Climate change impacts on the health of South Asian children and women subpopulations - A scoping review.

Background and objectives: Climate change impacts are felt unequally worldwide; populations that experience geographical vulnerability, those living in small island states and densely populated coastal areas, and children and women are affected disproportionately. This scoping review aims to synthesize evidence from relevant studies centred on South Asia, identify research gaps specifically focused on children and women's health, and contribute to knowledge about South Asia's existing mitigation and adaptation strategies. Methods: A research librarian executed the search on six databases using controlled vocabulary (e.g., MeSH, Emtree, etc.) and keywords representing the concepts "vulnerable populations" and "climate change" and "health impacts" and "South Asia." Databases were searched from January 2010 to May 2020. Papers were screened independently by two researchers. Results: Forty-two studies were included, of which 23 were based in India, 14 in Bangladesh, and five in other South Asian countries. Nineteen studies focused on meteorological factors as the primary exposure. In contrast, thirteen focused on extreme weather events, nine on air pollution, and one on salinity in coastal areas. Thirty-four studies focused on the health impacts on children related to extreme weather events, meteorological factors, and air pollution, while only eight studies looked at health impacts on women. Undernutrition, ARI (acute respiratory infection), diarrheal diseases, low birth weight, and premature mortality were the major health impacts attributed to extreme weather events, meteorological factors, and air pollution exposure in children and women in the region. Conclusion: Extreme weather events, meteorological factors and air pollution have affected the health of children and women in South Asia. However, the gap in the literature across the South Asian countries concerning relationships between exposure to extreme weather events, meteorological factors, air pollution and health effects, including mental health problems in children and women, are opportunities for future work.

Revisiting COVID-19 policies: 10 evidence-based recommendations for where to go from here.

BACKGROUND: Strategies to control coronavirus 2019 disease (COVID-19) have often been based on preliminary and limited data and have tended to be slow to evolve as new evidence emerges. Yet knowledge about COVID-19 has grown exponentially, and the expanding rollout of vaccines presents further opportunity to reassess the response to the pandemic more broadly. MAIN TEXT: We review the latest evidence concerning 10 key COVID-19 policy and strategic areas, specifically addressing: 1) the expansion of equitable vaccine distribution, 2) the need to ease restrictions as hospitalization and mortality rates eventually fall, 3) the advantages of emphasizing educational and harm reduction approaches over coercive and punitive measures, 4) the need to encourage outdoor activities, 5) the imperative to reopen schools, 6) the far-reaching and long-term economic and psychosocial consequences of sustained lockdowns, 7) the excessive focus on surface disinfection and other ineffective measures, 8) the importance of reassessing testing policies and practices, 9) the need for increasing access to outpatient therapies and prophylactics, and 10) the necessity to better prepare for future pandemics. CONCLUSIONS: While remarkably effective vaccines have engendered great hope, some widely held assumptions underlying current policy approaches call for an evidence-based reassessment. COVID-19 will require ongoing mitigation for the foreseeable future as it transforms from a pandemic into an endemic infection, but maintaining a constant state of emergency is not viable. A more realistic public health approach is to adjust current mitigation goals to be more data-driven and to minimize unintended harms associated with unfocused or ineffective control efforts. Based on the latest evidence, we therefore present recommendations for refining 10 key policy areas, and for applying lessons learned from COVID-19 to prevent and prepare for future pandemics.

Community health workers at the dawn of a new era: 1. Introduction: tensions confronting large-scale CHW programmes.

BACKGROUND: Community health worker (CHW) programmes are again receiving more attention in global health, as reflected in important recent WHO guidance. However, there is a risk that current CHW programme efforts may result in disappointing performance if those promoting and delivering them fail to learn from past efforts. This is the first of a series of 11 articles for a supplement entitled "Community Health Workers at the Dawn of a New Era". METHODS: Drawing on lessons from case studies of large well-established CHW programmes, published literature, and the authors' experience, the paper highlights major issues that need to be acknowledged to design and deliver effective CHW programmes at large scale. The paper also serves as an introduction to a set of articles addressing these issues in detail. RESULTS: The article highlights the diversity and complexity of CHW programmes, and offers insights to programme planners, policymakers, donors, and others to inform development of more effective programmes. The article proposes that be understood as actors within community health system(s) and examines five tensions confronting large-scale CHW programmes; the first two tensions concern the role of the CHW, and the remaining three, broader strategic issues: 1) What kind of an actor is the CHW? A lackey or a liberator? Provider of clinical services or health promoter? 2) Lay versus professional? 3) Government programme at scale or nongovernmental organization-led demonstration project? 4) Standardized versus tailored to context? 5) Vertical versus horizontal? CONCLUSION: CHWs can play a vital role in primary healthcare, but multiple conditions need to be met for them to reach their full potential.

What Could Explain the Lower COVID-19 Burden in Africa despite Considerable Circulation of the SARS-CoV-2 Virus?

The differential spread and impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing Coronavirus Disease 2019 (COVID-19), across regions is a major focus for researchers and policy makers. Africa has attracted tremendous attention, due to predictions of catastrophic impacts that have not yet materialized. Early in the pandemic, the seemingly low African case count was largely attributed to low testing and case reporting. However, there is reason to consider that many African countries attenuated the spread and impacts early on. Factors explaining low spread include early government community-wide actions, population distribution, social contacts, and ecology of human habitation. While recent data from seroprevalence studies posit more extensive circulation of the virus, continuing low COVID-19 burden may be explained by the demographic pyramid, prevalence of pre-existing conditions, trained immunity, genetics, and broader sociocultural dynamics. Though all these prongs contribute to the observed profile of COVID-19 in Africa, some provide stronger evidence than others. This review is important to expand what is known about the differential impacts of pandemics, enhancing scientific understanding and gearing appropriate public health responses. Furthermore, it highlights potential lessons to draw from Africa for global health on assumptions regarding deadly viral pandemics, given its long experience with infectious diseases.

"Our Home Is a Muddy Structure": Perceptions of Housing and Health Risks Among Older Adults in Contrasting Neighborhoods in Ghana.

Aging occurs in a variety of social and physical environmental settings that affect health. However, despite their rapidly growing populations, public health research in sub-Saharan Africa has yet to address the role of residential environments in the health and well-being of older adults. In this study, we utilized an ethnographic research methodology to explore barriers and facilitators to health among older adults residing in two contrasting neighborhoods in Accra, Ghana. Our specific objective was to identify patterns of health risks among older adults in the two neighborhoods. Data were collected through qualitative interviews with a purposive sample of health workers (n = 5), community leaders (n = 2), and older adults residing in a slum and non-slum neighborhood (n = 30). Our thematic data analysis revealed that, despite different underlying drivers, health barriers across the slum and non-slum were largely similar. The harmful effects of these health barriers - poor built environments, housing precariousness, unsanitary living conditions, defective public services, and social incivilities - were mitigated by several facilitators to health, including affordable housing and social supports in the slum and better housing and appealing doors in the non-slum. Our study contributes to a more nuanced understanding of the ways in which aging and urban environments intersect to influence population health in resource poor settings. In particular, rather than the commonly referenced dichotomy of poor and non-poor settlements in discourses of neighborhood health, our findings point to convergence of health vulnerabilities that are broadly linked to urban poverty and governmental neglect of the elderly.

Quality of life of older adults in two contrasting neighbourhoods in Accra, Ghana.

As is the case elsewhere in sub-Saharan Africa, Ghana is experiencing a rapid increase in the population of older adults. Despite their rising numbers, the living conditions and wellbeing of older Ghanaians remain woefully understudied. This paper presents the results of a study exploring the quality of life (QoL) of older adults in two contrasting neighbourhoods in Accra, Ghana. The objectives of the study were to: (1) explore and compare the QoL of older slum and non-slum dwellers in Ghana; and (2) determine the extent of QoL disparities between slum and non-slum older adults. To accomplish these objectives, we undertook a cross-sectional survey of older adults (N = 603) residing in a slum and non-slum neighbourhood. QoL was self-assessed in four domains - physical, psychological, social, and environment - using the World Health Organization (WHO) QoL assessment tool (WHOQoL-BREF). Multivariable linear regression analyses of the data revealed no statistically significant difference between the slum and non-slum respondents in physical (coeff: 0.5; 95% CI: -1.7, 2.8; p = 0.642) and psychological (coeff: -0.2; 95% CI: -3.0, 2.6; p = 0.893) QoL. However, the slum respondents reported significantly higher social QoL than the non-slum respondents (coeff: -3.2; 95% CI: -5.6, -0.8; p = 0.010), while the reverse was true in environmental QoL (coeff: 4.2; 95% CI: 2.3, 6.2; p < 0.001). The existence of strong social support systems in the slum and better housing and neighbourhood environmental conditions in the non-slum may have accounted for the observed variation in social and environmental QoL. Thus, contrary to popular discourses that vilify slums as health-damaging milieus, these findings offer a more nuanced picture, and suggest that some features of slums may constitute important health resources for older adults.

Community-based cluster randomized controlled trial: empowering households to identify and provide appropriate care for low-birthweight newborns in Nepal.

BACKGROUND: Most newborn deaths occur among those of low birthweight (LBWt), due to prematurity &/or impaired fetal growth. Simple practices can substantially mitigate this risk. In low-income country settings where many births occur at home, strategies are needed that empower mothers to determine if their babies are at higher risk and, if so, to take measures to reduce risk. Earlier studies suggest that foot-length may be a good proxy for birthweight. An earlier Nepal study found a 6.9 cm cut-off performed relatively well, differentiating normal from low birthweight. METHODS: Community-based, cluster-randomized controlled trial. OBJECTIVE: to determine whether family-administered screening, associated with targeted messages improves care practices known to mitigate LBWt-associated risks. PARTICIPANTS: women participating in a parent trial in rural Nepal, recruited late in pregnancy. Women were given a 6.9 cm card to assess whether the baby's foot is small; if so, to call a number on the card for advice. Follow-up visits were made over the 2 weeks following the birth, assessing for 2 behavioral outcomes: reported skin-to-skin thermal care, and care-seeking outside the home; assessed restricting to low birthweight (using 2 cutoffs: 2500 g and 2000 g). Randomization: 17 clusters intervention, 17 control. The study also documented performance along the presumed causal chain from intervention through behavioral impact. RESULTS: 2022 intervention, 2432 control. Intervention arm: 519 had birthweight < 2500 g (vs. 663 among controls), of which 503 were available for analysis (vs. 649 among controls). No significant difference found on care-seeking; for those < 2500 g RR 1.13 (95%CI: 0.97-1.131). A higher proportion of those in the intervention arm reported skin-to-skin thermal care than among controls; for those < 2500 g RR 2.50 (95%CI: 2.01-3.1). However, process measures suggest this apparent effect cannot be attributed to the intervention; the card performed poorly as a proxy for LBWt, misclassifying 84.5% of those < 2000 as normal weight. CONCLUSIONS: Although the trial found an apparent effect on one of the behavioral outcomes, this cannot be attributed to the intervention; most likely it was a result of pure chance. Other approaches are needed for identifying small, at-risk babies in such settings, and targeting them for appropriate care messaging. TRIAL REGISTRATION: ClinicalTrials.gov NCT02802332 , registered 6/16/2016.

A national survey of private-sector outpatient care of sick infants and young children in Nepal.

BACKGROUND: Previous research has documented that across South Asia, as well as in some countries in Sub-Saharan Africa, the private sector is the primary source of outpatient care for sick infants and children and, in many settings, informal providers play a bigger role than credentialed health professionals (particularly for the poorer segments of the population). This is the case in Nepal. This study sought to characterize medicine shop-based service providers in rural areas and small urban centers in Nepal, their role in the care and treatment of sick infants and children (with a particular focus on infants aged < 2 months), and the quality of the care provided. A secondary objective was to characterize availability and quality of such care provided by physicians in these settings. METHODS: A nationally representative sample of medicine shops was drawn, in rural settings and small urban centers in Nepal, from 25 of the 75 districts in Nepal, using multi-stage cluster methodology, with a final sample of 501 shops and 82 physician-run clinics. Face-to-face interviews were conducted. RESULTS: Most medicine shops outside urban areas were not registered with the Department of Drug Administration (DDA). Most functioned as de facto clinics, with credentialed paramedical workers (having 2-3 years of training) diagnosing patients and making treatment decisions. Such a role falls outside their formally sanctioned scope of practice. Quality of care problems were identified among medicine shop-based providers and physicians, including over-use of antibiotics for treating diarrhea, inaccurate weighing technique to determine antibiotic dose, and inappropriate use of injectable steroids for treating potentially severe infections in young infants. CONCLUSIONS: Medicine shop-based practitioners in Nepal represent a particular type of informal provider; although most have recognized paramedical credentials, they offer services falling outside their formal scope of practice. Nevertheless, given the large proportion of the population served by these practitioners, engagement to strengthen quality of care by these providers and referral to the formal health sector is warranted.