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BACKGROUND: As in many Sub-Saharan African countries, the health system in Somalia is not operating at the capacity needed to lift childhood vaccination coverage to ninety percent or above, as recommended by United Nations Children's Fund. Current national estimates of coverage for the six major vaccine preventable childhood diseases range from thirty to sixty percent. Infectious disease outbreaks continue to pose significant challenges for the country's health authorities.

OBJECTIVE: This important qualitative study, conducted in Galkayo District, Somalia, investigates limiting factors associated with childhood vaccination uptake from the perspective of both communities and health care workers.

METHODS: Qualitative information was collected through six focus group discussions with parents (n = 48) and five one-to-one interviews with health workers (n = 15) between March and May 2017, in three settings in the Galkayo District - Galkayo city, Bayra and Bacadwayn.

RESULTS: From a health system perspective, the factors are: awareness raising, hard to reach areas, negative attitudes and perceived knowledge of health workers, inadequate supplies and infrastructure, and missed vaccination opportunities. From the perspective of individuals and communities the factors are: low trust in vaccines, misinterpretation of religious beliefs, vaccine refusals, Somalia's patriarchal system and rumours and misinformation. Parents mostly received immunization information from social mobilizers and health facilities. Fathers, who are typically family decision-makers, were poorly informed. The findings highlight the need for in-service training to enable health workers to improve communication with parents, particularly fathers, peripheral communities and local religious leaders.

CONCLUSIONS: Enhancing knowledge and awareness of vaccination among parents is crucial. Fathers' involvement is lacking. This may be boosted by highlighting fathers' obligation to protect their children's health through vaccination. It is also important that men engage with the wider community in decision-making and advance towards the global vaccination targets.

This report describes the 2020 “From a Thesis to a Paper” Course hosted by the Department of Epidemiology and Global Health (EpiGH) at Umeå University, Sweden, and run across weeks 26-35 2020 (22nd June -28th August). The Course guides and advises early career researchers in scientific writing for targeted peer reviewed journals. Students develop papers based on their own research – typically a masters’ thesis. They work in small groups reviewing one another’s work and revising and re-drafting their manuscripts with support and input from the teacher. By the end of the Course students are expected to produce formatted draft documents suitable for submission to a peer reviewed journal of choice.

Eligibility requires either one- or two-year masters’ qualifications in public health (MPH), health care or health education. Students and alumni from EpiGH are the target group. Applications and enrolments are processed by Umeå University. Students residing outside the European Union (EU) or European Economic Area (EEA) are required to pay University tuition fees (12,367 Swedish Krona).

The majority of students enrolled in EpiGH masters’ courses are from low- and middle-income countries. In 2019 the Taylor & Francis Company (T&F) introduced a Scholarship Fund to pay tuition fees for up to ten non-EU/EEA students to enrol in the “From a Thesis to a Paper” Course each year. This report is in accordance with section 4.4 of the contract between T&F and Umeå University which affirms this financial support. See Appendix A.

Health system responsiveness is an indicator that can be used for evaluating how well healthcare systems respond to people's needs in non-clinical areas such as communication, autonomy and confidentiality. This study analyses health system responsiveness from the perspective of community-dwelling adults aged 50 and over in China, Ghana, India, the Russian Federation and South Africa using cross-sectional data from the World Health Organization Study on global AGEing and adult health. The aim is to assess and compare how individual, health condition and healthcare factors impact differently on outpatient and inpatient responsiveness.

Poor responsiveness is measured according to participants' responses to questions on a five-point Likert scale. Five univariate and multiple logistic regression models test associations between individual, health condition and healthcare factors and poor responsiveness. The final model adjusts for country.

Key results are that travel time is a major contributor to poor responsiveness across all countries. Similarly there are wealth inequalities in responsiveness. However no clear difference in responsiveness was observed in presentations for chronic versus other types of conditions.

This study provides an interesting baseline on older patients' perceived treatment within outpatient and inpatient facilities in five diverse low- and middle-income countries.

Background: The use of large quantities of antimicrobial drugs for human health and agriculture is advancing the predominance of drug resistant pathogens in the environment. Antimicrobial resistance is now a major public health threat posing significant challenges for achieving the Sustainable Development Goals. In Bangladesh, where over one third of the population is below the poverty line, the achievement of safe and effective antibiotic medication use for human health is challenging.

Objective: To explore factors and practices around access and use of antibiotics and understanding of antimicrobial resistance in rural communities in Bangladesh from a socio-cultural perspective.

Methods: This qualitative study comprises the second phase of the multi-country ABACUS (Antibiotic Access and Use) project in Matlab, Bangladesh. Information was collected through six focus group discussions and 16 in-depth interviews. Informants were selected from ten villages in four geographic locations using the Health and Demographic Surveillance System database. The Access to Healthcare Framework guided the interpretation and framing of the findings in terms of individuals' abilities to: perceive, seek, reach, pay and engage with healthcare.

Results: Village pharmacies were the preferred and trusted source of antibiotics for self-treatment. Cultural and religious beliefs informed the use of herbal and other complementary medicines. Advice on antibiotic use was also sourced from trusted friends and family members. Access to government-run facilities required travel on poorly maintained roads. Reports of structural corruption, stock-outs and patient safety risks eroded trust in the public sector. Some expressed a willingness to learn about antibiotic resistance.

Conclusion: Antimicrobial resistance is both a health and development issue. Social and economic contexts shape medicine seeking, use and behaviours. Multi-sectoral action is needed to confront the underlying social, economic, cultural and political drivers that impact on the access and use of antibiotic medicines in Bangladesh.

COVID-19 shocked health and economic systems leaving millions of people without employment and safety nets. The pandemic disproportionately affects people with substance use disorders (SUDs) due to the collision between SUDs and COVID-19. Comorbidities and risk environments for SUDs are likely risk factors for COVID-19. The pandemic, in turn, diminishes resources that people with SUD need for their recovery and well-being. This article presents an interdisciplinary and international perspective on how COVID-19 and the related systemic shock impact on individuals with SUDs directly and indirectly. We highlight a need to understand SUDs as biopsychosocial disorders and use evidence-based policies to destigmatize SUDs. We recommend a suite of multi-sectorial actions and strategies to strengthen, modernize and complement addiction care systems which will become resilient and responsive to future systemic shocks similar to the COVID-19 pandemic.

In 2019 the Department of Epidemiology and Global Health (EpiGH) Umeå University, conducted the “From a Thesis to a Paper” Summer Course for Master of Public Health (MPH) students and alumni from June 18th to August 30th. The aim of this optional Course was to guide and advise early career researchers in the development of material from their masters theses into manuscripts suitable for submission to peer reviewed journals. Scholarships awarded to MPH students from low- and middle-income countries (LMICs) do not cover fees for non-compulsory courses. In 2019 the Taylor & Francis Company introduced a Scholarship Fund which provides course fee waivers for up to ten eligible students in the “From a Thesis to a Paper” Course each year. This report describes the implementation of the Fund and sponsored students’ academic progress. Scheduling the Course in the first year of the Scholarship Fund was not without administrative difficulties because University admissions processes for 2019 summer courses opened prior to the signing of the contract with the Taylor & Francis Company. (See Attachment 1). However we are confident that the “teething issues” outlined here will be resolved in future cycles.

OBJECTIVES: To conduct a health economic evaluation of a proposed investment in urban bicycle infrastructure in Stockholm County, Sweden.

DESIGN: A cost-effectiveness analysis is undertaken from a healthcare perspective. Investment costs over a 50-year life cycle are offset by averted healthcare costs and compared with estimated long-term impacts on morbidity, quantified in disability-adjusted life years (DALYs). The results are re-calculated under different assumptions to model the effects of uncertainty.

SETTING: The Municipality of Stockholm (population 2.27 million) committed funds for bicycle path infrastructure with the aim of achieving a 15% increase in the number of bicycle commuters by 2030. This work is based on a previously constructed scenario, in which individual registry data on home and work address and a transport model allocation to different modes of transport identified 111 487 individuals with the physical capacity to bicycle to work within 30 min but that currently drive a car to work.

RESULTS: Morbidity impacts and healthcare costs attributed to increased physical activity, change in air pollution exposure and accident risk are quantified under the scenario. The largest reduction in healthcare costs is attributed to increased physical activity and the second largest to reduced air pollution exposure among the population of Greater Stockholm. The expected net benefit from the investment is 8.7% of the 2017 Stockholm County healthcare budget, and 3.7% after discounting. The economic evaluation estimates that the intervention is cost-effective and each DALY averted gives a surplus of €9933. The results remained robust under varied assumptions pertaining to reduced numbers of additional bicycle commuters.

CONCLUSION: Investing in urban infrastructure to increase bicycling as active transport is cost-effective from a healthcare sector perspective.

Background: Despite global achievements in reducing early childhood mortality, disparities remain. There have been empirical studies of inequalities conducted in low- and middle-income countries. However, there have been no epidemiological studies on socioeconomic inequalities and early childhood survival in Myanmar.

Objective: To estimate associations between two measures of parental socioeconomic status - household wealth and education - and age-specific early childhood mortality in Myanmar.

Methods: Using cross-sectional data obtained from the Myanmar Demographic Health Survey (2015-2016), univariate and multiple logistic regressions were performed to investigate associations between household wealth and highest attained parental education, and under-5, neonatal, post-neonatal and child mortality. Data for 10,081 children born to 5,932 married women (aged 15-49 years) 10 years prior to the survey, were analysed.

Results: Mortality during the first five years was associated with household wealth. In multiple logistic models, wealth was protective for post-neonatal mortality. After adjusting for individual proximate determinants, the odds of post-neonatal mortality in the richest households were 85% lower (95% CI: 50-96%) than in the poorest households. However, significant association was not found between wealth and neonatal mortality. Parental education was important for early childhood mortality; the highest benefit from parental education was for child mortality in the one- to five-year age bracket. After adjusting for proximate determinants, children with a higher educated parent had 95% (95% CI 77-99%) lower odds of death in this age group compared with children whose parents' highest educational attainment was at primary level. The association between parental education and neonatal mortality was not significant.

Conclusions: In Myanmar, household wealth and parental education are important for childhood survival before five years of age. This study identified nuanced age-related differences in associations. Health policy must take socioeconomic determinants into account in order to address unfair inequalities in early childhood mortality.