Neighbourhood effect and inequality in access to essential health services among mother-child paired samples: a decomposition analysis of data from 58 low- and middle-income countries.

INTRODUCTION: Neighbourhood effect on health outcomes is well established, but little is known about its effect on access to essential health services (EHS). Therefore, this study aimed to assess the contributing factors to access to EHS in slum versus non-slum settings. METHODOLOGY: The most recent data from 58 Demographic and Health Surveys (DHS) conducted between 2011 and 2018 were used, including a total of 157,000 pairs of currently married women aged 15-49 and their children aged 12-23 months. We used meta-analysis techniques to examine the inequality gaps in suboptimal access to EHS between mother-children pairs living in slums and non-slums. Blinder-Oaxaca decomposition technique was used to identify the factors contributing to the inequality gaps in each low- and middle-income country (LMIC) included. RESULT: The percentage of mother-child pairs living in slums ranged from 0.5% in Egypt to 63.7% in Congo. Meta-analysis of proportions for the pooled sample revealed that 31.2% [27.1, 35.5] of slum residents and 20.0% [15.3, 25.2] among non-slum residents had suboptimal access to EHS. We observed significant pro-slum inequalities in suboptimal access to EHS in 28 of the 52 LMICs with sufficient data. Of the 34 African countries included, 16 showed statistically significant pro-slum inequality in suboptimal access to EHS, with the highest in Egypt and Mali (2.64 [0.84-4.44] and 1.76 [1.65, 1.87] respectively). Findings from the decomposition analysis showed that, on average, household wealth, neighbourhood education level, access to media, and neighbourhood-level illiteracy contributed mostly to slum & non-slum inequality gaps in suboptimal access to EHS. CONCLUSION: The study showed evidence of inequality in access to EHS due to neighbourhood effects in 26 LMICs. This evidence suggests that increased focus on the urban poor might be a important for increasing access to EHS and achieving the universal health coverage (UHC) goals.

Metabolic changes with intermittent fasting.

BACKGROUND: The prevalence of obesity is rising globally and effective strategies to treat obesity are needed. Intermittent fasting, a dietary intervention for weight management, has received growing interest from the general public, as well as healthcare professionals, as a form of lifestyle intervention. METHODS: We executed a rapid review using PUBMED database to identify systematic reviews that examined the impact of intermittent fasting on metabolic indices, published between 2011 and 2022. RESULTS: Intermittent fasting leads to weight loss of a similar magnitude to continuous energy restriction. Most of the evidence shows that intermittent fasting leads to greater fat loss as measured by fat mass (kg) or body fat percentage compared to an ad libitum diet, but fat loss attained during intermittent fasting is not significantly different to continuous energy restriction, although recent evidence shows intermittent fasting to be superior. There is mixed evidence for the impact of intermittent fasting on insulin resistance, fasting glucose and lipid profile. Some studies focused on populations of Muslim people, which showed that Ramadan fasting may lead to weight loss and improvement of metabolic parameters during fasting, although the effects are reversed when fasting is finished. CONCLUSIONS: Intermittent fasting is more effective than an ad libitum dietary intake, and equally or more effective as continuous energy restriction, for weight management. However, there is inconclusive evidence on whether intermittent fasting has a clinically beneficial effect on glucose and lipid metabolism.

Swahili translation and validation of the Warwick Edinburgh Mental Wellbeing Scale (WEMWBS) in adolescents and adults taking part in the girls' education challenge fund project in Tanzania.

BACKGROUND: The Warwick Edinburgh Mental Wellbeing Scale (WEMWBS) is validated for measuring mental wellbeing in populations aged 11 + and has been translated into 30 + languages. The aims of this study were a) to translate and validate WEMWBS for use in Swahili-speaking populations to facilitate measurement and understanding of wellbeing, evaluation of policy and practice, and enable international comparisons; and b) to examine sociodemographic characteristics associated with higher and lower mental wellbeing in participants in the Girls' Education Challenge (GEC) project in Tanzania. METHODS: A short questionnaire including WEMWBS and similar scales for comparison, socio-demographic information, and self-reported health was translated into Swahili using gold standard methodology. This questionnaire was used to collect data from secondary school students, learner guides, teacher mentors and teachers taking part in the GEC project in Tanzania. Focus groups were used to assess acceptability and comprehensibility of WEMWBS and conceptual understanding of mental wellbeing. These were audio-taped, transcribed and analysed thematically. Internal consistency of WEMWBS, correlation with comparator scales and confirmatory factor analysis were completed as quantitative validation. Finally, multivariable logistic regression was used to explore associations between individual characteristics and 'high' and 'low' mental wellbeing, defined as the highest and lowest quartile of WEMWBS scores. RESULTS: 3052 students and 574 adults were recruited into the study. Participants reported that WEMWBS was understandable and relevant to their lives. Both WEMWBS and its short form met quantitative standards of reliability and validity, were correlated with comparator scales and met the criteria to determine a single factor structure. For students in the GEC supported government schools: mental wellbeing was higher in students in the final two 'forms' of school compared with the first two. In addition: being male, urban residence, the absence of markers of social marginality and better self-reported health were all significantly associated with better mental wellbeing. For adults, urban residence and better self-reported health were associated with better mental wellbeing. CONCLUSIONS: The Swahili translation of WEMWBS is available for use. Further work to explore how to intervene to increase mental wellbeing in vulnerable GEC participants is needed.

How and to what extent did the Coventry City of Culture 'City Host' volunteer programme effect the volunteers' mental wellbeing? A qualitative study.

BACKGROUND: A team of volunteers, known as City Hosts, were recruited to support UK City of Culture 2021 awarded to Coventry. City Hosts held various roles facilitating cultural event delivery and promoting a positive experience for visitors. This study aimed to (i) understand how and to what extent the volunteering programme impacted volunteer subjective wellbeing, and (ii) explore the mechanisms of change and intermediate outcomes between volunteering and subjective wellbeing. METHODS: This qualitative study comprised inductive and deductive analysis of data collected through semi-structured interviews, conducted between December 2021-May 2022 with City Hosts. This was complimented with secondary qualitative analysis of free text responses within Monitoring and Evaluation data collected from City Hosts in surveys conducted in August and November 2021, and April 2022. RESULTS: Approximately 180 City Hosts responded to the free text questions in each survey and 27 completed interviews. Analysis of data collected from City Hosts suggested positive wellbeing impacts from volunteering and supported theorised pathways to improved wellbeing. Strengths of the City Host programme included (i) facilitating the full range of mechanisms of change that mediate improved volunteer wellbeing, particularly promoting social connections and developing a strong role and group identity and (ii) flexibility around what volunteers do, how much, and how often. CONCLUSIONS: This study offers lessons for others designing volunteering programmes who wish to promote wellbeing among associated volunteers. We also offer evidence that exposure to culture may be one mechanism by which volunteering can improve wellbeing.

Trends in socioeconomic inequalities in behavioural non-communicable disease risk factors: analysis of repeated cross-sectional health surveys in England between 2003 and 2019.

BACKGROUND: Previous studies have shown that those in lower socioeconomic positions (SEPs) generally have higher levels of behavioural non-communicable disease (NCD) risk factors. However, there are limited studies examining recent trends in inequalities. This study examined trends in socioeconomic inequalities in NCD behavioural risk factors and their co-occurrence in England from 2003-19. METHODS: This time-trend analysis of repeated cross-sectional data from the Health Survey for England examined the relative index of inequalities (RII) and slope index of inequalities (SII) in four NCD behavioural risk factors: smoking; drinking above recommended limits; insufficient fruit and vegetables consumption; and physical inactivity. FINDINGS: Prevalence of risk factors has reduced over time, however, this has not been consistent across SEPs. Absolute and relative inequalities increased for physical inactivity; relative inequalities also increased for smoking; for insufficient fruit and vegetable consumption, the trends in inequalities depended on SEPs measure. Those in lower SEPs experienced persistent socioeconomic inequalities and clustering of behavioural risk factors. In contrast, those in higher SEPs had higher prevalence of excessive alcohol consumption; this inequality widened over the study period. INTERPRETATION: Inequalities in smoking and physical inactivity are persisting or widening. The pattern of higher drinking in higher SEPs obscure the fact that the greatest burden of alcohol-related harm falls on lower SEPs. Policy attention is required to tackle increasing inequalities in smoking prevalence, low fruit and vegetable consumption and physical inactivity, and to reduce alcohol harm.

Meat versus meat alternatives: which is better for the environment and health? A nutritional and environmental analysis of animal-based products compared with their plant-based alternatives.

BACKGROUND: Poor diets lead to negative health outcomes, including increased risk of noncommunicable diseases. Food systems, most notably agriculture, contribute to greenhouse gas emissions (GHGE) that lead to climate change. Meat consumption plays a role in both health and environmental burden. Consumption of meat alternatives may reduce these harms. The aim was to compare meat products and their plant-based alternatives on nutritional parameters, GHGE and price to examine if it is feasible and beneficial for policymakers and health professionals to recommend meat alternatives. METHODS: Data on nutritional information and cost for 99 selected products were collected from five UK supermarkets. Estimates for GHGEs for 97 of these products were found through secondary articles. Median values for nutritional value, GHGE (kgCO2 e) and price per 100 g were calculated to allow comparisons between meat products and their alternatives. Mann-Whitney U tests were used to look for significant differences for each nutrient, emissions and price. RESULTS: Meat alternatives contained significantly more fibre and sugar and were significantly higher in price compared to the equivalent meat products. Meat alternatives had a significantly lower number of calories, saturated fat, protein and kgCO2 e than meat products. There was no significant difference in the amount of salt between meat and meat alternatives. CONCLUSIONS: Overall, this paper found that meat alternatives are likely to be better for health according to most parameters, while also being more environmentally friendly, with lower GHGEs. However, the higher price of these products may be a barrier to switching to meat alternatives for the poorest in society.

"We think about the quantity more": factors influencing emerging adults' food outlet choice in a university food environment, a qualitative enquiry.

BACKGROUND: In recent decades, the food environment has seen rapid transformation globally, altering food availability and access along with how people interact with the food environment and make food-related choice. OBJECTIVES & METHOD: This explorative study aimed to identify the factors that shape the decision-making process for food outlet choices among emerging adults in a Ghanaian University food environment. The study uses focus group discussions in combination with novel dyadic interviews with best friend pairs. Verbatim transcripts were analysed thematically using NVivo 12. RESULTS: Drawing on socio-ecological model (SEM) of behaviour, the study used testimony from 46 participants aged 18-25, 47% female, including individuals from major ethnicities and religions in Ghana, and identified three interwoven levels of influence shaping emerging adults' choices of food outlet. The main factors influencing food outlet choice were identified as food prices, spatial accessibility, budget, and food quantity/satiety with additional factors including hygiene, variety of foods, food quality and taste preferences as well as societal factors such as ambience and peer influence. CONCLUSION: Multi-component approaches that combine structural level interventions in food retailing along with individual level components may be effective at changing emerging adult consumption behaviour in SSA, although this needs to be studied.

'Choice should be made through educated decisions not regressive dictates': discursive framings of a proposed 'sugar tax' in Bermuda: analysis of submissions to a government consultation.

BACKGROUND: Several governments have introduced taxes on products with high sugar content as part of their obesity prevention strategies. Bermuda is the first jurisdiction to apply such measures in the Caribbean - a region of small island developing states and territories with high obesity prevalence and substantial reliance on imported food products. This study examines how commercial and health actors framed the proposed introduction of a 75% import tariff on high-sugar products, based on written submissions to the Bermudan government. METHODS: Eleven submissions containing written comments were analysed with reference to their framing of the proposed import tariff, the 'problem' of obesity, and the relationship between the two (including alternative policy approaches for tackling obesity). RESULTS: Key emergent frames were complexity, partnership, products, personal responsibility, affordability and evidence. Respondents favoured different framings, depending on whether they supported or opposed the proposed import duty. Commercial actors were universally opposed, presenting obesity as a 'complex' problem that would be better addressed through government-industry partnerships (a framing particularly favoured by international and regional business associations). Increased product range and an emphasis on personal responsibility were also positioned as policy alternatives. Health actors expressed partial support for the proposed sugar tax, although this was tempered by a perceived lack of evidence where the proposal differed from sugar taxes introduced elsewhere. Like commercial respondents, health actors framed obesity as a 'complex' problem and emphasised the need for other measures, including efforts to address the affordability of fruits and vegetables. CONCLUSION: In responding to a proposed 'sugar tax' in Bermuda, commercial actors opposed the proposal and stated a clear preference for 'partnership' approaches to tackling obesity. Commercial responses were dominated by local businesses (with only two responses received from international or regional business associations), perhaps reflecting Bermuda's reliance on tourism and hospitality and the specificity of the proposed intervention (that is, an import tariff rather than an excise tax). The much smaller number of responses from health actors suggests limited civil society capacity. Nevertheless, the Bermudan government successfully introduced a 75% tariff on high-sugar imports, demonstrating the potential for policy innovation to address obesity in small-island jurisdictions.

Variation in financial protection and its association with health expenditure indicators: an analysis of low- and middle-income countries.

BACKGROUND: An insight into variation in financial protection among countries and the underpinning factors associated with the variations observed will help to inform public health policy and practice. METHOD: Secondary datasets from Global Health Expenditure Database and World Bank Development Indicators collected between 2000 and 2016 were used. Financial protection was measured in 75 low- and middle-income countries (LMICs) using the sustainable development goals framework. Funnel plot charts were used to explore the variation, and regression models were used to measure associations. RESULT: Fifty-three (67%) countries were within the 99% control limits indicating common-cause variation; 11 countries were above the upper control limit and 15 countries were below the lower control limit. In the fully adjusted model, country, spending on health relative to their economy had the strongest association with the variation in catastrophic spending. Every 1% increase in health spending relative to gross domestic product (GDP) was found to be associated with a reduction of 0.13% in the number of people that incurred catastrophic health spending. CONCLUSION: There is substantial variation in financial protection, as measured by the number of people that incurred catastrophic health spending, in LMICs; a proportion of this could be explained by the difference in GDP and external health expenditure.

Equity of national publicly funded health insurance schemes under the universal health coverage agenda: a systematic review of studies conducted in Africa.

BACKGROUND: The implementation of publicly funded health insurance schemes (PFHIS) is the major strategy to drive progress and achievement of universal health coverage (UHC) by 2030. We appraised evidence on the equity of insurance schemes across Africa. METHODS: We conducted a systematic review of published studies that assessed equity in health insurance schemes implemented under the UHC agenda in Africa. Seven databases, Web of Science, Medline, CINAHL, Scopus, Cochrane Library, EMBASE and World Bank eLibrary, were searched; we operationalized the PROGRESS-Plus (place of residence; race/ethnicity/culture/language; occupation; gender/sex religion; education; socioeconomic status; social capital) equity framework to assess equity areas. RESULTS: Forty-five studies met the inclusion criteria and were included in the study, in which 90% assessed equity by socioeconomic status. Evidence showed that rural residents, those self-employed or working in the informal sector, men, those with lower educational attainment, and the poor were less likely to be covered by health insurance schemes. Broadly, the insurance schemes, especially, community-based health insurance (CBI) schemes improved utilization by disadvantaged groups, however, the same groups were less likely to benefit from health services. CONCLUSIONS: Evidence on equity of PFHIS is mixed, however, CBI schemes seem to offer more equitable coverage and utilization of essential health services in Africa.

Food shortages, stockpiling and panic buying ahead of Brexit as reported by the British media: a mixed methods content analysis.

BACKGROUND: On 23 June 2016, the United Kingdom voted to leave the European Union. From that date until the UK left the EU in January 2021, there were frequent warnings from industry and government sources of potential disruption to the food supply chain and possible food shortages. Over this period, the media had an important role in communicating on the potential impacts of Brexit. This study examines how food supply and demand, in the context of Brexit, was portrayed by the British media. METHODS: The study consisted of two components: (1) a quantitative analysis measuring frequency of reporting and information sources for articles on food supply and demand in the context of Brexit, in three daily newspapers, between January 2015 and January 2020; and (2) a content analysis exploring key themes and media framing of relevant issues in a subset of articles. RESULTS: Reports by the media about the impact of Brexit on the UK food system were largely absent in the six months before the UK voted to leave the EU in June 2016, increasing in frequency from mid-2018 onward, peaking in mid-2019 following the appointment of Boris Johnson as prime minister. Five themes were developed from included articles: food shortages/panic buying (appearing in 96% of articles); food chain disruption (86%); economic impacts (80%); preparation and stockpiling by the government/food sector (63%) and preparation and stockpiling by individuals (22%). CONCLUSION: Government messaging sought to reassure the public that even under a worst-case scenario there would be no food shortages. These messages, however, contradicted warnings in the media of disruption to the food supply chain and food shortages. The media further reinforced this narrative of potential food shortages by reporting on the experiences of those preparing for Brexit by stockpiling food. The media must consider the impact of their messaging on public behaviour, as even imagined food shortages can instigate stockpiling and panic buying behaviour, as observed during the COVID-19 pandemic.

Type, density, and healthiness of food-outlets in a university foodscape: a geographical mapping and characterisation of food resources in a Ghanaian university campus.

INTRODUCTION: Food environments are viewed as the interface where individuals interact with the wider food system to procure and/or consume food. Institutional food environment characteristics have been associated with health outcomes including obesity and nutrition-related non-communicable diseases (NR-NCDs) in studies from high-income countries. The objectives of this study were (1) to map and characterise the food-outlets within a Ghanaian university campus; and (2) to assess the healthiness of the food outlets. METHODS: Data collection was undertaken based on geospatial open-source technologies and the collaborative mapping platform OpenStreetMap using a systematic approach involving three phases: remote mapping, ground-truthing, and food-outlet survey. Spatial analyses were performed using Quantum Geographical Information System (QGIS) and comprised kernel density, buffer, and average nearest neighbour analyses to assess outlet distribution, density, and proximity. A classification system was developed to assess the healthiness of food-outlets within the University foodscape. RESULTS: Food-outlets were unevenly distributed over the University foodscape, with many outlets clustered closer to student residencies. Informal food-outlets were the most frequent food-outlet type. Compared to NCD-healthy food-outlets, NCD-unhealthy food-outlets dominated the foodscape (50.7% vs 39.9%) with 9.4% being NCD-intermediate, suggesting a less-healthy university foodscape. More NCD-unhealthy food outlets than NCD-healthy food outlets clustered around student residences. This difference was statistically significant for food outlets within a 100-m buffer (p < 0.001) of student residence and those within 100 and 500 m from departmental buildings/lecture halls (at 5% level of significance). CONCLUSION: Further action, including research to ascertain how the features of the University's food environment have or are influencing students' dietary behaviours are needed to inform interventions aimed at creating healthier foodscapes in the study University and other campuses and to lead the way towards the creation of healthy food environments at the home, work, and community levels.

Prevalence and socio-demographic associations of diet and physical activity risk-factors for cardiovascular disease in Bo, Sierra Leone.

BACKGROUND: Little is known about modifiable dietary and physical activity risk factors for cardiovascular diseases (CVDs) in Sierra Leone. This information is critical to the development of health improvement interventions to reduce the prevalence of these diseases. This cross-sectional study investigated the prevalence and socio-demographic correlates of dietary and physical activity risk behaviours amongst adults in Bo District, Sierra Leone. METHODS: Adults aged 40+ were recruited from 10 urban and 30 rural sub-districts in Bo. We examined risk factors including: ≤150 min of moderate or vigorous-intensity physical activity (MVPA) weekly, physical inactivity for ≥3 h daily, ≤5 daily portions of fruit and vegetables, and salt consumption (during cooking, at the table, and in salty snacks). We used logistic regression to investigate the relationship between these outcomes and participants' socio-demographic characteristics. RESULTS: 1978 eligible participants (39.1% urban, 55.6% female) were included in the study. The prevalence of behavioural risk factors was 83.6% for ≤5 daily portions of fruit and vegetables; 41.4 and 91.6% for adding salt at the table or during cooking, respectively and 31.1% for eating salty snacks; 26.1% for MVPA ≤150 min weekly, and 45.6% for being physically inactive ≥3 h daily. Most MVPA was accrued at work (nearly 24 h weekly). Multivariable analysis showed that urban individuals were more likely than rural individuals to consume ≤5 daily portions of fruit and vegetables (Odds Ratio (OR) 1.09, 95% Confidence Interval (1.04-1.15)), add salt at the Table (OR 1.88 (1.82-1.94)), eat salty snacks (OR 2.00 (1.94-2.07)), and do MVPA ≤150 min weekly (OR 1.16 (1.12-1.21)). Male individuals were more likely to add salt at the Table (OR 1.23 (1.20-1.27)) or consume salty snacks (OR 1.35 (1.31-1.40)) than female individuals but were less likely to report the other behavioural risk-factors examined. Generally, people in lower wealth quintiles had lower odds of each risk factor than those in the higher wealth quintiles. CONCLUSION: Dietary risk factors for CVD are highly prevalent, particularly among urban residents, of Bo District, Sierra Leone. Our findings highlight that forthcoming policies in Sierra Leone need to consider modifiable risk factors for CVD in the context of urbanisation.

Enabling women to access preferred methods of contraception: a rapid review and behavioural analysis.

BACKGROUND: Many pregnancies in the UK are either unplanned or ambivalent. This review aimed to (i) explore barriers and facilitators to women choosing and accessing a preferred method of contraception in the United Kingdom, and (ii) identify opportunities for behavioural interventions based on examination of interventions that are currently available nationally. METHODS: Three databases were searched, and experts contacted to identify grey literature for studies presenting barriers and facilitators to women choosing and accessing a preferred method of contraception, conducted in the UK and published between 2009 and October 2019. Information on barriers and facilitators were coded into overarching themes, which were then coded into Mechanisms of Actions (MoAs) as listed in the Theory and Techniques Tool. National interventions were identified by consulting stakeholders and coded into the Behaviour Change Wheel. The match between barriers/facilitators and intervention content was assessed using the Behaviour Change Wheel. RESULTS: We included 32 studies and identified 46 barrier and facilitator themes. The most cited MoA was Environmental Context and Resources, which primarily related to the services women had access to and care they received. Social Influences, Beliefs about Consequences (e.g., side effects) and Knowledge were also key. The behavioural analysis highlighted four priority intervention functions (Modelling, Enablement, Education and Environmental Restructuring) that can be targeted to support women to choose and access their preferred method of contraception. Relevant policy categories and behaviour change techniques are also highlighted. CONCLUSIONS: This review highlights factors that influence women's choices and access to contraception and recommends opportunities that may be targeted for future interventions in order to support women to access preferred contraception. REGISTRATION: Protocol was registered with PROSPERO (an international database of prospectively registered systematic reviews in health and social care) in December 2019, CRD42019161156 .

Realising sexual and reproductive health and rights of adolescent girls and young women living in slums in Uganda: a qualitative study.

BACKGROUND: Sexual and reproductive health and rights are critical entitlements best supported through human rights-based approaches empowering rights-holders to claim their rights and duty bearers to fulfil their obligations. Implementing these requires information on the current needs and challenges faced by those seeking to claim their sexual and reproductive health and rights. We aimed to identify the underlying factors influencing the realisation of sexual and reproductive health and rights for adolescent girls and young women living Ugandan slums by: (1) exploring the role of relevant service providers and stakeholders; and (2) uncovering knowledge and gaps in protecting adolescent girls' and young women's sexual and reproductive health and rights. METHODS: Qualitative data were collected through focus groups and interviews focused on current knowledge, behaviours and attitudes towards sexual and reproductive health and rights among adolescent girls and young women, service providers and stakeholders. Data were analysed thematically using NVivo software. Ten in-depth interviews were conducted with key informants; two focus groups were held with adolescent girls and young women living in two slums in Uganda (21 participants in total); and three focus groups were held with community leaders, service providers, teachers and parents (30 participants in total). RESULTS: Adolescent girls and young women lacked information regarding their sexual health, services available, and redress mechanisms for rights violations. Formal sources of information were frequently inaccessible. Family members were sometimes the source of rights violations, and informal methods of redressing rights were often sought. Stigma and fear were common features both in healthcare and in the pursuit of formal justice, with duty-bearers habitually breaking confidentiality. Education and training were the predominant suggestions offered for change. CONCLUSIONS: Adolescent girls and young women continue to face obstacles in achieving their full sexual and reproductive health and rights. Targeted interventions for the realisation of adolescent girls' and young women's sexual and reproductive health and rights can address underlying causes and positively shift attitudes to promote health.

Every woman is entitled to good sexual and reproductive health. This involves being free from sexually transmitted infections, gender-based violence and maternal mortality, and able to access essential health services. In low and middle-income countries, adolescents comprise a fifth of the population, yet their sexual and reproductive health needs are often overlooked. Adolescent girls and young women are more likely to experience gender-based violence, sexually transmitted infections and poor access to sexual and reproductive health services. Those living in slums have even worse outcomes, but little evidence exists regarding the opportunities and barriers to improving sexual and reproductive health among adolescent girls and young women in a slum setting.In this study, we conducted focus groups and interviews with 21 adolescent girls and young women living in two Ugandan slums, 10 individuals with an essential role, for example, at state level, as well as 30 other stakeholders including healthcare workers, teachers, parents, district leaders and community support officers working with adolescent girls and young women.Results indicate that adolescent girls and young women lack information regarding their sexual health, what services are available and who and where to go if they experience violations such as sexual assault. In instances of sexual assault, fear and stigma prevented adolescent girls and young women from going to the police, and instead disputes were handled informally between families.Participants in our focus groups and interviews felt that education and training were needed, and that health services need to improve. Interventions are necessary to improve adolescent girls' and young women's sexual and reproductive health in this setting.

Improving the health and welfare of people who live in slums.

In the first paper in this Series we assessed theoretical and empirical evidence and concluded that the health of people living in slums is a function not only of poverty but of intimately shared physical and social environments. In this paper we extend the theory of so-called neighbourhood effects. Slums offer high returns on investment because beneficial effects are shared across many people in densely populated neighbourhoods. Neighbourhood effects also help explain how and why the benefits of interventions vary between slum and non-slum spaces and between slums. We build on this spatial concept of slums to argue that, in all low-income and-middle-income countries, census tracts should henceforth be designated slum or non-slum both to inform local policy and as the basis for research surveys that build on censuses. We argue that slum health should be promoted as a topic of enquiry alongside poverty and health.

The history, geography, and sociology of slums and the health problems of people who live in slums.

Massive slums have become major features of cities in many low-income and middle-income countries. Here, in the first in a Series of two papers, we discuss why slums are unhealthy places with especially high risks of infection and injury. We show that children are especially vulnerable, and that the combination of malnutrition and recurrent diarrhoea leads to stunted growth and longer-term effects on cognitive development. We find that the scientific literature on slum health is underdeveloped in comparison to urban health, and poverty and health. This shortcoming is important because health is affected by factors arising from the shared physical and social environment, which have effects beyond those of poverty alone. In the second paper we will consider what can be done to improve health and make recommendations for the development of slum health as a field of study.

Inequalities in smoking prevalence: a missed opportunity for tobacco control in Pakistan.

Background: Pakistan is one of the highest tobacco consuming countries in South Asia and consumption is increasing. To implement equity orientated tobacco control policies, the most vulnerable groups must be identified. We aimed to identify these groups using the Pakistan Demographic and Health Survey (PDHS) 2012-13. Methods: Descriptive statistics, univariate and multivariate analyses were used to explore household and participant characteristics associated with smoking inside the home or tobacco smoking, respectively. Survey weights were used to give nationally representative findings. Results: Data for 12 931 households, 3132 men and 13 538 women were examined. About 58.3% of surveyed households were smoke-free, 39.1% were exposed to indoor tobacco smoke every day, 2.6% less frequently. Significantly more rural households were exposed to indoor tobacco smoke than urban households (45.2% versus 34.9%). Of men, 28.3% reported smoking compared with 1.3% of women. Smoking prevalence was higher in older age groups. Increasing wealth was associated with lower smoking prevalence and indoor smoking. For men, but not women, increasing education was associated with reduced smoking. Conclusions: Inequalities in smoking behaviour impose harm to those who can least afford the financial and health costs. Future tobacco control policies in Pakistan must be sensitive to gender, geography and socio-economic status.

Experiences of young smokers in quitting smoking in twin cities of Pakistan: a phenomenological study.

BACKGROUND: Smoking is highly prevalent in Pakistan claiming the lives of over 100,000 individuals every year. A significant proportion of smokers (24.7%) make an attempt to quit each year but 97.4% fail to quit successfully. Little is known about the reasons for, and experiences of, failed quit attempts. This study was carried out to explore the experiences of young male smokers in quitting smoking in the twin cities of Pakistan METHOD: A qualitative study was carried out using a phenomenological approach in Rawalpindi and Islamabad. A total of 11 participants were interviewed. All study participants were male and had made at least one quit attempt. Study participants were a mix of smokers who failed to quit smoking, intermittent smokers and successful quitters. Streubert's (1991) method of phenomenology was followed during data analysis. RESULTS: The experiences of smokers while smoking "the smoking phase" have major effects on their journey towards quitting smoking. The smoking phase consists of three major stages: contact with initial smoking stimuli, the journey from first puff to enjoying smoking and then finally smoking becoming part of life. However, the journey towards quitting smoking is not as simple as the journey towards becoming a smoker. Instead, smokers get trapped in three overlapping cycles of smoking and quit attempts: smoking & forced quitting, smoking & intentional quitting, and smoking & intermittent smoking before successful quitting. Breaking the cycle is not easy in the presence of trapping factors (addiction, high availability, easy affordability, conducive social setup and low perceived risks of smoking). Three factors play a major role in breaking these cycles which are strong will power, continuous peer support and avoidance of smokers' company. CONCLUSION: A young smoker, during his experience of quitting smoking gets entrapped in several overlapping cycles of smoking & quit attempts before successful quitting. There are known entrapping factors as well as factors which help in breaking these cycles. Targeted interventions are needed to facilitate smoking cessation among young smokers in Pakistan.