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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.

Background: Less than 2% of scientific publications originate in low-income countries. Transfer of information from South to North and from South to South is grossly limited and hinders understanding of global health, while Northern-generated information fails to adequately address the needs of a Southern readership.

Methods: A survey of a new generation of health researchers from nine low-income countries was conducted using a combination of email questionnaires and face-to-face interviews. Data were gathered on personal experiences, use and aspirations regarding access and contribution to published research.

Results: A total of 23 individuals from 9 countries responded. Preference for journal use over textbooks was apparent, however a preference for print over online formats was described among African respondents compared to respondents from other areas. Almost all respondents (96%) described ambition to publish in international journals, but cited English language as a significant barrier.

Conclusion: The desire to contribute to and utilise contemporary scientific debate appears to be strong among study respondents. However, longstanding barriers

Background: Somali women suffer from one of the highest maternal mortality rates in the world. Somalia characterises a specific low-income country situation with a mix of newly urbanized and nomadic culture combined with a frail health care infrastructure set in a post-conflict era. Very little is known about the effects that these contextual factors can have on maternal mortality.

Objectives: To explore and describe causes and contributing factors concerning maternal deaths in the Bosaso District, Puntland State of Somalia.

Methods: Data was collected using an adapted Verbal Autopsy tool. In 2017 30 cases of maternal deaths occurring in 2016 in the Bosaso District were reviewed. Information was assessed by three independent reviewers who classified the cause of death and the contributing factors. The Three Delay Model was employed to identify socio-cultural and economic and health system factors that may have contributed to these maternal deaths.

Results: Direct obstetric deaths accounted for 28 cases. Among these, haemorrhage was the leading cause, followed by eclampsia, sepsis and obstructed labour. Two cases were indirect obstetric deaths, caused by anaemia. All three types of delay were frequent among the studied cases. Delay in deciding to seek care was found in 25 cases, delay in reaching care in 22 cases and delay in receiving health care in 24 cases. Lack of knowledge, money, transportation, poor access and availability of adequate services, as well as substandard management by health care providers, were all underlying the delays.

Conclusion: A comprehensive intervention programme is needed in order to decrease maternal mortality among Somali women. Such a programme must include health education, improved referral systems and strategic upgrading of care services.

For the last two and a half decades, a network of human health experts under the Arctic Monitoring and Assessment Program (AMAP) has produced several human health assessment reports. These reports have provided a base of scientific knowledge regarding environmental contaminants and their impact on human health in the Arctic. These reports provide scientific information and policy-relevant recommendations to Arctic governments. They also support international agreements such as the Stockholm Convention on Persistent Organic Pollutants (POPs) and the Minamata Convention on Mercury. Key topics discussed in this paper regarding future human health research in the circumpolar Arctic are continued contaminant biomonitoring, health effects research and risk communication. The objective of this paper is to describe knowledge gaps and future priorities for these fields.

BACKGROUND: The major chronic non-communicable diseases (NCDs) operate through a cluster of common risk factors, whose presence or absence determines not only the occurrence and severity of the disease, but also informs treatment approaches. Primary prevention based on mitigation of these common risk factors through population-based programmes is the most cost-effective approach to contain the emerging epidemic of chronic NCDs.

OBJECTIVES: This study was conducted to explore the extent of risk factors clustering for the major chronic NCDs and its determinants in nine

INDEPTH Health and Demographic Surveillance System (HDSS) sites of five Asian countries. DESIGN: Data originated from a multi-site chronic NCD risk factor prevalence survey conducted in 2005. This cross-sectional survey used a standardised questionnaire developed by the WHO to collect core data on common risk factors such as tobacco use, intake of fruits and vegetables, physical inactivity, blood pressure levels, and body mass index. Respondents included randomly selected sample of adults (25-64 years) living in nine rural HDSS sites in Bangladesh, India, Indonesia, Thailand, and Vietnam.

RESULTS: Findings revealed a substantial proportion (>70%) of these largely rural populations having three or more risk factors for chronic NCDs. Chronic NCD risk factors clustering was associated with increasing age, being male, and higher educational achievements. Differences were noted among the different sites, both between and within country.

CONCLUSIONS: Since there is an extensive clustering of risk factors for the chronic NCDs in the populations studied, the interventions also need to be based on a comprehensive approach rather than on a single factor to forestall its cumulative effects which occur over time. This can work best if it is integrated within the primary health care system and the HDSS can be an invaluable epidemiological resource in this endeavor.

Background: There is increasing demand for trainers to shift from traditional didactic training to innovative approaches that are more results-oriented. Mentorship is one such approach that could bridge the clinical knowledge gap among health workers.

Objectives: This paper describes the experiences of an attempt to improve health-worker performance in maternal and newborn health in three rural districts through a mentoring process using the cascade model. The paper further highlights achievements and lessons learnt during implementation of the cascade model.

Methods: The cascade model started with initial training of health workers from three districts of Pallisa, Kibuku and Kamuli from where potential local mentors were selected for further training and mentorship by central mentors. These local mentors then went on to conduct mentorship visits supported by the external mentors. The mentorship process concentrated on partograph use, newborn resuscitation, prevention and management of Post-Partum Haemorrhage (PPH), including active management of third stage of labour, preeclampsia management and management of the sick newborn. Data for this paper was obtained from key informant interviews with district-level managers and local mentors.

Results: Mentorship improved several aspects of health-care delivery, ranging from improved competencies and responsiveness to emergencies and health-worker professionalism. In addition, due to better district leadership for Maternal and Newborn Health (MNH), there were improved supplies/medicine availability, team work and innovative local problem-solving approaches. Health workers were ultimately empowered to perform better.

Conclusions: The study demonstrated that it is possible to improve the competencies of frontline health workers through performance enhancement for MNH services using locally built capacity in clinical mentorship for Emergency Obstetric and Newborn Care (EmONC). The cascade mentoring process needed strong external mentorship support at the start to ensure improved capacity among local mentors to provide mentorship among local district staff.

Background: If current trends continue, Ghana's aged population will increase in the coming decades. Currently, there is little knowledge on the health of the aged in Ghana. Research on vision problems among this group is virtually non-existent. This research gap needs to be filled immediately in order to promote the general health among older people in Ghana.

Objective: The objective of the study was to analyse vision health and its determinants among the older adult population in a district in one of the poorest regions in Ghana - the Kassena-Nankana district.

Methods: Data were obtained from the WHO multi-country studies unit (SAGE). A total of 4,294 people over the age of 50 responded to the survey. Data analysis was conducted using Stata statistical package. The aim of the analysis was to identify the prevalence of self-reported vision problems and assistive device use. Age, level of education, marital status, living arrangement, socio-economic status and proportion of people aged 50 and over in a household were used as determinants of vision health.

Results: In total, 54 and 63% (p-value, 0.00) of men and women reported having far-sightedness, while 35% of men and 40.6% of women reported having near-sightedness (p-value, 0.00). In total, 33.5% of men and 38.6% of women reported having both near-sightedness and far-sightedness (p-value, 0.00). Of those who reported having either vision problems, 2.9% reported the use of visual assistive devices. Men had a higher assistive device use of 4.5% compared to 2.1% among women (p = 0.002). Age and household socio-economic status was positively associated with reporting vision problems and assistive device use, respectively.

Conclusions: The results from this analysis showed that despite the high reporting of vision problems, only 2.9% reported using assistive devices. This outcome shows that there is a need to prevent vision problems and increase access to assistive devices among older people in the Kassena-Nankana district in Ghana.

Background: The antiretroviral treatment (ART) scale-up service has been a recent development in Ethiopia, but its impact on mortality has not been well investigated. The aim of this study was to assess the early survival outcome of the scale-up service by utilizing routine hospital data.

Methods: All adult HIV/AIDS patients who started on antiretroviral treatment in Shashemene and Assela hospitals from January 1, 2006 to May 31, 2006 were included and followed up for 2 years. Data were extracted from standard patient medical registrations. Kaplan-Meier curves were used to estimate survival probability and the Cox proportional hazard model was applied to determine predictors of mortality. Two alterative assumptions (real case and worst case) were made in determining predictors of mortality.

Results: The median age of patients was 33 years and 57% were female. Eighty-five percent had CD4 <200 cells/mu L with a median CD4 count of 103 cells/mu L. The median survival time was 104.4 weeks. A total of 28 (10.3%) deaths were observed during the 2-year period and 48 patients (18%) were lost to follow up. The majority of deaths occurred in the first 4 months of treatment. In multivariate analysis, 2-year survival was significantly associated with the clinical stage of the disease, baseline hemoglobin, and cotrimoxazole prophylaxis therapy (CPT) at or before ART initiation in both assumptions. The median CD4 count and body weight showed a marked improvement during the first 6 months of treatment, followed by stagnation thereafter.

Conclusion: The study has shown an overall low mortality but a high loss to follow-up rate of the cohort. Advanced clinical stage, anemia, low body weight, and lack of CPT initiation were independent predictors of mortality - but not gender. CPT initiation should be encouraged in routine HIV care services, and patient retention mechanisms have to be strengthened. Stagnation in immunological and weight recovery after the first 6 months should be further investigated. The utilization of routine data should be encouraged in order to facilitate appropriate decision making.

Background: Cambodia is a country where the resources for treating mental health disorders are far from sufficient. One strategy to narrow the treatment gap is to integrate mental health into primary health care (PHC). Understanding the knowledge and attitudes towards mental health integration that health-care workers have is important for assessing the challenges and opportunities when planning a potential integration project. Objective: The aim of this study was to assess these basic conditions in Lvea Em District, Cambodia. Design: A structured self-reporting questionnaire regarding attitudes and knowledge about mental health and its integration into PHC was collected from 75 health-care workers in Lvea Em District, Cambodia in October 2015. Firstly, descriptive analyses were carried out, and secondly, linear regression analyses to assess the relationship between attitudes and socio-demographic variables were conducted. Results: There was clear support towards integrating mental health services into PHC among these participants as 81.3% were interested in personally delivering mental health care at their units. Respondents who reported having received some kind of mental health-care training tended to have a more positive attitude towards mentally ill people (p = 0.005) and those who thought there was a high need for mental health care had a more favourable attitude towards the integration of mental health services (p = 0.007). Conclusions: The most important finding from this survey was the willingness and the acceptance of the need for integration of mental health care. This enhances the feasibility of integrating mental health services at the PHC level. Improving the competence of mental health care in these settings will likely help to reduce the treatment gap for mental, neurological and substance use disorders in Cambodia.

Background: Pakistan is a patriarchal society where men are the primary authority figures and women are subordinate. This has serious implications on women’s and men’s life prospects.

Objective: The aim was to explore current gender roles in urban Pakistan, how these are reproduced and maintained and influence men’s and women’s life circumstances.

Design: Five focus group discussions were conducted, including 28 women representing employed, unemployed, educated and uneducated women from different socio-economic strata. Manifest and latent content analyses were applied.

Findings: Two major themes emerged during analysis: ‘Reiteration of gender roles’ and ‘Agents of change’. The first theme included perceptions of traditional gender roles and how these preserve women’s subordination. The power gradient, with men holding a superior position in relation to women, distinctive features in the culture and the role of the extended family were considered to interact to suppress women. The second theme included agents of change, where the role of education was prominent as well as the role of mass media. It was further emphasised that the younger generation was more positive to modernisation of gender roles than the elder generation.

Conclusions: This study reveals serious gender inequalities and human rights violations against women in the Pakistani society. The unequal gender roles were perceived as static and enforced by structures imbedded in society. Women routinely faced serious restrictions and limitations of autonomy. However, attainment of higher levels of education especially not only for women but also for men was viewed as an agent towards change. Furthermore, mass media was perceived as having a positive role to play in supporting women’s empowerment.

Background: South Africa's epidemiological transition is characterised by an increasing burden of chronic communicable and non-communicable diseases. However, little is known about predictors of health care use (HCU) for the prevention and control of chronic diseases among older adults.

Objective: To describe reported health problems and determine predictors of HCU by adults aged 50+ living in a rural sub-district of South Africa.

Design: A cross-sectional study to measure HCU was conducted in 2010 in the Agincourt sub-district of Mpumalanga Province, an area underpinned by a robust health and demographic surveillance system. HCU, socio-demographic variables, reception of social grants, and type of medical aid were measured, and compared between responders who used health care services with those who did not. Predictors of HCU were determined by binary logistic regression adjusted for socio-demographic variables.

Results: Seventy-five percent of the eligible adults aged 50+ responded to the survey. Average age of the targeted 7,870 older adults was 66 years (95% CI: 65.3, 65.8), and there were more women than men (70% vs. 30%, p<0.001). All 5,795 responders reported health problems, of which 96% used health care, predominantly at public health facilities (82%). Reported health problems were: chronic non-communicable diseases (41% - e. g. hypertension), acute conditions (27% - e. g. flu and fever), other conditions (26% - e. g. musculoskeletal pain), chronic communicable diseases (3% - e. g. HIV and TB), and injuries (3%). In multivariate logistic regression, responders with chronic communicable disease (OR = 5.91, 95% CI: 1.44, 24.32) and non-communicable disease (OR = 2.85, 95% CI: 1.96, 4.14) had significantly higher odds of using health care compared with those with acute conditions. Responders with six or more years of education had a two-fold increased odds of using health care (OR = 2.49, 95% CI: 1.27, 4.86) compared with those with no formal education.

Conclusion: Chronic communicable and non-communicable diseases were the most prevalent and main predictors of HCU in this population, suggesting prioritisation of public health care services for chronic diseases among older people in this rural setting.

Background: There has been a substantial increase of income inequalities in Sweden over the last 20 years, which also could be reflected in health inequalities, including mental health inequalities. Despite the growing body of literature focusing on health inequalities in Sweden, income-related inequalities in mental health have received little attention. Particularly scarce are research from Northern Sweden and examinations of the social determinants of health inequalities.

Objectives: The present study seeks to provide evidence regarding inequalities in mental health in Northern Sweden. The specific aims were to (1) quantify the income-related inequality in mental health in Northern Sweden, and (2) determine the contribution of social determinants to the inequality.

Methods: The study population comprised 25,646 participants of the 2014 Health on Equal Terms survey in the four northernmost counties of Sweden, aged 16 to 84 years old. Income-related inequalities in mental health were quantified by the concentration index and further decomposed by applying Wagstaff-type decomposition analysis.

Results: The overall concentration index of mental health in Northern Sweden was −0.15 (95% CI: −0.17 to −0.13), indicating income inequalities in mental health disfavoring the less affluent population. The decomposition analysis results revealed that socio-economic conditions, including employment status (31%), income (22.6%), and cash margin (14%), made the largest contribution to the pro-rich inequalities in mental health. The second-largest contribution came from demographic factors, mainly age (11.3%) and gender (6%). Psychosocial factors were of smaller importance, with perceived discrimination (8%) and emotional support (3.4%) making moderate contributions to the health inequalities. 

Conclusions: The present study demonstrates substantial income-related mental health inequalities in Northern Sweden, and provides insights into their underpinnings. These findings suggest that addressing the root causes is essential for promoting mental health equity in this region.

Background: Physical activity is a useful means to improve symptoms and memory performance to some extent in individuals with stress-induced exhaustion disorder. Individuals in this group commonly do not need to reach the recommended levels of physical activity. Developing methods to support physical activity as a lasting behaviour is important.

Objective: The aim of the study was to explore the processes involved when using physical activity prescription as part of rehabilitation in a group context for individuals with stress-induced exhaustion disorder.

Method: A total of 27 individuals with stress-induced exhaustion disorder participated in six focus groups. The informants underwent a multimodal intervention including prescription of physical activity. The physical activity prescription had a cognitive behaviour approach and included information about physical activity, home assignments and goal setting. The data was analysed with grounded theory method using constant comparison.

Results: The analysis of the data was developed into the core category ‘trying to integrate physical activity into daily life in a sustainable way’, and three categories: ‘acceptance of being good enough’, ‘learning physical activity by doing’ and ‘advocation for physical activity in rehabilitation’. The informants identified that during the physical activity prescription sessions they learned what physical activity was, what was ‘good enough’ in terms of dose and intensity of physical activity, and how to listen to the body’s signals. These insights, in combination with performing physical activity during home assignments and reflecting with peers, helped them incorporate physical activity in a new and sustainable way. A need for more customised physical activity with the ability to adjust to individual circumstances was requested.

Conclusion: Prescription of physical activity in a group context may be a useful method of managing and adjusting physical activity in a sustainable way for individuals with stress-induced exhaustion disorder. However, identifying people who need more tailored support is important.

Since the theoretical frameworks and conceptual tools we employ shape research outcomes by guiding research pathways, it is important that we subject them to ongoing critical reflection. A thoroughgoing analysis of the global production of women's health inequality calls for a comprehensive theorization of how social relations of gender and the biological body mutually interact in local contexts in a nexus with women's health. However, to date, the predominant concern of research has been to identify the biological effects of social relations of gender on the body, to the relative neglect of the co-constitutive role that these biological changes themselves may play in ongoing cycles of gendered health oppressions. Drawing on feminist and gender theoretical approaches, and with the health of women and girls as our focus, we seek to extend our understanding of this recursive process by discussing what we call the 'shaping processes' of the 'gender-biology nexus' which call attention to not only the 'gender-shaping of biology' but also the 'biologic-shaping of gender'. We consider female genital mutilation/cutting as an illustration of this process and conclude by proposing that a framework which attends to both the 'gender-shaping of biology' and the 'biologic-shaping of gender' as interweaving processes provides a fruitful approach to theorising the wider health inequalities experienced by women and girls.

Background: Indigenous children and adolescents of the Peruvian Amazon live in precarious conditions that could increase the risk of malnutrition. A particular problem in the Corrientes river communities is the high exposure to lead among children and adolescents. Objective: This study aimed to determine the nutritional status of children and adolescents in indigenous communities in the Corrientes river basin and examine risk factors for anemia, stunting, underweight, and wasting. Design: This was a cross-sectional assessment in children and adolescents aged 0-17 years from six communities (n = 330). Data collection included measurement of hemoglobin levels, anthropometrics, blood lead levels (BLLs); a parental questionnaire including demographic and dwelling information; parents' occupation; and the child's duration of breastfeeding and food consumption. Analysis included univariate, bivariate, and logistic regression. Results: Overall, anemia prevalence was 51.0%, stunting (proxy for chronic malnutrition) 50.0%, and underweight 20.0%. Bivariate analysis showed that anemia and underweight prevalence was higher in the 0-4 years group (p<0.05). No association was found between anemia, stunting, or underweight with gender, community exposure to oil activity, or consumption of river water. Stunting prevalence was higher in the group whose BLLs were >5 mu g/dL (p<0.05). In the logistic regression analysis, no variable was associated with anemia or underweight. The group 5-11 years and >12 years had 1.9 and 3.1 times higher risk of stunting than the group under five years, respectively. Children and adolescents with BLLs >5 mu g/dL had twice the risk of stunting compared to those with lower BLLs. Conclusions: Half of the study population was found with anemia and stunting. Anemia was more prevalent in the 0- to 5-year age group and stunting in the 12- to 17-year group. The association between stunting and BLLs might be attributed to a direct effect of lead on human growth. Also, poor nutrition and other socioeconomic-related factors may contribute to the simultaneous existence of stunting and elevated BLLs.

Background: The COVID-19 pandemic prompted varied policy responses globally, with LatinAmerica facing unique challenges. A detailed examination of these policies’ impacts on healthsystems is crucial, particularly in Bolivia, where information about policy implementation andoutcomes is limited.

Objective: To describe the COVID-19 testing trends and evaluate the effects of quarantinemeasures on these trends in Cochabamba, Bolivia.

Methods: Utilizing COVID-19 testing data from the Cochabamba Department Health Servicefor the 2020–2022 period. Stratified testing rates in the health system sectors were firstestimated followed by an interrupted time series analysis using a quasi-Poisson regressionmodel for assessing the quarantine effects on the mitigation of cases during surge periods.

Results: The public sector reported the larger percentage of tests (65%), followed by theprivate sector (23%) with almost double as many tests as the public-social security sector(11%). In the time series analysis, a correlation between the implementation of quarantinepolicies and a decrease in the slope of positive rates of COVID-19 cases was observedcompared to periods without or with reduced quarantine policies.

Conclusion: This research underscores the local health system disparities and the effective-ness of stringent quarantine measures in curbing COVID-19 transmission in the Cochabambaregion. The findings stress the importance of the measures’ intensity and duration, providingvaluable lessons for Bolivia and beyond. As the global community learns from the pandemic,these insights are critical for shaping resilient and effective health policy responses.

Background: Nutrition is the intake of food in relation to the body's dietary needs. Malnutrition results from the intake of inadequate or excess food. This can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity. Objective: To perform a systematic review to assess research conducted by the International Network for the Demographic Evaluation of Populations and their Health (INDEPTH) of health and demographic surveillance systems (HDSSs) over a 15-year period on malnutrition, its determinants, the effects of under and over nutrition, and intervention research on malnutrition in low- and middle-income countries (LMICs). Methods: Relevant publication titles were uploaded onto the Zotero research tool from different databases (60% from PubMed). Using the keywords 'nutrition', 'malnutrition', 'over and under nutrition', we selected publications that were based only on data generated through the longitudinal HDSS platform. All titles and abstracts were screened to determine inclusion eligibility and full articles were independently assessed according to inclusion/exclusion criteria. For inclusion in this study, papers had to cover research on at least one of the following topics: the problem of malnutrition, its determinants, its effects, and intervention research on malnutrition. One hundred and forty eight paperswere identified and reviewed, and 67 were selected for this study. Results: The INDEPTH research identified rising levels of overweight and obesity, sometimes in the same settings as under-nutrition. Urbanisation appears to be protective against under-nutrition, but it heightens the risk of obesity. Appropriately timed breastfeeding interventions were protective against malnutrition. Conclusions: Although INDEPTH has expanded the global knowledge base on nutrition, many questions remain unresolved. There is a need for more investment in nutrition research in LMICs in order to generate evidence to inform policies in these settings.

BACKGROUND: Tobacco use is the most preventable cause of premature death and disability. Even though tobacco use is common in many Asian countries, reliable and comparable data on the burden imposed by tobacco use in this region are sparse, and surveillance systems to track trends are in their infancy.

OBJECTIVE: To assess and compare the prevalence of tobacco use and its associated factors in nine selected rural sites in five Asian countries.

METHODS: Tobacco use among 9,208 men and 9,221 women aged 25-64 years in nine Health and Demographic Surveillance System (HDSS) sites in five Asian countries of the INDEPTH Network were examined in 2005 as part of a broader survey of the major chronic non-communicable disease risk factors. All sites used a standardised protocol based on the WHO STEPS approach to risk factor surveillance; expanded questions of local relevance, including chewing tobacco, were also included. Multivariable logistic regression was used to assess demographic factors associated with tobacco use.

RESULTS: Tobacco use, whether smoked or chewed, was common across all sites with some notable variations. More than 50% of men smoked daily; this applied to almost all age groups. Few women smoked daily in any of the sites. However, women were more likely to chew tobacco than men in all sites except Vadu in India. Tobacco use in men began in late adolescence in most of the sites and the number of cigarettes smoked daily ranged from three to 15. Use of both forms of tobacco, smoked and chewed, was associated with age, gender and education. Men were more likely to smoke compared to women, smoking increased with age in the four sites in Bangladesh but not in other sites and with low level of education in all the sites.

CONCLUSION: The prevalence of tobacco use, regardless of the type of tobacco, was high among men in all of these rural populations with tobacco use started during adolescence in all HDSS sites. Innovative communication strategies for behaviour change targeting adolescents in schools and adult men and women at work or at home, may create a mass awareness about adverse health consequences of tobacco smoking or chewing tobacco. Such efforts, to be effective, however, need to be supported by strong legislation and leadership. Only four of the five countries involved in this multi-site study have ratified the Framework Convention on Tobacco Control, and even where it has been ratified, implementation is uneven.

Background: Suicide ideation is a health issue affecting adolescents worldwide. There are significant variations in suicide ideation between countries and genders, which have not been fully explained. Research is especially lacking in countries outside Europe and North America. Gender equality has been shown to matter in other aspects of adolescent mental health, such as life satisfaction, but has not been researched in relation to suicide ideation at national level.

Objective: To investigate how national gender inequality is related to self-reported suicide ideation among adolescents, and whether this association differs between boys and girls.

Methods: This is a cross-national, cross-sectional study using individual survey data from the Global School-based Student Health Survey, a survey in Africa, Asia, Latin America and the South Pacific, developed and supported by among others the WHO and the CDC; connecting this to national data: the gender inequality index from the UNDP; controlling for GDP per capita and secondary school enrolment. The data was analysed using a multilevel logistic regression method and included 149,306 students from 37 countries.

Results: Higher national gender inequality, as measured by the gender inequality index, was significantly associated with a higher likelihood of suicide ideation in both girls and boys (odds ratio: 1.38 p-value: 0.015), but for girls and both sexes this was only after adjusting for selection bias due to secondary school enrolment (as well as GDP/capita). Interaction models showed that this association was stronger in boys than in girls.

Conclusions: National gender inequality seems to be associated with higher levels of suicide ideation among adolescents in mainly low- and middle-income countries, especially among boys.

BACKGROUND: Globally, alcohol use significantly contributes to the disease burden. Alcohol consumption in Uganda is related to several health consequences among young people, including university students. Social media is commonly used by students to share academic information and create social networks. Among young people in high-income countries, previous studies have also shown that social media use can have negative health outcomes related to alcohol use, and associated problems. To date, similar studies conducted in low- and middle-income countries are largely missing.

OBJECTIVE: To assess the prevalence of and associations between social media use and alcohol consumption among university students in Uganda.

METHOD: This was a cross-sectional study among 996 undergraduate students at Makerere University. Data were collected using a questionnaire. Alcohol use in the previous 12 months was the dependent variable. The independent variable was social media use categorised as general use, alcohol-related use, and social media lurking/passive participation. Multinomial logistic regression was used to assess associations. Crude and adjusted odds ratios were reported.

RESULTS: Nearly all students (97%) used social media and 39% reported alcohol use. Regular alcohol use was significantly associated with moderate (OR = 2.22, CI: 1.35-3.66) and high level general social media use (OR = 2.45, CI: 1.43-4.20). Regular alcohol use was also associated with alcohol-related social media (OR = 6.46, CI: 4.04-10.30), and alcohol-related lurking (OR = 4.59, CI: 2.84-7.39). Similar, although weaker associations were identified for occasional alcohol use.

CONCLUSIONS: Approximately four in ten students reported alcohol use in the past year, and almost all students used social media. Alcohol-related social media use was associated with occasional and regular alcohol use, with stronger associations for regular use. These findings may guide further research and present an opportunity for potential alcohol control interventions to improve health among young populations in low- and middle-income countries.

Background: Cash Transfer (CT) schemes have become popular poverty reducing measures in many low and middle-income countries. Research indicates that when provided to girls in resource poor settings, cash transfers can increase education and postpone marriage and pregnancy. However, a few studies indicate that they can also have negative effects which can affect their acceptability, such as generating intra-community tensions.

Objective: Conceptually informed by Rogers’ diffusion of innovation theory, this paper explores factors affecting the acceptability of economic support in a randomized controlled trial in rural Monze and Pemba Districts of Southern Province in Zambia.

Methods: Qualitative data were collected through five focus group discussions and six in-depth, semi-structured interviews and analysed using thematic analysis. This study was done in the combined arm of a trial where girls received both economic support and participated in youth clubs offering sexuality and life-skills education.

Results: In the study communities, acceptability was encouraging by the belief that economic support provided benefits beyond beneficiaries and that it improved access to education, and reduced teen pregnancies, marriages and school drop-out. However, provision of economic support only to selected girls and their parents and fear among some that the support was linked to satanic practices negatively affected acceptability. These fears were mitigated through community sensitisations.

Conclusion: The study demonstrated that relative advantage, observability, simplicity and compatibility were key factors in influencing acceptability of the economic support. However, to enhance acceptability of cash transfer schemes aimed at addressing early marriage and pregnancy, it is important to explore socio-cultural factors that create suspicions and negative perceptions and to provide schemes that are perceived as relatively better than available similar schemes, understood, compatible and viable beyond the immediate beneficiary.

The rapid increase in mobile phone use and other telecommunication technologies in health care during the past decade has paved the way for optimism. mHealth (mobile health) initiatives need to be integrated into national health systems and priorities and fit into the system that the country has already invested in. Partnership between government, regional governments, health care systems, Community Health Workers, the private sector and universities is considered as a precondition for success. In turn, this requires strategic and integrative policy decisions on the national/regional level to be defined in the action plans as concrete steps. Decision makers are calling for scale-up plans to be in place even in the pilot phases. Hope is expressed that the initial joy and curiosity that new technology generates in the implementation phase will be transferred to routine work. Standards and a common technical architecture that enables interoperability and upscaling are key issues. Based on publications on policy and national strategies, this paper highlights some key areas for decision makers' role and expectations with regard to mHealth. The paper will also report some mHealth experiences from Ethiopia, Ghana and Sweden.

Background: Although the sexual and reproductive health and rights (SRHR) of young people and migrants should be prioritised, young migrants’ sexual and reproductive health (SRH) is rarely studied in Sweden.

Objectives: To explore young migrants’ understanding and experiences of sexual rights and examine their perceptions and experiences in accessing SRH services.

Methods: This is a mixed method study including a national survey that recruited 1773 newly arrived young migrants; a youth clinic survey that recruited 1089 youths after visiting youth clinics; and a qualitative study that included 13 interviews with newly arrived Arabic-speaking migrant men. The results are synthesised using a new ecological framework of access to understand the factors influencing young migrant access to health care based on the levels of the ecological model and the five steps of access: approachability, acceptability, adequacy, affordability, and quality.

Results: Young migrants understood SRH as both ‘essential’ and ‘a right.’ Their sexual rights were less fulfiled compared to other young people in Sweden, particularly for men, non-binary, LGBTQ+, those born in South Asia, without a residence permit, and those of low economic conditions. SRH services were largely unapproachable as almost half of those who needed them did not utilise them. Services were generally acceptable due to the ‘open environment,’ however, some young migrants faced cultural insensitivity, fear of exposure, low parental support, and long waiting times. SRH services’ quality was perceived as good, however, negative experiences were reported, particularly in the domains of respect, equity, privacy, non-prejudice, and consultation quality.

Conclusion: The access of young migrants to SRH services is facilitated by an ‘open environment’ and available and good quality services; however, they faced serious barriers such as limited access to information about the health system, comprehensive sexual education, lack of cultural sensitivity, and cultural racism.

The aim of this study was to assess the dimensionality of YFHS-Swe and identify possible unique factors in the evaluation of youth-friendliness. YFHS-Swe was answered by 1110 youths aged 16 to 25 years visiting youth clinics in Northern Sweden. Thirteen factors were identified by exploratory factor analysis and except for one factor they all proved to fit well and have good reliability when assessed by the confirmatory factor analysis. The YFHS-Swe proved to be credible and suitable for assessing youth-friendliness of differentiated health services in Sweden. With cultural and linguistic adaptations, it can be used in similar settings internationally.

Background: HIV/AIDS prevention has historically encountered many obstacles. Understanding the factors affecting HIV/AIDS prevention is central to designing and implementing suitable context-specific interventions. Research relating to HIV prevention in the Middle East and North African region is required to address the gradually increasing HIV epidemic.

Objective: This study aimed to explore the perspectives of employees/health care professionals who are working or have worked within HIV prevention in Sudan and Yemen on the challenges and facilitating factors facing HIV prevention.

Methods: A qualitative approach was employed using an open-ended questionnaire. Sixteen stakeholders from governmental and non-governmental agencies participated in the study. The questionnaire focused on the various challenges and facilitating factors facing HIV prevention as well as proposed possible solutions from the perspectives of the participants. The data were analysed using thematic analysis.

Results: The study illustrated the similarities in context and HIV prevention systems between Sudan and Yemen. Thematic analysis resulted in three main themes: I) much is achieved despite difficulties; II) a programme left to be paralysed; this theme addressed the main obstacles facing HIV prevention in Sudan and Yemen generating a total of six sub-themes; III) comprehensive change is needed. The participants drew focus and attention to vital changes required to improve the delivery of HIV prevention services. Conclusion: Increased financial support for HIV prevention in Sudan and Yemen is urgently needed. De-stigmatisation and increased political support, advocacy and improved legislation for people living with HIV (PLHIV) are required for the sustainability and effectiveness of HIV prevention programmes in Sudan and Yemen. Civil society organisations must be aided and supported in their role in engaging key populations.

BACKGROUND: Current guidelines for the conduct of cost-effectiveness analysis (CEA) are mainly applicable to facility-based interventions in high-income settings. Differences in the unit of analysis and the high cost of data collection can make these guidelines challenging to follow within public health trials in low- and middle- income settings.

OBJECTIVE: This paper reflects on the challenges experienced within our own work and proposes solutions that may be useful to others attempting to collect, analyse, and compare cost data between public health research sites in low- and middle- income countries.

DESIGN: We describe the generally accepted methods (norms) for collecting and analysing cost data in a single-site trial from the provider perspective. We then describe our own experience applying these methods within eight comparable cluster randomised, controlled, trials. We describe the strategies used to maximise adherence to the norm, highlight ways in which we deviated from the norm, and reflect on the learning and limitations that resulted.

RESULTS: When the expenses incurred by a number of small research sites are used to estimate the cost-effectiveness of delivering an intervention on a national scale, then deciding which expenses constitute 'start-up' costs will be a nontrivial decision that may differ among sites. Similarly, the decision to include or exclude research or monitoring and evaluation costs can have a significant impact on the findings. We separated out research costs and argued that monitoring and evaluation costs should be reported as part of the total trial cost. The human resource constraints that we experienced are also likely to be common to other trials. As we did not have an economist in each site, we collaborated with key personnel at each site who were trained to use a standardised cost collection tool. This approach both accommodated our resource constraints and served as a knowledge sharing and capacity building process within the research teams.

CONCLUSIONS: Given the practical reality of conducting randomised, controlled trials of public health interventions in low- and middle- income countries, it is not always possible to adhere to prescribed guidelines for the analysis of cost effectiveness. Compromises are frequently required as researchers seek a pragmatic balance between rigor and feasibility. There is no single solution to this tension but researchers are encouraged to be mindful of the limitations that accompany compromise, whilst being reassured that meaningful analyses can still be conducted with the resulting data.

AIM: The Västerbotten Intervention Programme (VIP) addresses cardiovascular disease and diabetes in the middle-aged population of Västerbotten County, Sweden. Self-reported health (SRH) is one of the risk factors for both conditions. The aim of this study was to analyse the development patterns of SRH among the VIP participants.

METHODS: Cross-sectional data from 1990 to 2007 were used to analyse the prevalence of poor SRH among 101,396 VIP participants aged 40-60 years. Panel data were used to study the change in SRH among 25,695 persons aged 30-60 years, who participated in the VIP twice within a 10-year interval.

RESULTS: Prevalence of poor SRH fluctuated between 1990 and 2007 in Västerbotten County. There was a temporary decline around 2000, with SRH continuously improving thereafter. The majority of panel participants remained in good SRH; over half of those with poor or fair SRH at baseline reported better SRH at follow-up. SRH declined in 19% of the panel participants, mostly among those who had good SRH at the baseline. The decline was common among both women and men, in all educational, age and marital status groups.

CONCLUSIONS: The SRH improvement among those with poor and fair SRH at baseline suggests that VIP has been successful in addressing its target population. However, the deterioration of SRH among 21% of the individuals with good SRH at baseline is of concern. From a public health perspective, it is important for health interventions to address not only the risk group but also those with a healthy profile to prevent the negative development among the seemingly healthy participants.

Background: National surveys in low-income countries increasingly rely on self-reported measures of health. The ease, speed, and economy of collecting self-reports of health make such collection attractive for rapid appraisals. However, the interpretation of these measures is complicated since different cultures understand and respond to the same question in different ways. Objective: The aim of this pilot study was to develop a culturally sensitive tool to study the self-reported health (SRH) of the local adult population in Burkina Faso. Design: The study was carried out in the 2009 rainy season. The sample included 27 men and 25 women aged 18 or older who live in semi-urban Nouna, Burkina Faso. Three culturally adapted instruments were tested: a SRH question, a wooden visual analogue scale (VAS), and a drawn VAS. Respondents were asked to explain their answers to each instrument. The narratives were analyzed with the content analysis technique, and the prevalence of poor SRH was estimated from the quantitative data by stratification for respondent background variables (sex, age, literacy, education, marital status, ethnicity, chronic diseases). The correlation between the instruments was tested with Spearman's correlation test. Results: The SRH question showed a 38.5% prevalence of poor SRH and 44.2% prevalence with both VAS. The correlation between the VAS was 0.89, whereas the correlation between the VAS and the SRH question was 0.60-0.64. Nevertheless, the question used as the basis of each instrument was culturally sensitive and clear to all respondents. Analysis of the narratives shows that respondents clearly differentiated between the various health statuses. Conclusion: In this pilot, we developed and tested a new version of the SRH question that may be more culturally sensitive than its non-adapted equivalents. Additional insight into this population's understanding and reporting of health was also obtained. A larger sample is needed to further study the validity and reliability of the SRH question and the VAS and understand which instrument is best suited to study SRH in the low-income setting of semi-rural Burkina Faso.

Sampling rules do not apply in a Health and Demographic Surveillance System (HDSS) that covers exhaustively a district-level population and is not meant to be representative of a national population. We highlight the advantages of HDSS data for causal analysis and identify in the literature the principles of conditional generalisation that best apply to HDSS. A probabilistic view on HDSS data is still justified by the need to model complex causal inference. Accounting for contextual knowledge, reducing omitted-variable bias, detailing order of events, and high statistical power brings credence to HDSS data. Generalisation of causal mechanisms identified in HDSS data is consolidated through systematic comparison and triangulation with national or international data.

Despite a growing awareness of Africans' vulnerability to climate change, there is relatively little empirical evidence published about the effects of climate on population health in Africa. This review brings together some of the generalised predictions about the potential continent-wide effects of climate change with examples of the relatively few locally documented population studies in which climate change and health interact. Although ecologically determined diseases such as malaria are obvious candidates for susceptibility to climate change, wider health effects also need to be considered, particularly among populations where adequacy of food and water supplies may already be marginal.

Background: The outbreak of COVID-19 in China in early 2020 provides a rich data source for exploring the ecological determinants of this new infection, which may be of relevance as the pandemic develops.

Objectives: Assessing the spread of the COVID-19 across China, in relation to associations between cases and ecological factors including population density, temperature, solar radiation and precipitation.

Methods: Open-access COVID-19 case data include 18,069 geo-located cases in China during January and February 2020, which were mapped onto a 0.25 degrees latitude/longitude grid together with population and weather data (temperature, solar radiation and precipitation). Of 15,539 grid cells, 559 (3.6%) contained at least one case, and these were used to construct a Poisson regression model of cell-weeks. Weather parameters were taken for the preceding week given the established 5-7 day incubation period for COVID-19. The dependent variable in the Poisson model was incident cases per cell-week and exposure was cell population, allowing for clustering of cells over weeks, to give incidence rate ratios.

Results: The overall COVID-19 incidence rate in cells with confirmed cases was 0.12 per 1,000. There was a single confirmed case in 113/559 (20.2%) of cells, while two grid cells recorded over 1,000 confirmed cases. Weekly means of maximum daily temperature varied from -28.0 degrees C to 30.1 degrees C, minimum daily temperature from -42.4 degrees C to 23.0 degrees C, maximum solar radiation from 0.04 to 2.74 MJm(-2) and total precipitation from 0 to 72.6 mm. Adjusted incidence rate ratios suggested brighter, warmer and drier conditions were associated with lower incidence.

Conclusion: Though not demonstrating cause and effect, there were appreciable associations between weather and COVID-19 incidence during the epidemic in China. This does not mean the pandemic will go away with summer weather but demonstrates the importance of using weather conditions in understanding and forecasting the spread of COVID-19.

BACKGROUND: Most analyses of global health use country as a unit of observation, not least because countries are intrinsic to health services and to many international organisations. However, this can mask geographical influences on population health, which do not respect political boundaries.

METHODS: A global anational database was constructed with one degree cells of latitude and longitude, and used to calculate densities for population and key health indicators. These data were aggregated into 240 15 degrees ansectors, 171 of which were populated. Differences in ansector rank orders between population density and health outcomes (infant, maternal and HIV-related deaths and income) were calculated and mapped as quintiles.

FINDINGS: Individual ansectors contained parts of 1-21 countries. Mapping by ansector showed that the four outcomes analysed were strongly geographically correlated. Sub-Saharan Africa was consistently disadvantaged in terms of health outcomes, while the Indian sub-continent was at an advantage in terms of HIV mortality, despite poverty.

INTERPRETATION: Although in most cases it makes sense to analyse health on a national basis, these findings highlight the often unquestioned assumptions involved in doing so. Even if global patterns of health do not turn out so differently when analysed anationally, some major effects on health, such as climate change, are not nationally based, and should not necessarily be nationally analysed. Progress towards Millennium Development Goals must be evaluated on a population basis, rather than by counting countries achieving targets. Data files are available in Excel format and attached as separate files to this paper (see Supplementary files under Reading Tools online).

This editorial is based on a keynote address given at the International Conference on Global Public Health, Colombo, Sri Lanka, in December 2012. It accompanies a set of papers which were also presented at the conference. So far, these papers describe a range of global health issues, from the health status of the United Arab Emirates through to social determinants of health in India. Two papers from Rwanda and India consider specific aspects of oral public health, which was a major sub-theme of the conference.

BACKGROUND: Reliable population-based data on HIV infection and AIDS mortality in sub-Saharan Africa are scanty, even though that is the region where most of the world's AIDS deaths occur. There is therefore a great need for reliable and valid public health tools for assessing AIDS mortality.

OBJECTIVE: The aim of this article is to validate the InterVA-4 verbal autopsy (VA) interpretative model within African populations where HIV sero-status is recorded on a prospective basis, and examine the distribution of cause-specific mortality among HIV-positive and HIV-negative people.

DESIGN: Data from six sites of the Alpha Network, including HIV sero-status and VA interviews, were pooled. VA data according to the 2012 WHO format were extracted, and processed using the InterVA-4 model into likely causes of death. The model was blinded to the sero-status data. Cases with known pre-mortem HIV infection status were used to determine the specificity with which InterVA-4 could attribute HIV/AIDS as a cause of death. Cause-specific mortality fractions by HIV infection status were calculated, and a person-time model was built to analyse adjusted cause-specific mortality rate ratios.

RESULTS: The InterVA-4 model identified HIV/AIDS-related deaths with a specificity of 90.1% (95% CI 88.7-91.4%). Overall sensitivity could not be calculated, because HIV-positive people die from a range of causes. In a person-time model including 1,739 deaths in 1,161,688 HIV-negative person-years observed and 2,890 deaths in 75,110 HIV-positive person-years observed, the mortality ratio HIV-positive:negative was 29.0 (95% CI 27.1-31.0), after adjustment for age, sex, and study site. Cause-specific HIV-positive:negative mortality ratios for acute respiratory infections, HIV/AIDS-related deaths, meningitis, tuberculosis, and malnutrition were higher than the all-cause ratio; all causes had HIV-positive:negative mortality ratios significantly higher than unity.

CONCLUSIONS: These results were generally consistent with relatively small post-mortem and hospital-based diagnosis studies in the literature. The high specificity in cause of death attribution achieved in relation to HIV status, and large differences between specific causes by HIV status, show that InterVA-4 is an effective and valid tool for assessing HIV-related mortality.

Background: Verbal autopsy (VA) is the only available approach for determining the cause of many deaths, where routine certification is not in place. Therefore, it is important to use standards and methods for VA that maximise efficiency, consistency and comparability. The World Health Organization (WHO) has led the development of the 2012 WHO VA instrument as a new standard, intended both as a research tool and for routine registration of deaths. Objective: A new public-domain probabilistic model for interpreting VA data, InterVA-4, is described, which builds on previous versions and is aligned with the 2012 WHO VA instrument. Design: The new model has been designed to use the VA input indicators defined in the 2012 WHO VA instrument and to deliver causes of death compatible with the International Classification of Diseases version 10 (ICD-10) categorised into 62 groups as defined in the 2012 WHO VA instrument. In addition, known shortcomings of previous InterVA models have been addressed in this revision, as well as integrating other work on maternal and perinatal deaths. Results: The InterVA-4 model is presented here to facilitate its widespread use and to enable further field evaluation to take place. Results from a demonstration dataset from Agincourt, South Africa, show continuity of interpretation between InterVA-3 and InterVA-4, as well as differences reflecting specific issues addressed in the design and development of InterVA-4. Conclusions: InterVA-4 is made freely available as a new standard model for interpreting VA data into causes of death. It can be used for determining cause of death both in research settings and for routine registration. Further validation opportunities will be explored. These developments in cause of death registration are likely to substantially increase the global coverage of cause-specific mortality data.

BACKGROUND: Despite indications that infection-related mortality in sub-Saharan Africa may be decreasing and the burden of non-communicable diseases increasing, the overwhelming reality is that health information systems across most of sub-Saharan Africa remain too weak to track epidemiological transition in a meaningful and effective way.

PROPOSALS: We propose a minimum dataset as the basis of a functional health information system in countries where health information is lacking. This would involve continuous monitoring of cause-specific mortality through routine civil registration, regular documentation of exposure to leading risk factors, and monitoring effective coverage of key preventive and curative interventions in the health sector. Consideration must be given as to how these minimum data requirements can be effectively integrated within national health information systems, what methods and tools are needed, and ensuring that ethical and political issues are addressed. A more strategic approach to health information systems in sub-Saharan African countries, along these lines, is essential if epidemiological changes are to be tracked effectively for the benefit of local health planners and policy makers.

CONCLUSION: African countries have a unique opportunity to capitalize on modern information and communications technology in order to achieve this. Methodological standards need to be established and political momentum fostered so that the African continent's health status can be reliably tracked. This will greatly strengthen the evidence base for health policies and facilitate the effective delivery of services.

Background: Mortality in a population may be clustered in space and time for a variety of reasons, including geography, socio-economics, environment and demographics. Analysing mortality clusters can therefore reveal important insights into patterns and risks of mortality in a particular setting. Objective and design: To investigate the extent of spatio-temporal clustering of mortality in the Butajira District, Ethiopia, from 1987 to 2008. The Health and Demographic Surveillance System (HDSS) dataset recorded 10,696 deaths among 951,842 person-years of observation, with each death located by household, in which population time at risk was also recorded. The surveyed population increased from 28,614 in 1987 to 62,322 in 2008, in an area approximately 25 km in diameter. Spatio-temporal clustering analyses were conducted for overall mortality and by specific age groups, grouping the population into a 0.01° latitude-longitude grid. Results: A number of significantly high- and low-mortality clusters were identified at various times and places. Butajira town was characterised by significantly low mortality throughout the period. A previously documented major mortality crisis in 1998-1999, largely resulting from malaria and diarrhoea, dominated the clustering analysis. Other local high-mortality clusters, appreciably attributable to meningitis, malaria and diarrhoea, occurred in the earlier part of the period. In the later years, a more homogeneous distribution of mortality at lower rates was observed. Conclusions: Mortality was by no means randomly distributed in this community during the period of observation. The clustering analyses revealed a clear epidemiological transition, away from localised infectious epidemics, over a generation.

Global health currently finds itself in an exciting, almost bewildering, state of flux. A plethora of initiatives, statements, high-level meetings, and other activities are generating a continuous flow of new ideas, with the impetus at least partly driven by the advent of the 2015 target date set for the Millennium Development Goals that were adopted in 2000. Whatever shape the post-2015 global health landscape may eventually take, it is already clear that there will be new targets of some kind as the world tries to make further progress on some of the less tractable health issues.

Background: It is widely accepted that assessing the impact of heat on populations is an important aspect of climate change research. However, this raises questions about how best to measure people’s exposure to heat under everyday living conditions in more detail than is possible by relying on nearby sources of meteorological data. Objective: This study aimed to investigate practical and viable approaches to measuring air temperature and humidity within a population, making comparisons with contemporaneous external data sources. This was done in a rural South African population during the subtropical summer season. Results: Air temperature and humidity were measured indoors and outdoors at three locations over 10 days and the datalogger technology proved reliable and easy to use. There was little variation in measurements over distances of 10 km. Conclusions: Small battery-powered automatic dataloggers proved to be a feasible option for collecting weather data among a rural South African population. These data were consistent with external sources but offered more local detail. Detailed local contemporary data may also allow post hoc modelling of previously unmeasured local weather data in conjunction with global gridded climate models.

BACKGROUND: The amount a government should be willing to invest in adopting new medical treatments has long been under debate. With many countries using formal cost-effectiveness (C/E) thresholds when examining potential new treatments and ever-growing medical costs, accurately setting the level of a C/E threshold can be essential for an efficient healthcare system.

OBJECTIVES: The aim of this systematic review is to describe the prominent approaches to setting a C/E threshold, compile available national-level C/E threshold data and willingness-to-pay (WTP) data, and to discern whether associations exist between these values, gross domestic product (GDP) and health-adjusted life expectancy (HALE). This review further examines current obstacles faced with the presently available data.

METHODS: A systematic review was performed to collect articles which have studied national C/E thresholds and willingness-to-pay (WTP) per quality-adjusted life year (QALY) in the general population. Associations between GDP, HALE, WTP, and C/E thresholds were analyzed with correlations.

RESULTS: Seventeen countries were identified from nine unique sources to have formal C/E thresholds within our inclusion criteria. Thirteen countries from nine sources were identified to have WTP per QALY data within our inclusion criteria. Two possible associations were identified: C/E thresholds with HALE (quadratic correlation of 0.63), and C/E thresholds with GDP per capita (polynomial correlation of 0.84). However, these results are based on few observations and therefore firm conclusions cannot be made.

CONCLUSIONS: Most national C/E thresholds identified in our review fall within the WHO's recommended range of one-to-three times GDP per capita. However, the quality and quantity of data available regarding national average WTP per QALY, opportunity costs, and C/E thresholds is poor in comparison to the importance of adequate investment in healthcare. There exists an obvious risk that countries might either over- or underinvest in healthcare if they base their decision-making process on erroneous presumptions or non-evidence-based methodologies. The commonly referred to value of 100,000$ USD per QALY may potentially have some basis.

Background: Unsafe abortion contributes to a significant portion of maternal mortality in India. Access to safe abortion care is known to reduce maternal mortality. Availability and distribution of abortion care facilities can influence women's access to these services, especially in rural areas. Objectives: To assess the availability and distribution of abortion care at facilities providing childbirth care in three districts of Madhya Pradesh (MP) province of India. Design: Three socio demographically heterogeneous districts of MP were selected for this study. Facilities conducting at least 10 deliveries a month were surveyed to assess availability and provision of abortion services using UN signal functions for emergency obstetric care. Geographical Information System was used for visualisation of the distribution of facilities. Results: The three districts had 99 facilities that conducted > 10 deliveries a month: 74 in public and 25 in private sector. Overall, 48% of facilities reported an ability to provide safe surgical abortion service. Of public centres, 32% reported the ability compared to 100% among private centres while 18% of public centres and 77% of private centres had performed an abortion in the last 3 months. The availability of abortion services was higher at higher facility levels with better equipped and skilled personnel availability, in urban areas and in private sector facilities. Conclusions: Findings showed that availability of safe abortion care is limited especially in rural areas. More emphasis on providing safe abortion services, particularly at primary care level, is important to more significantly dent maternal mortality in India.

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.

Background: Understanding socioeconomic disparities in all-cause and cause-specific mortality can help inform prevention and treatment strategies.

Objectives: To quantify cause-specific mortality rates by socioeconomic status across seven health and demographic surveillance systems (HDSS) in five countries (Ethiopia, Kenya, Malawi, Mozambique, and Nigeria) in the INDEPTH Network in sub-Saharan Africa.

Methods: We linked demographic residence data with household survey data containing living standards and education information we used to create a poverty index. Person-years lived and deaths between 2003 and 2016 (periods varied by HDSS) were stratified in each HDSS by age, sex, year, and number of deprivations on the poverty index (0-8). Causes of death were assigned to each death using the InterVA-4 model based on responses to verbal autopsy questionnaires. We estimated rate ratios between socioeconomic groups (2-4 and 5-8 deprivations on our poverty index compared to 0-2 deprivations) for specific causes of death and calculated life expectancy for the deprivation groups.

Results: Our pooled data contained almost 3.5 million person-years of observation and 25,038 deaths. All-cause mortality rates were higher among people in households with 5-8 deprivations on our poverty index compared to 0-2 deprivations, controlling for age, sex, and year (rate ratios ranged 1.42 to 2.06 across HDSS sites). The poorest group had consistently higher death rates in communicable, maternal, neonatal, and nutritional conditions (rate ratios ranged 1.34-4.05) and for non-communicable diseases in several sites (1.14-1.93). The disparities in mortality between 5-8 deprivation groups and 0-2 deprivation groups led to lower life expectancy in the higher-deprivation groups by six years in all sites and more than 10 years in five sites.

Conclusions: We show large disparities in mortality on the basis of socioeconomic status across seven HDSS in sub-Saharan Africa due to disparities in communicable disease mortality and from non-communicable diseases in some sites. Life expectancy gaps between socioeconomic groups within sites were similar to the gaps between high-income and lower-middle-income countries. Prevention and treatment efforts can benefit from understanding subpopulations facing higher mortality from specific conditions.

Background:

Migration and urbanization are central to sustainable development and health, but data on temporal trends in defined populations are scarce. Healthy men and women migrate because opportunities for employment and betterment are not equally distributed geographically. The disruption can result in unhealthy exposures and environments and income returns for the origin household.

Objectives: The objectives of the paper are to describe the patterns, levels, and trends of temporary migration in rural northeast South Africa; the mortality trends by cause category over the period 2000-2011; and the associations between temporary migration and mortality by broad cause of death categories.

Method:

Longitudinal, Agincourt Health and Demographic Surveillance System data are used in a continuous, survival time, competing-risk model. Findings: In rural, northeast South Africa, temporary migration, which involves migrants relocating mainly for work purposes and remaining linked to the rural household, is more important than age and sex in explaining variations in mortality, whatever the cause. In this setting, the changing relationship between temporary migration and communicable disease mortality is primarily affected by reduced exposure of the migrant to unhealthy conditions. The study suggests that the changing relationship between temporary migration and non-communicable disease mortality is mainly affected by increased livelihood benefits of longer duration migration.

Conclusion: Since temporary migration is not associated with communicable diseases only, public health policies should account for population mobility whatever the targeted health risk. There is a need to strengthen the rural health care system, because migrants tend to return to the rural households when they need health care.

Background: NCDs are non-infectious, long-term conditions that account for 40 million deaths per annum. 87% of premature NCD mortality occurs in low- and middle-income countries.

Objective: The aims were:develop methods to provide integrated biosocial accounts of NCD mortality; and explore the practical utility of extended mortality data for the primary health care system.

Methods: We drew on data from research programmes in the study area. Data were analysed in three steps: [a]analysis of levels, causes and circumstances of NCD mortality [n = 4,166] from routine census updates including Verbal Autopsy and of qualitative data on lived experiences of NCDs in rural villages from participatory research; [b] identifying areas of convergence and divergence between the analyses; and [c]exploration of the practical relevance of the data drawing on engagements with health systems stakeholders.

Results: NCDs constituted a significant proportion of mortality in this setting [36%]. VA data revealed multiple barriers to access in end-of-life care. Many deaths were attributed to problems with resources and health systems [21%;19% respectively]. The qualitative research provided rich complementary detail on the processes through which risk originates, accumulates and is expressed in access to end-of-life care, related to chronic poverty and perceptions of poor quality care in clinics. The exploration of practical relevance revealed chronic under-funding for NCD services, and an acute need for robust, timely data on the NCD burden.

Conclusions: VA data allowed a significant burden of NCD mortality to be quantified and revealed barriers to access at and around the time of death. Qualitative research contextualised these barriers, providing explanations of how and why they exist and persist. Health systems analysis revealed shortages of resources allocated to NCDs and a need for robust research to provide locally relevant evidence to organise and deliver care. Pragmatic interdisciplinary and mixed method analysis provides relevant renditions of complex problems to inform more effective responses.