect sizes were small and cluster-adjustment for a small number of settlements yielded non-significant effects, trends were consistent across models and bivariate analyses and were corroborated by qualitative findings. Several contextual factors may explain these results, including timing and duration of intervention activities and influence of COVID-19. Qualitative data suggested that the relationship between participatory design and social capital may be bidirectional, helping to explain why certain settlements appeared to be better equipped to benefit from intervention activities. Practitioners and program designers should carefully consider the social pre-conditions of communities in which they intend to work to optimize program outcomes and avoid unintended consequences.

A history of mental illness among women in the Straits Settlements in the nineteenth century.

The Straits Settlements, a collective colony under the administration of British Malaya, was a very unhealthy area in the early years of the nineteenth century. One of the most common sicknesses was mental illness, which could not be cured by medicines. The number of women suffering from mental illness was higher than in men, and it was found that there were many internal and external causes. The increasing number of women patients affected the role of mental hospitals, which were not only for treatment purposes, but also for business. This study will discuss the factors causing women to suffer from mental illness, and the role of the asylum for women mental patients in the nineteenth century.

Genome Sequencing of up to 6,000-Year-Old Citrullus Seeds Reveals Use of a Bitter-Fleshed Species Prior to Watermelon Domestication.

Iconographic evidence from Egypt suggests that watermelon pulp was consumed there as a dessert by 4,360 BP. Earlier archaeobotanical evidence comes from seeds from Neolithic settlements in Libya, but whether these were watermelons with sweet pulp or other forms is unknown. We generated genome sequences from 6,000- and 3,300-year-old seeds from Libya and Sudan, and from worldwide herbarium collections made between 1824 and 2019, and analyzed these data together with resequenced genomes from important germplasm collections for a total of 131 accessions. Phylogenomic and population-genomic analyses reveal that (1) much of the nuclear genome of both ancient seeds is traceable to West African seed-use "egusi-type" watermelon (Citrullus mucosospermus) rather than domesticated pulp-use watermelon (Citrullus lanatus ssp. vulgaris); (2) the 6,000-year-old watermelon likely had bitter pulp and greenish-white flesh as today found in C. mucosospermus, given alleles in the bitterness regulators ClBT and in the red color marker LYCB; and (3) both ancient genomes showed admixture from C. mucosospermus, C. lanatus ssp. cordophanus, C. lanatus ssp. vulgaris, and even South African Citrullus amarus, and evident introgression between the Libyan seed (UMB-6) and populations of C. lanatus. An unexpected new insight is that Citrullus appears to have initially been collected or cultivated for its seeds, not its flesh, consistent with seed damage patterns induced by human teeth in the oldest Libyan material.

Joint Food and Water Insecurity Had a Multiplicative Effect on Women's Depression in Urban Informal Settlements in Makassar, Indonesia during the COVID-19 Pandemic.

BACKGROUND: Women living in urban informal settlements may be particularly vulnerable to the detrimental effects of the COVID-19 pandemic because of increased economic and psychosocial stressors in resource-limited environments. OBJECTIVES: The objective of this study was to assess the associations between food and water insecurity during the pandemic and depression among women living in the urban informal settlements in Makassar, Indonesia. METHODS: We implemented surveys at 3 time points among women enrolled in the Revitalizing Informal Settlements and their Environments trial. Depression was measured using the Center for Epidemiologic Studies Depression Scale-10 (CESD-10) between November and December 2019 and again between February and March 2021. Food insecurity was measured using questions from the Innovation for Poverty Action's Research for Effective COVID-19 Reponses survey and water insecurity was measured using the Household Water Insecurity Experiences Short Form. Both were measured between August and September 2020. We built 3 multivariate quantile linear regression models to assess the effects of water insecurity, food insecurity, and joint food and water insecurity during the COVID-19 pandemic on CESD-10 score. RESULTS: In models with the full sample (n = 323), food insecurity (ß: 1.48; 95% CI: 0.79, 2.17), water insecurity (ß: 0.13; 95% CI: -0.01, 0.26), and joint food and water insecurity (ß: 2.40; 95% CI: 1.43, 3.38) were positively associated with CESD-10 score. In subgroup analyses of respondents for whom we had prepandemic CESD-10 scores (n = 221), joint food and water insecurity (ß: 1.96; 95% CI: 0.78, 3.15) maintained the strongest relationship with CESD-10 score. A limitation of this study is that inconsistency in respondents from households across the survey waves reduced the sample size used for this study. CONCLUSIONS: Our results find a larger association between depression and joint resource insecurity than with water or food insecurity alone, underlining the importance of addressing food and water insecurity together, particularly as they relate to women's mental health and well-being.

Bayesian belief network modelling approach for predicting and ranking risk factors for malaria infections among children under 5 years in refugee settlements in Uganda.

BACKGROUND: Malaria risk factors at household level are known to be complex, uncertain, stochastic, nonlinear, and multidimensional. The interplay among these factors, makes targeted interventions, and resource allocation for malaria control challenging. However, few studies have demonstrated malaria's transmission complexity, control, and integrated modelling, with no available evidence on Uganda's refugee settlements. Using the 2018-2019 Uganda's Malaria Indicator Survey (UMIS) data, an alternative Bayesian belief network (BBN) modelling approach was used to analyse, predict, rank and illustrate the conceptual reasoning, and complex causal relationships among the risk factors for malaria infections among children under-five in refugee settlements of Uganda. METHODS: In the UMIS, household level information was obtained using standardized questionnaires, and a total of 675 children under 5 years were tested for malaria. From the dataset, a casefile containing malaria test results, demographic, social-economic and environmental information was created. The casefile was divided into a training (80%, n = 540) and testing (20%, n = 135) datasets. The training dataset was used to develop the BBN model following well established guidelines. The testing dataset was used to evaluate model performance. RESULTS: Model accuracy was 91.11% with an area under the receiver-operating characteristic curve of 0.95. The model's spherical payoff was 0.91, with the logarithmic, and quadratic losses of 0.36, and 0.16 respectively, indicating a strong predictive, and classification ability of the model. The probability of refugee children testing positive, and negative for malaria was 48.1% and 51.9% respectively. The top ranked malaria risk factors based on the sensitivity analysis included: (1) age of child; (2) roof materials (i.e., thatch roofs); (3) wall materials (i.e., poles with mud and thatch walls); (4) whether children sleep under insecticide-treated nets; 5) type of toilet facility used (i.e., no toilet facility, and pit latrines with slabs); (6) walk time distance to water sources (between 0 and 10 min); (7) drinking water sources (i.e., open water sources, and piped water on premises). CONCLUSION: Ranking, rather than the statistical significance of the malaria risk factors, is crucial as an approach to applied research, as it helps stakeholders determine how to allocate resources for targeted malaria interventions within the constraints of limited funding in the refugee settlements.

Socioeconomic inequality in unmet outpatient healthcare needs among people living in urban informal settlements in Sanandaj city, Iran.

BACKGROUND: The growing trend of informal settlements is a serious humanitarian crisis. Unmet need for health care services is an indicator to measure the state of equality and access to healthcare services. This study, for the first time in Iran, examined the prevalence of unmet needs for outpatient healthcare services and related socioeconomic inequalities among residents of informal settlements in Sanandaj city. METHODS: This cross-sectional study was conducted on informal settlements of Sanandaj city with a sample size of 1345 people. Data were collected using a questionnaire. Multivariate logistic regression was used to determine significant predictors of unmet needs for healthcare services. Concentration index (C) and concentration curve (CC) were calculated to measure inequality in the prevalence of unmet needs for healthcare services. RESULTS: The prevalence of unmet needs for outpatient healthcare services was 31.7%. Financial and physical barriers were the most common reasons for not using the needed services. The highest unmet need was related to dental (80.6%) and rehabilitation services (78.8%). Being elderly with about 2.3 times (OR: 2.37, 95% CI: 1.19-4.75), not having a job with about 1.7 times (OR: 1.70, 95% CI: 1.13-2.57) and having a low economic status with about 4 times (OR: 4.46, 95% CI: 2.39-9.70) increased the odds of experiencing unmet need for outpatient healthcare services. The value of concentration index showed that unmet need for outpatient healthcare services was significantly concentrated among people with lower economic status (C= -0.330, 95% CI: -0.432 to -0.227). CONCLUSION: The unmet need is high among people living in informal settlements of Sanandaj city and a significant part of the residents of these settlements does not have access to required healthcare services. Regardless of the needs of people living in these settlements, who constitute a large population of Iran, access to universal health coverage is not possible in such areas. Removing the identified obstacles and causes behind the unmet needs requires the interdisciplinary participation of all actors, including the government, the nation, and civil society.

Spatial Distributions of Diarrheal Cases in Relation to Housing Conditions in Informal Settlements: A Cross-Sectional Study in Abidjan, Côte d'Ivoire.

In addition to individual practices and access to water, sanitation, and hygiene (WASH) facilities, housing conditions may also be associated with the risk of diarrhea. Our study embraced a broad approach to health determinants by looking at housing deprivation characteristics as exposures of interest and confronting the latter's spatial distribution to that of diarrheal cases. We tested the hypothesis that the risk of diarrhea in informal settlements is not only associated with WASH services, but also with inadequate dwelling characteristics, and that their spatial distributions follow similar patterns. We designed a cross-sectional study and collected primary data through georeferenced household surveys in two informal settlements in Abidjan, Côte d'Ivoire. We used local join count statistics to assess the spatial distribution of events and multiple logistic regressions to calculate adjusted odds ratios between diarrhea and exposures. A total of 567 households were enrolled. We found that constant access to basic WASH services, non-durable building materials, cooking outdoors, and water service discontinuity were associated with higher risks of diarrhea in the general population. The spatial distribution of diarrheal cases coincided with that of dwelling deprivation characteristics. We observed significant heterogeneity within the study sites regarding the spatial distribution of diarrheal cases and deprived dwellings. Along with WASH infrastructure, communities also need dignified housing to effectively prevent diarrhea. We recommend that decision-makers acknowledge a "spectrum" of deprivation within the heterogeneous universe of informal settlements, adopting a site-specific approach based on high-resolution data to address diarrhea and improve people's well-being.

Effect of mentorship and a mHealth application in updating provider skills and knowledge in maternal and newborn care in two informal settlements of Nairobi.

BACKGROUND: Children and women in urban informal settlements have fewer choices to access quality maternal and newborn health care. Many facilities serving these communities are under-resourced and staffed by fewer providers with limited access to skills updates. We sought to increase provider capacity by equipping them with skills to provide general and emergency obstetric and newborn care in 24 facilities serving two informal settlements in Nairobi. We present evidence of the combined effect of mentorship using facility-based mentors who demonstrate skills, support skills drills training, and provide practical feedback to mentees and a self-guided online learning platform with easily accessible EmONC information on providers' smart phones. METHODS: We used mixed methods research with before and after cross-sectional provider surveys conducted at baseline and end line. During end line, 18 in-depth interviews were conducted with mentors and mentees who were exposed, and providers not exposed to the intervention to explore effectiveness and experience of the intervention on quality maternal health services. RESULTS: Results illustrated marked improvement from ability to identify antepartum hemorrhage (APH), postpartum hemorrhage (PPH), manage retained placenta, ability to identify and manage obstructed labour, Pre-Eclampsia and Eclampsia (PE/E), puerperal sepsis, and actions taken to manage conditions when they present. Overall, out of 95 elements examined there were statistically significant improvements of both individual scores and overall scores from 29/95 at baseline (30.5%) to 44.3/95 (46.6%) during end line representing a 16- percentage point increase (p > 0.001). These improvements were evident in public health facilities representing a 17.3% point increase (from 30.9% at baseline to 48.2% at end line, p > 0.001). Similarly, providers working in private facilities exhibited a 15.8% point increase in knowledge from 29.7% at baseline to 45.5% at end line (p = 0.0001). CONCLUSION: This study adds to the literature on building capacity of providers delivering Maternal and Newborn Health (MNH) services to women in informal settlements. The complex challenges of delivering MNH services in informal urban settings where communities have limited access require a comprehensive approach including ensuring access to supplies and basic equipment. Nevertheless, the combined effects of the self-guided online platform and mentorship reinforces EmONC knowledge and skills. This combined approach is more likely to improve provider competency, and skills as well as improving maternal and newborn health outcomes.

Prevalence and predictors of sex under the influence of psychoactive substances among young people in informal settlements in Kampala, Uganda.

BACKGROUND: The use of psychoactive substances such as alcohol, heroin and marijuana is associated with negative health outcomes such as sexual violence and unintended pregnancies, and risky sexual behaviours. Although there is evidence linking psychoactive substance use and risky sexual behaviours such as inconsistent condom use and multiple sexual relationships, there is limited data on sex under the influence of psychoactive substances among young people. This study aimed to investigate the prevalence and predictors of sex under the influence of psychoactive substances among young people in informal settlements in Kampala, Uganda. METHODS: A cross-sectional study was conducted among 744 sexually active young psychoactive substance users in informal settlements in Kampala, Uganda. Data were collected through face-to-face interviews using a digitalized structured questionnaire, preloaded on the Kobocollect mobile application. The questionnaire captured data on the socio-demographic characteristics of the respondents, history of psychoactive substance use, and sexual behaviours. Data were analysed using STATA Version 14.0. A modified Poisson regression model was used to determine the predictors of sex under the influence of psychoactive substances.. Adjusted prevalence ratios at a p-value value ≤ 0.05 with a 95% confidence interval were considered. RESULTS: About 61.0% (454/744) of the respondents had had sex under the influence of psychoactive substances in the last 30 days. The predictors of sex under the influence of psychoactive substances were being female (PR 1.18, 95% CI: 1.04-1.34), being 20-24 years of age (PR: 1.22, 95% CI: 1.04-1.44), being married (PR 1.15, 95% CI: 1.01-1.31) or divorced/separated (PR 1.43, 95% CI: 1.26-1.61), not living with biological parents or guardians (PR 1.22, 95% CI: 0.99-1.50), earning 71 USD and below (PR 0.86, 95% CI: 0.79-1.03) and using alcohol (PR 1.43, 95% CI: 1.25-1.69), marijuana (PR 1.16, 95% CI: 1.02-1.31) and khat (PR 1.25, 95% CI: 1.10-1.42) in the last 30 days. CONCLUSION: The study found that a high proportion of sexually active young people in informal settlements in Kampala, Uganda had engaged in sex under the influence of psychoactive substances in the past 30 days. The study also identified several factors associated with sex under the influence of psychoactive substances, including being female, being aged 20-24 years, being married or divorced or separated, not living with biological parents or guardians, and using alcohol, marijuana, or khat in the past 30 days. Our findings suggest the need for targeted sexual and reproductive health programs that incorporate risk-reduction interventions aimed at reducing sex under the influence of psychoactive substances, especially among females and those who do not live with their parents.

Climate change and health risks in Mukuru informal settlement in Nairobi, Kenya - knowledge, attitudes and practices among residents.

BACKGROUND: Residents of informal settlements in Sub-Sahara Africa (SSA) are vulnerable to the health impacts of climate change. Little is known about the knowledge, attitudes and practices (KAP) of inhabitants of informal settlements in SSA regarding climate change and its health impacts. The aim of this study was to investigate how inhabitants of an informal settlement in SSA experience climate change and its health impacts and assess related knowledge, attitudes and practices. The study was conducted in Mukuru informal settlement in Nairobi City County, Kenya. METHODS: A cross-sectional study was conducted in September 2021 using a structured, semi-closed KAP questionnaire. Inclusion criteria were ≥ 18 years of age and living in one of the three main sections in Mukuru: Kwa Njenga, Kwa Reuben or Viwandani. By spinning a pen at the geographic centre of each section, a random direction was selected. Then, in every second household one individual was interviewed, creating a representative mix of ages and genders of the local community. To assess participant characteristics associated with climate change knowledge multivariable logistic regression was used. Thematic content analysis was performed for qualitative responses. RESULTS: Out of 402 study participants, 76.4% (n = 307) had heard of climate change before the interview, 90.8% (n = 365) reported that climate change was affecting their community, and 92.6% (n = 372) were concerned with the health-related impact of climate change. Having lived in Mukuru for more than 10 years and living in a dwelling close to the riverside were factors significantly associated with having heard of climate change before (aOR 3.1, 95%CI 1.7 - 5.8 and aOR 2.6, 95%CI 1.1 - 6.1, respectively) and experiencing a climate change related impact on the community (aOR 10.7, 95%CI 4.0 - 28.4 and aOR 7.7; 95%CI 1.7 - 34.0, respectively). Chronic respiratory conditions, vector-borne diseases, including infectious diarrhoea, malnutrition and cardiovascular diseases were identified by respondents as climate related health risks. CONCLUSIONS: Most respondents were knowledgeable about climate change and were experiencing its (health-related) impact on their community. This study provides insights which may prove useful for policy makers, intervention planners and researchers to work on locally adapted mitigation and adaption strategies.