Healthcare system resilience in Bangladesh and Haiti in times of global changes (climate-related events, migration and Covid-19): an interdisciplinary mixed method research protocol.

BACKGROUND: Since climate change, pandemics and population mobility are challenging healthcare systems, an empirical and integrative research to studying and help improving the health systems resilience is needed. We present an interdisciplinary and mixed-methods research protocol, ClimHB, focusing on vulnerable localities in Bangladesh and Haiti, two countries highly sensitive to global changes. We develop a protocol studying the resilience of the healthcare system at multiple levels in the context of climate change and variability, population mobility and the Covid-19 pandemic, both from an institutional and community perspective. METHODS: The conceptual framework designed is based on a combination of Levesque's Health Access Framework and the Foreign, Commonwealth and Development Office's Resilience Framework to address both outputs and the processes of resilience of healthcare systems. It uses a mixed-method sequential exploratory research design combining multi-sites and longitudinal approaches. Forty clusters spread over four sites will be studied to understand the importance of context, involving more than 40 healthcare service providers and 2000 households to be surveyed. We will collect primary data through questionnaires, in-depth and semi-structured interviews, focus groups and participatory filming. We will also use secondary data on environmental events sensitive to climate change and potential health risks, healthcare providers' functioning and organisation. Statistical analyses will include event-history analyses, development of composite indices, multilevel modelling and spatial analyses. DISCUSSION: This research will generate inter-disciplinary evidence and thus, through knowledge transfer activities, contribute to research on low and middle-income countries (LMIC) health systems and global changes and will better inform decision-makers and populations.

Inequality in the household and rural-urban migration in Ethiopian farmers.

Parental investment theory predicts that biases in investment favour migration by driving some of the sibling group to disperse for resources. Here we test hypotheses arising from this theory to explain patterns of rural-urban migration in south-central Ethiopia considering familial and individual strategies. We focus on the migration of low-skilled men, predicting two scenarios based on a low level of resource availability. Firstly, last-born sons will be more likely to migrate in order to offset their intra-household disadvantage when resources are limited (sibling competition). Alternatively, in households facing livelihood insecurity, older sons will migrate in order to free resources for their younger dependant brothers (reflecting sibling cooperation). Demographic, economic and relational data were collected from 217 families of male migrants, including information for 830 male adults. We performed multivariate analyses, including Bayesian generalised linear models and mixed models, to analyse quantitative data with a focus on household and individual likelihood of out-migration. Consistent with the predictions from parental investment theory, migration is dependent on intra-household resource allocation. Depending on the stage of the family cycle and livelihood context, families and individuals present different strategies: labour migration may result from sibling competition or from cooperation for resource enhancement.

Does Kin-Selection Theory Help to Explain Support Networks among Farmers in South-Central Ethiopia?

Social support networks play a key role in human livelihood security, especially in vulnerable communities. Here we explore how evolutionary ideas of kin selection and intrahousehold resource competition can explain individual variation in daily support network size and composition in a south-central Ethiopian agricultural community. We consider both domestic and agricultural help across two generations with different wealth-transfer norms that yield different contexts for sibling competition. For farmers who inherited land rights from family, firstborns were more likely to report daily support from parents and to have larger nonparental kin networks (n = 180). Compared with other farmers, firstborns were also more likely to reciprocate their parents' support, and to help nonparental kin without reciprocity. For farmers who received land rights from the government (n = 151), middle-born farmers reported more nonparental kin in their support networks compared with other farmers; nonreciprocal interactions were particularly common in both directions. This suggests a diversification of adult support networks to nonparental kin, possibly in response to a long-term parental investment disadvantage of being middle-born sons. In all instances, regardless of inheritance, lastborn farmers were the most disadvantaged in terms of kin support. Overall, we found that nonreciprocal interactions among farmers followed kin selection predictions. Direct reciprocity explained a substantial part of the support received from kin, suggesting the importance of the combined effects of kin selection and reciprocity for investment from kin.

Combining Footwear with Public Health Iconography to Prevent Soil-Transmitted Helminth Infections.

Shoes are effective for blocking soil-transmitted helminths (STHs) that penetrate the skin. Unfortunately, shoe-wearing is uncommon in many areas where STHs are prevalent, in part because local populations are unaware of the health benefits of wearing shoes. This is especially true in low-literacy populations, where information dissemination through written messages is not possible. We launched a public health intervention that combines a public health image with sandals. The image is a "lenticular image" that combines two alternating pictures to depict the efficacy of shoes for preventing STH infection. This image is adhered to the shoe, such that the message is linked directly to the primary means of prevention. To create a culturally appropriate image, we conducted five focus group discussions, each with a different gender and age combination. Results of focus group discussions reinforced the importance of refining public health messages well in advance of distribution so that cultural acceptability is strong. After the image was finalized, we deployed shoes with the image in communities in western Uganda where hookworm is prevalent. We found that the frequency of shoe-wearing was 25% higher in communities receiving the shoes than in control communities. Microscopic analyses of fecal samples for parasites showed a sustained reduction in infection intensity for parasites transmitted directly through the feet when people received shoes with a public health image. Our results show that combining culturally appropriate images with public health interventions can be effective in low-literacy populations.