Cytotoxicity of water supply in a Palestinian refugee camp and a Syrian informal tented settlement in Lebanon.

Deficient water, sanitation, and hygiene (WASH) significantly account for a high burden of disease across the globe. Lebanon, an Eastern Mediterranean lower-middle-income country with a polluted environment, a fragmented healthcare system, and an ongoing severe economic crisis, faces serious challenges in sustaining safe water supplies, especially in vulnerable communities, while also hosting the world highest refugee population per capita. This study aimed to examine the mutagenicity, and the estrogenic and androgenic activities of water supplies, across both a Palestinian refugee camp and a Syrian informal settlement. Water samples were collected from two targeted camps in Dbayeh and Choueifat, North and South of the Capital City Beirut, respectively, between the months of September and October 2022. Microbial and physicochemical properties of samples were determined, including fecal contamination, total dissolved solids, and various minerals and salts. Organic pollutants were extracted using pre-packed solid phase extraction (SPE) columns, and then mutagenicity of extracts was examined using the Ames test in two Salmonella typhi bacterial strains. The estrogenic and androgenic activities of extracts were assessed using the yeast estrogen and androgen screen tests assays (YES/YAS). Results show excessive levels of total coliforms and total dissolved solids (TDS) in samples from both sites. In addition, the water supply from the Dbayeh Palestinian refugee camp is mutagenic, while the water supply from the Choueifat Syrian informal settlement shows anti-androgen activity. Our findings provide valuable WASH baseline data in two major vulnerable communities in Lebanon, and highlight the importance of a water toxicity testing approach concomitant with a water safety plan, based on a holistic strategy that covers all stages of the water supply chain.

The World after COVID-19: Reflections on Global Health and Policy.

COVID-19 has infected hundreds of millions of people across the globe. The pandemic has also inflicted serious damages on global and regional governing political structures to a degree meriting a revisit of their own raison d'etre. The global economic fallout is also unprecedented as the flows of goods and people got severely disrupted while lockdowns hit the transport, services and retail industries, among others. We argue that three realities need to be genuinely addressed for building a post COVID-19 order that has to be amply equipped to deal with the next global crisis, as well as the ones on-going for decades. First, there is need to shelf-away the hitherto practiced doctrine that global crises and problems are confronted through local responses. Second, the COVID-19 pandemic has cautioned us on the need to (re)invest in basic, many may consider naïve and simple, public health functions such as sanitation as well as transparent national and global health monitoring. Third, the pandemic is a clear reprimand to discard the mantra that privatization of healthcare delivery system is the solution in favor of viewing health as a public good that needs to be managed and executed by the state and its public sector, be it national, sub-regional or local. It is critical that we learn from such pandemic and advance our societies to become stronger.

Does knowing about the long-term health effects of alcohol matter? Evidence from a university sample in Lebanon.

BACKGROUND: Research linking awareness of health effects of alcohol and harmful alcohol drinking status is limited. AIMS: To investigate the association between awareness of long-term alcohol effects and alcohol use disorders. METHODS: University students aged 18-25 years (n = 1155) completed a self-filled survey. Participants were asked if they knew that alcohol causes: (1) problems in the liver; (2) cancers of the mouth, throat, oesophagus and breast; (3) damage to the heart; and (4) weakening of the immune system. Multinomial regression analyses were conducted to assess the association between awareness of long-term alcohol effects and alcohol drinking status, including Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) alcohol use disorders. RESULTS: One third (32.8%) were past-year drinkers and 18% screened positive for DSM-5 alcohol use disorders. Compared to past-year drinkers with no alcohol use disorders, non-past-year ever drinkers were twice as likely to know about the link between alcohol and cancers of the mouth, throat, oesophagus and breast. Past-year drinkers with an alcohol use disorders were less likely to know about this association. Non-past-year ever drinkers (vs past-year drinkers with no alcohol use disorders) were also 2.6 times more likely to know the alcohol liver risks. CONCLUSIONS: There is a strong inverse relationship between awareness of the effects of alcohol and harmful consumption among young people, providing preliminary support for the protective nature of knowledge on alcohol drinking status. Efforts to increase public awareness of the long-term health effects of alcohol may be useful in reducing alcohol-related harm.

The impact of broad-based vs targeted taxation on youth alcohol consumption in Lebanon.

This study aims to model youth's off-premise alcohol demand and forecasts ethanol intake responsiveness to alcohol taxes. Using stated preference alcohol purchase data from a survey of 1024 university students in Lebanon, we derive price elasticities that we use to forecast the effects of two excise tax scenarios on overall ethanol intake. The first scenario imposes a broad-based 20% tax on all types of alcoholic beverages, and the second scenario imposes a targeted 20% tax only on the high ethanol content, while exempting the lower ethanol beverages. Overall, targeted taxes are found to achieve a reduction in ethanol intake that is nearly three times that achieved by broad taxes (15.7% vs 5.3%). For 'past-month binge drinkers', targeted taxes would decrease alcohol intake by 16.3%, while broad taxes increase it by 3.3%. Finally, ethanol intake among participants who prefer low ethanol content would decrease under targeted taxes by more than five times as much as under broad taxes. For 'high-ethanol drinkers', targeted taxes decrease alcohol intake by an even larger proportion than for 'low-ethanol drinkers' (19.0% vs 15.6%), while broad taxes increase their ethanol intake by ∼16.0%. This study contributes evidence that taxation policy substantially reduces alcohol consumption and that alcohol consumption patterns should be accounted for when designing taxes.

Bullying Victimization and Use of Substances in High School: Does Religiosity Moderate the Association?

Alcohol, tobacco and other drug use continue to pose serious public health concerns among youth. Bullying victimization has been identified as a risk factor and religiosity a protective factor for adolescent substance use. No previous research has examined the potential moderating role of religiosity. We explore the association between bullying victimization and substance use in adolescents with low and high levels of religiosity. A cross-sectional survey was conducted with a representative sample of high school students in greater Beirut. Binary and multinomial logistic models were used, adjusting for demographics, and stratified by level of religiosity. Of the 986 students responding to the survey, 65% were females; 48% had experienced some form of bullying; and 52% self-rated as low in religiosity. Between 10 and 30% were current users of alcohol or tobacco. Students of lower religiosity levels who had been bullied were more likely to use substances than those who self-rated as high religiosity. Religiosity may be a potential moderator of the association between being bullied and substance use, but the exact mechanisms and underlying reasons need further investigation.

"Everyone Has the Right to Drink Beer": A Stakeholder Analysis of Challenges to Youth Alcohol Harm-Reduction Policies in Lebanon.

BACKGROUND: Alcohol use is a major risk factor in premature death and disability, especially among youth. Evidence-based policies to prevent and control the detrimental effect of alcohol use have been recommended. In countries with weak alcohol control policies-such as Lebanon, stakeholder analysis provides critical information to influence policy interventions. This paper assesses the views of stakeholders regarding a national alcohol harm reduction policy for youth. METHODS: We interviewed a total of 22 key stakeholders over a period of 8 months in 2015. Stakeholders were selected purposively, to include representatives of governmental and non-governmental organizations and industry that could answer questions related to core intervention areas: affordability, availability, regulation of marketing, and drinking and driving. We analyzed interview transcripts using thematic analysis. RESULTS: Three themes emerged: Inadequacy of current alcohol control policies; weak governance and disregard for rule of law as a determinant of the status quo; and diverting of responsibility towards 'other' stakeholders. In addition, industry representatives argued against evidence-based policies using time-worn strategies identified globally. CONCLUSIONS: Our findings indicate that alcohol harm reduction policies are far from becoming a policy priority in Lebanon. There is a clear need to shift the narrative from victim blaming to structural conditions.

Assessment of the health needs of Syrian refugees in Lebanon and Syria's neighboring countries.

BACKGROUND: Health needs of displaced Syrians in refugee hosting countries have become increasingly complex in light of the protracted Syrian conflict. The primary aim of this study was to identify the primary health needs of displaced Syrians in Iraq, Jordan, Lebanon, Turkey, and Syria. METHODS: A systematic review was performed using 6 electronic databases, and multiple grey literature sources. Title, abstract, and full text screening were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The target population was Syrian individuals displaced due to conflict in Syria and its neighboring countries. The outcomes of interest were health needs (i.e. health problems that can be addressed by health services), gaps in health services, training, and workforce. Studies on mixed refugee populations and Syrians displaced prior to the conflict were excluded. RESULTS: The Lebanon-specific results of the review were validated through two stakeholder roundtable discussions conducted with representatives from primary healthcare centers, non-governmental organizations and humanitarian aid agencies. A total of 63 articles were included in the analysis. Mental health and women's health were identified as the greatest health needs in the region. The most common health problems were Non-communicable diseases in Jordan, women's health in Lebanon and mental health in Turkey. Studies addressing gaps in services found the highest gap in general healthcare services, followed by women's health, mental health, and vaccinations. Sub-optimal training and availability of health workers was also noted particularly in Syria.Results from the stakeholders' discussions in Lebanon showed communicable diseases, women's health and mental health as the main health needs of Syrian refugees in Lebanon. Reported barriers to accessing health services included geographical barriers and lack of necessary awareness and education. CONCLUSION: There is a need for an enhanced synchronized approach in Syria's refugee hosting neighboring countries to reduce the existing gaps in responding to the needs of Syrian refugees, especially in regards to women's health, mental health, and communicable diseases. This mainly includes training of healthcare workers to ensure a skilled workforce and community-based efforts to overcome barriers to access, including lack of knowledge and awareness about highly prevalent health conditions.

Towards improved governance for sustainable solid waste management in Lebanon: Centralised vs decentralised approaches.

Solid waste management is a multifaceted task that incorporates a diverse set of shareholders and operations. To create a sustainable solid waste management system, governments should select the most advantageous organisational structure, given a country's current setting; contextualising the sector's administrative structure in accordance with a nation's organisational constraints. This research aimed to determine the recommended level of administrative and financial decentralisation for each solid waste management operation and explore the susceptibilities and prospects of each level of governance in Lebanon. Primary data was gathered from environmental experts and concerned organisations using a semi-structured in-depth interview. Results revealed that the optimal model for solid waste management in the case of Lebanon incurs devolving collection, which would assimilate local populations into the decision-making process and reduce opposition towards devised solid waste management plans. Delegation and the construction of centralised treatment facilities is recommended as it incentivises municipal cooperation and permits the installation of methodologies and technologies that reflect the limitations, public attitudes, and waste dynamics of each distinct geographical territory. Deconcentrating disposal would limit the number of landfills constructed and facilitate monitoring. Administrative and constitutional reformations that clearly define the roles and responsibilities of public agencies would reduce the influence of the central authority on peripheral states. The establishment of municipal cooperation models would diminish regional economic disparities by enhancing the level of communication and collaboration between subnational bodies. The performance of decentralised strategies should be continuously monitored to ensure that local administrators are held accountable.

Surveying Alcohol Outlet Density in Four Neighborhoods of Beirut Lebanon: Implications for Future Research and National Policy.

Underage drinking among youth in Lebanon is increasing. Regulating availability is one of the best buy policies recommended by the World Health Organization. To quantitatively document the current status of alcohol availability to youth in Lebanon, we used GPS technology to survey alcohol outlet density in four highly populated neighborhoods in Beirut, Lebanon, and to estimate their proximity to educational institutions. The density of alcohol outlets ranged from 18.30 to 80.95 per km² (average of 39.6 alcohol outlets/km²). The highest number of total alcohol outlets was in the "Hamra & Jamiaa" area, which includes one of the largest private universities in the country. Thirteen out of 109 (12%) alcohol outlets (on and off-premise) were located less 100 m away from educational institutions, in violation of the current licensing law. None of the off-premise and the majority (94%) of on-premise alcohol outlets displayed the "no sale for <18" sign. Findings were indicative of an environment conducive to increased access and availability of alcohol among youth in Lebanon probably attributed to the prevailing weak alcohol policies and their enforcement. Systematic collection and reporting of alcohol outlet densities is critical to understand the alcogenic environment and guide local harm reduction policies.

"There Is Zero Regulation on the Selling of Alcohol": The Voice of the Youth on the Context and Determinants of Alcohol Drinking in Lebanon.

Alcohol-related research from the Arab world has rarely touched on the experiences or views of Arab adolescents. In this article, we present an in-depth analysis of youth alcohol drinking patterns and determinants derived from focus group discussions completed with more than 100 Lebanese high school/vocational students (15-19 years). The social ecology of alcohol use framework guided our research and analysis. Findings reveal that alcohol drinking is perceived as a pervasive and serious public health problem, triggered by a complex web of social relations, and facilitated by lax policies. Recommendations to curb heavy/harmful alcohol drinking among adolescents include regulating the role of alcohol industry, providing alternative recreational spaces/pass-times, educating about alcohol-related harms, and promoting more research on alcohol and its harms. Findings confirm the social ecology of alcohol use framework, and suggest the addition of the macro level of influence to this model, namely, a comprehensive alcohol harm reduction policy.

Evaluating a Mental Health Program for Palestinian Refugees in Lebanon.

Medecins sans Frontière, an international non-governmental organization, initiated a mental health program for Palestinian refugees living in Lebanon. To evaluate the impact of the program after its completion, focus groups were conducted with three target groups: (1) patients, (2) staff, and (3) local community stakeholders. Participants voiced overall satisfaction with the program. The program provided easy access, good quality care, decreased stigma, as perceived by participants, and revealed a sense of community contentedness. In addition, several short-term outcomes were achieved, such as increasing the numbers of patients visiting the center/ receiving mental health treatment. However, lack of planning for sustainability and proper procedures for hand-over of the program constituted a major downfall. Program discontinuation posed ethical dilemmas, common in provisional interventions in underprivileged refugee communities.

Alcohol consumption in the Arab region: What do we know, why does it matter, and what are the policy implications for youth harm reduction?

Alcohol is a recognized global risk factor for many diseases and injury types and a major contributor to disability and death. While cost-effective interventions do exist, many countries lack a comprehensive national alcohol harm reduction policy. The Arab world includes 22 diverse countries stretching from North Africa to Western Asia having varying dispositions with regards to alcohol sale and consumption. Epidemiological data is scattered and the picture on alcohol consumption remains blurry. This paper presents the findings of an extensive review conducted on all 22 Arab countries, specifically describing: (1) the density and methodology of alcohol-related peer-reviewed publications over the last two decades (1993-2013); (2) the epidemiology of alcohol consumption given all available data; and (3) the current status of policies in the region. Our search revealed a strikingly low number of alcohol-related peer-reviewed published studies - a total of 81 publications across 22 countries and two decades. Most studies are based on clinical or student samples. Where data is available, age of onset is low and drinking is frequent, in the absence of any available or enforced harm reduction policies. We submit that countries in the Arab region can be divided into four categories by alcohol ban and published data. One category includes countries where alcohol is not banned but data is absent, suggesting an ostrich-like response to a controversial behavior, or reflecting a weak research infrastructure and/or policy landscape. Evidence-informed recommendations and future directions for policy and research are discussed and tailored to countries' current stance on alcohol legislation and consumption. Given the particular vulnerability of youth to uptake of alcohol as well as the resulting short and long term consequences, the paper concludes by focusing on the implications of the findings for youth alcohol harm reduction.

Double trouble: Exploring the association between waterpipe tobacco smoking and the nonmedical use of psychoactive prescription drugs among adolescents.

BACKGROUND: In youth, both waterpipe tobacco smoking (WTS) and nonmedical use of prescription drugs (NMUPD) are globally growing concerns. This study assesses for the first time the lifetime and past-year associations between WTS and four classes of psychoactive prescription drugs. METHODS: Cross-sectional data (2011) on 986 high school students attending public and private high schools in Beirut (Lebanon) was analyzed. Schools were selected using proportionate random cluster sampling from a comprehensive list of schools provided by the Ministry of Education. RESULTS: Almost half (46%) had tried WTS compared to 25% who had ever tried cigarettes. Lifetime prevalence estimates of NMUPD were: pain relievers (8.2%), sedatives/tranquilizers (5.6%), stimulants (3.5%), antidepressants (2.5%), and sleeping pills (2.3%). WTS was associated with increased odds of sedatives/tranquilizer use (OR = 3.22, 95% CI: 1.25, 8.25), pain reliever use (OR = 4.31, 95% CI: 2.02, 9.17), and sleeping medication use (OR = 8.31, 95% CI: 2.37, 29.20), controlling for sex, age, school type, and other substance use. For cigarettes, the associations were consistently either weaker or non-existent, except with stimulant use (OR = 5.29, 95% CI: 1.55, 18.05). CONCLUSIONS: While public health professionals have watched with caution the global prevalence of youth cigarette use-worldwide, an insidious alternative form of tobacco use has grown. Further research is needed to understand the unique risk factors and motives associated with WTS and how these relate to NMUPD in order to inform the development of effective intervention programs and policies that support youth positive health decisions.

Health and ecological sustainability in the Arab world: a matter of survival.

Discussions leading to the Rio+20 UN conference have emphasised the importance of sustainable development and the protection of the environment for future generations. The Arab world faces large-scale threats to its sustainable development and, most of all, to the viability and existence of the ecological systems for its human settlements. The dynamics of population change, ecological degradation, and resource scarcity, and development policies and practices, all occurring in complex and highly unstable geopolitical and economic environments, are fostering the poor prospects. In this report, we discuss the most pertinent population-environment-development dynamics in the Arab world, and the two-way interactions between these dynamics and health, on the basis of current data. We draw attention to trends that are relevant to health professionals and researchers, but emphasise that the dynamics generating these trends have implications that go well beyond health. We argue that the current discourse on health, population, and development in the Arab world has largely failed to convey a sense of urgency, when the survival of whole communities is at stake. The dismal ecological and development records of Arab countries over the past two decades call for new directions. We suggest that regional ecological integration around exchange of water, energy, food, and labour, though politically difficult to achieve, offers the best hope to improve the adaptive capacity of individual Arab nations. The transformative political changes taking place in the Arab world offer promise, indeed an imperative, for such renewal. We call on policy makers, researchers, practitioners, and international agencies to emphasise the urgency and take action.

They aren't all first cousins: Bedouin marriage and health policies in Lebanon.

OBJECTIVE: Fertility and consanguineous marriages among the Bedouin tribes of the Middle East have long generated interest particularly around health outcomes and social relations. In particular, Bedouin in Lebanon have increasingly embraced the Lebanese national bio-medical health system in the past two decades, while Lebanese policy-makers' responses continue to be minimal and ill-informed. This paper investigates the mismatch between policy-makers' formulations of Bedouin consanguineous marriages and the Bedouins's actual reproductive practices and discusses the implications of these formulations on the Bedouins's access to health services. DESIGN: The findings are drawn from the data collected as part of the Bedouin Health Project, an EU-funded five-year study (2005-2010), aiming at assessing access to reproductive and child health care among the Bedouin in Lebanon. The data was collected from 6 clusters representing the main Bedouin informal and unrecognized settlements in the Bekaa Valley of Lebanon. The data consists of 111 socioeconomic questionnaires with Bedouin women users of local public, private, and nongovernmental reproductive and child health-focused clinics, in addition to 40 in-depth interviews with Bedouin women across the clusters and 17 semi-structured interviews with policy-makers. RESULTS: The findings suggest a gap between the perceptions of policy-makers and the incidence of consanguineous marriages and reproductive practices among the Bedouin. While there was no national data available for the Bedouin populations, policy-makers relied on a constructed 'Bedouin reproductive profile' that portrayed them as 'a problematic health group'. The national policy formulation of the Bedouin reproductive profile has an exclusionary impact on the Bedouin population as they are ignored from any targeted health policies or provided with politically motivated palliative care provision. CONCLUSION: These findings highlight the importance of addressing stereotyping and discrimination among health practitioners and policy-makers, as a crucial part of improving the overall marriage and reproductive health practices of the Bedouin.

Bedouin in Lebanon: Social discrimination, political exclusion, and compromised health care.

Global inequalities in health have long been associated with disparities between rich and poor nations. The middle-income countries of the Levant (Lebanon, Syria and Jordan) have developed models of health care delivery that mirror the often complex make-up of their states. In Lebanon, which is characterized by political clientelism and sectarian structures, access to health care is more contingent on ethnicity and religious affiliation than on poverty. This case study of the Bedouin of the Middle Bekaa Valley of Lebanon is based on interviews with policymakers, health care providers and the Bedouin as part of a study funded by the European Commission between 2006 and 2010. The study explores the importance of considering social discrimination and political exclusion in understanding compromised health care. Three decades after the Declaration of Alma Ata (1978), which declared that an acceptable level of health care for all should be attained by the year 2000, the Bedouin community of Lebanon remains largely invisible to the government and, thus, invisible to national health care policy and practice. They experience significant social discrimination from health practitioners and policymakers alike. Their unfair treatment under the health system is generally disassociated from issues of wealth or poverty; it is manifested in issues of access and use, discrimination, and resistance and agency. Overcoming their political exclusion and recognizing the social discrimination they face are steps that can be taken to protect and promote equal access to basic reproductive and child health care. This case study of the Bedouin in Lebanon is also relevant to the health needs of other marginalized populations in remote and rural areas.

Double jeopardy: assessing the association between internal displacement, housing quality and chronic illness in a low-income neighborhood.

PURPOSE: This study analyzed associations between war-related internal displacement, housing quality and the prevalence of chronic illness in Nabaa, a low-income neighborhood on the outskirts of Beirut, Lebanon. METHODS: A cross-sectional survey of sociodemographics, household characteristics and health conditions of the study population was carried out in 2002. Using a structured questionnaire, the research team surveyed 1,151 households representing 4,987 residents of all ages. The survey was administered to a proxy respondent from each household in face-to-face interviews. A multiple logistic regression model using the generalized estimation equation method was constructed to assess the simultaneous effect of displacement and housing quality on reported ill health, while adjusting for potential confounders. RESULTS: Housing quality and internal displacement were strongly associated with occurrences of chronic illness. The most vulnerable respondents were older residents, females and internally displaced people, who reported high rates of chronic illnesses. Residents with high levels of education were less likely to report a chronic illness than those that had elementary education or less. CONCLUSION: Nabaa residents' experience of poor health was associated with inadequate housing quality. Moreover, residents who have been displaced experience worse living conditions and were more likely to experience poor health than those who were not displaced. These results reveal a need for policies to improve housing quality and alleviate war-related consequences in low-income neighborhoods.

Evaluating a community based participatory approach to research with disadvantaged women in the southern suburbs of Beirut.

This manuscript presents the evaluation of a 3 year community-based participatory research (CBPR) approach involving the testing of a psychosocial intervention to improve reproductive and mental health of married women in a disadvantaged community in Beirut, Lebanon. The community-based participatory approach involved a community advisory committee (CAC), a local women committee (LWC), and university researchers. The evaluation of the CBPR approach followed qualitative assessment which included: analysis of compiled field notes and minutes of meetings of CAC and LWC throughout the 3 years of the intervention, and focus group discussions and individual interviews conducted with the CAC and the LWC members following completion of the trial. The CBPR approach confirmed feasibility, cultural adequacy, as well as representation of community needs. Five main emerging themes came out of the FGD and interviews with CAC and LWC. The community and women involved viewed that the CBPR approach allowed for a good understanding of the community, they felt ownership of the study, acknowledged that participation gave the women voices, and established trust, and acknowledged the challenges faced. This manuscript describes how the community was involved, reports on their evaluation of the CBPR process, and discusses challenges to CBPR in this particular context.

Process evaluation of a psychosocial intervention addressing women in a disadvantaged setting.

OBJECTIVES: This paper presents the process evaluation of a community-based randomized psycho-social trial aimed to enhance reproductive and mental health outcomes of disadvantaged women living in the southern suburb of Beirut-Lebanon. Process evaluation of public health interventions involves the monitoring and documentation of interventions' implementation to allow for better understanding of planned outcomes and of intervention effectiveness. METHODS: A community-based randomized trial was conducted. The intervention consisted of 12 sessions (of combined 30 minutes of relaxation exercises and 75 minutes of structured support groups) delivered twice per week over a period of six-weeks. A process evaluation was conducted during the implementation of the intervention. This process evaluation aimed to ensure that the intervention was delivered and implemented as planned, as well as to monitor women's satisfaction and attendance. The main components of the process evaluation included: dose delivered, dose received, and reach. Closed ended questionnaires were administered before/after/during each intervention session. Data was entered and analyzed using SPSS. Analysis revolved around simple frequency distribution for categorical variables and means (SD) for continuous variables. Limited bivariate analysis (using CHI Square and Anova) was done. RESULTS: RESULTS indicated that the delivery, implementation, and reach of the intervention were favorable. Participation was acceptable and satisfaction rates were very high. CONCLUSION: These favorable findings pertaining to intervention satisfaction, reach and participation highlight a number of lessons for future intervention studies in the context of disadvantaged settings. They also support the importance of involving the local community members in intervention planning, implementation and evaluation early on. We believe that the community involvement in this trial directly and significantly contributed to the results of this process evaluation.