N Groce

Managing the health effects of climate change

Climate change is the biggest global health threat of the 21st century. Effects of climate change on health will affect most populations in the next decades and put the lives and wellbeing of billions of people at increased risk. During this century, earthﾒs average surface temperature rises are likely to exceed the safe threshold of 2ﾰC above preindustrial average temperature. Rises will be greater at higher latitudes, with medium-risk scenarios predicting 2ﾖ3ﾰC rises by 2090 and 4ﾖ5ﾰC rises in northern Canada, Greenland, and Siberia. In this report, we have outlined the major threatsﾗboth direct and indirectﾗto global health from climate change through changing patterns of disease, water and food insecurity, vulnerable shelter and human settlements, extreme climatic events, and population growth and migration. Although vector-borne diseases will expand their reach and death tolls, especially among elderly people, will increase because of heatwaves, the indirect effects of climate change on water, food security, and extreme climatic events are likely to have the biggest effect on global health.

Shaping cities for health: complexity and the planning of urban environments in the 21st century

3·4 billion people—about half the world’s population--live in urban areas, and this number might rise to 6·3 billion by 2050.1 The proportion of the global population living in cities will be 60% by 2030,2 a 72% increase in 30 years (figures 1 and ​and2).2). Urban growth will be greatest in Africa and Asia, followed by Latin America and Oceania.5 Even in long-established urban areas in Europe, urban population growth during that period will reach almost 5%.5 This growth will not only result in more megacities (cities of more than 10 million people), increasingly concentrated in Asia, but also in more medium-sized cities, especially in Africa. UN estimates are that about 1 billion people, nearly a sixth of the global population, live in slum-like conditions. With the worldwide population predicted to expand to 9 billion by 2030, the number of people living in slum-like conditions could reach 2 billion.5 Figure 1 World population growth, 1950-2050 Figure 2 Proportion of the world population living in urban areas The understanding of how urban environments affect health outcomes and can produce health benefits is therefore an urgent priority, as recognised by WHO in their declaration of 2010 as the Year of Urban Health. From this perspective, there are reasons to be optimistic. The idea of the so-called urban advantage encapsulates the health benefits of living in urban as opposed to rural areas. However, factors such as economic growth and associated urban expansion cannot be relied on to drive improvements in health outcomes. Health improvements need to be actively planned for. The Healthy Cities movement has appreciated this fact and generated much action. Assessments have, however, pointed to a gap between aspirations and outcomes and limitations in the coherence of the models behind action. In response to this problem, the UCL Lancet Commission met from November, 2009, to June, 2011, bringing together an interdisciplinary team of experts to under stand how better health outcomes can be delivered through interventions in the urban environment in cities across the world, and to generate policy recommendations. We began with the definition of health as both the absence of ill health and the presence of mental and physical wellbeing,6 and the urban environment as the physical context within which urban activities take place, including the material fabric of buildings and infrastructure and their spatial organisation. The Commission focused on the potential for shaping the urban environment for better health outcomes; we explicitly did not address the issue of health-service provision within cities, but acknowledge that this is a key component of urban policy. We undertook expert-led reviews of available studies and desk-top research into the connection between urban planning and health in more than a dozen cities, with additional information provided by Commission members who have experience of working in many of these cities. The work informed discussions at monthly meetings with experts in public health, planning, architecture, building physics, engineering, development studies, anthropology, and philosophy. The Commission developed an approach based on complexity thinking—an approach that looks at the interconnected elements of a system and how that system has properties not readily apparent from the properties of the individual elements—and used this approach to develop proposals for an effective way forward. We begin by addressing the arguments around the urban advantage idea and then review the work of the Healthy Cities movement in the promotion of action for urban health. We then set out a complex systems approach for the understanding of how urban environments affect urban health, followed by five short case studies of urban interventions: the inter-related domains of sanitation and water management, building standards and indoor health, transportation and the links to mobility, urban form and the urban heat island effect, and the promotion of urban agriculture. We then turn to the implications of our analysis for urban governance if effective interventions to improve urban health are to be delivered, concluding with recommendations for policy and practice.

Disability and Poverty: the need for a more nuanced understanding of implications for development policy and practice

Abstract The international development community is beginning to recognise that people with disabilities constitute among the poorest and most vulnerable of all groups, and thus must be a core issue in development policies and programmes. Yet the relationship between disability and poverty remains ill-defined and under-researched, with few studies providing robust and verifiable data that examine the intricacies of this relationship. A second, linked issue is the need for—and current lack of—criteria to assess whether and how disability-specific and disability ‘mainstreamed’ or ‘inclusive’ programmes work in combating the exclusion, marginalisation and poverty of people with disabilities. This article reviews existing knowledge and theory regarding the disability–poverty nexus. Using both established theoretical constructs and field-based data, it attempts to identify what knowledge gaps exist and need to be addressed with future research.

Surviving sepsis in low-income and middle-income countries: new directions for care and research

Sepsis is a disorder characterised by systemic inflammation secondary to infection. Despite recent progress in the understanding and treatment of sepsis, no data or recommendations exist that detail effective approaches to sepsis care in resource-limited low-income and middle-income countries (LMICs). Although few data exist on the burden of sepsis in LMICs, the prevalence of HIV and other comorbid conditions in some LMICs suggest that sepsis is a substantial contributor to mortality in these regions. In well-resourced countries, sepsis management relies on protocols and complex invasive technologies not widely available in most LMICs. However, the key concepts and components of sepsis management are potentially translatable to resource-limited environments. Health personnel in LMICs should be educated in the recognition of sepsis and the importance of early and appropriate antibiotic use. Simple and low-cost standardised laboratory testing should be emphasised to allow accurate diagnosis, prognosis, and monitoring of treatment response. Evidence-based interventions and treatment algorithms tailored to LMIC ecology and resources should thus be developed and validated.

The role of the extended family in women's risk of intimate partner violence in Jordan

The extended family as a potential cause of and protection against intimate partner violence (IPV) remains relatively unstudied. This mixed-methods study used focus group discussions (FGDs) and a clinic-based survey to investigate several family-based risk and protective factors associated with womens risk of IPV in Jordan. Seventeen FGDs (total number of participants = 105) were conducted with women in Amman. Each transcript was coded for categories using open coding methodology and mapping. Relevant categories and subcategories were family support, family interference, family abuse, exposure to violence in childhood, and place of residence. For the survey, systematic probability proportionate to size methodology was used to select a sample of 517 literate, ever married, women from seven reproductive health clinics located throughout the country (response rate = < or = 70%); due to missing data, the analytic sample was restricted to 418 women. Measures assessed the categories mentioned above. Bivariate and multivariate logistic regression models were constructed to examine the relationship between IPV and the main predictors of interest (residence, family interference, family violence, exposure to violence as a child, and family support). The combined results of the FGDs and the survey demonstrated that the respondents husbands exposure to violence in childhood and violence perpetrated by other family members were risk factors for IPV. Family interference was also significantly related to IPV but only when the respondent identified the interference as harmful to her relationship. Residence with the respondents in-laws demonstrated mixed effects. A supportive family was protective against IPV, although the FGDs revealed that families were not always an effective source of assistance. Findings demonstrate the continued role of the wifes and husbands kin in womens risk of IPV in Jordan, highlighting the importance of a broader view of the context of IPV.

HIV/AIDS and disability: Differences in HIV/AIDS knowledge between deaf and hearing people in Nigeria

Purpose. Studies both in North America and Europe have found that deaf individuals lack access to AIDS information, due to problems in communication, low literacy and tightly woven social networks within the deaf community. However few comparable studies are available from countries in the Developing World. The present study was undertaken in Nigeria where there is an estimated adult HIV prevalence rate of 5.4%. We sought to compare HIV knowledge among deaf and hearing individuals in order to identify how effectively deaf members of the community are being reached by HIV/AIDS messages. Methods. A survey comparing knowledge about HIV/AIDS among deaf and hard of hearing adolescents (n = 50) and young adults (n = 50) was undertaken. Results. Significant differences (p < 0.05) in levels of understanding about certain aspects of how AIDS is spread were identified as well as differences in available resources for access to accurate information among deaf members of the population. Conclusion. These findings from Nigeria speak strongly to the need for the development of interventions that include people with disabilities in public health and HIV/AIDS strategies and that address their specific vulnerabilities. Evaluating the adaptation of education material and the inclusion of the deaf population in HIV awareness programmes is an urgent ‘next step.’

Knowledge, personal risk and experiences of HIV/AIDS among people with disabilities in Swaziland

Although there has been research focused on the disabling consequences of HIV/AIDS, there has been very little documented information about HIV/AIDS for individuals with disability prior to infection. There is evidence to suggest that people with disabilities face inequalities in accessing health information and services. The aim of this study was to explore whether disabled and non-disabled young adults in Swaziland perceive HIV/AIDS similarly. A qualitative study using focus-group discussions was conducted. Four focus groups were conducted with a total of 56 non-disabled adults (aged 16–29 years) and four focus groups were conducted with a total of 32 adults with either a physical or hearing disability (aged 18–32 years). The focus-group schedule explored knowledge about HIV/AIDS, personal risk and experiences of health-seeking practices. Information and awareness about HIV/AIDS was good in both rural and urban areas among the non-disabled participants, who obtained their information from a wide range of sources. In contrast, participants with disability, who obtained information about HIV/AIDS from a limited range of sources, lacked knowledge about HIV/AIDS and were misinformed about modes of transmission. Women with disabilities described experiences of sexual exploitation and abuse, which was perceived to be higher among disabled women than their non-disabled peers; they felt this was because disabled women were perceived to be ‘free’ from the HIV virus by non-disabled men. Further research is necessary to enable HIV/AIDS programmes to address the specific needs of people with disabilities.

Access to health care, reproductive health and disability: A large scale survey in Sierra Leone

This is the first study to compare health status and access to health care services between disabled and non-disabled men and women in urban and peri-urban areas of Sierra Leone. It pays particular attention to access to reproductive health care services and maternal health care for disabled women. A cross-sectional study was conducted in 2009 in 5 districts of Sierra Leone, randomly selecting 17 clusters for a total sample of 425 households. All adults who were identified as being disabled, as well as a control group of randomly selected non-disabled adults, were interviewed about health and reproductive health. As expected, we showed that people with severe disabilities had less access to public health care services than non-disabled people after adjustment for other socioeconomic characteristics (bivariate modelling). However, there were no significant differences in reporting use of contraception between disabled and non-disabled people; contrary to expectations, women with disabilities were as likely to report access to maternal health care services as did non-disabled women. Rather than disability, it is socioeconomic inequality that governs access to such services. We also found that disabled women were as likely as non-disabled women to report having children and to desiring another child: they are not only sexually active, but also need access to reproductive health services. We conclude that disparity in access to government-supported health care facilities constitutes a major and persisting health inequity between persons with and without disabilities in Sierra Leone. Ensuring equal access will require further strengthening of the countrys health care system. Furthermore, because the morbidity and mortality rates of pregnant women are persistently high in Sierra Leone, assessing the quality of services received is an important priority for future research.

HIV issues and People with Disabilities: A Review and Agenda for Research

The recent AIDS and Disability Partners Forum at the UN General Assembly High Level Meetings on AIDS in New York in June 2011 and the International AIDS Conference in Washington, DC in July 2012 underscores the growing attention to the impact of HIV and AIDS on persons with disabilities. However, research on AIDS and disability, particularly a solid evidence base upon which to build policy and programming remains thin, scattered and difficult to access. In this review paper, we summarise what is currently known about the intersection between HIV and AIDS and disability, paying particular attention to the small but emerging body of epidemiology data on the prevalence of HIV for people with disabilities, as well as the increasing understanding of HIV risk factors for people with disabilities. We find that the number of papers in the peer-reviewed literature remains distressingly small. Over the past 20 years an average of 5 articles on some aspect of disability and HIV and AIDS were published annually in the peer-reviewed literature from 1990 to 2000, increasing slightly to an average of 6 per year from 2000 to 2010. Given the vast amount of research around HIV and AIDS and the thousands of articles on the subject published in the peer-reviewed literature annually, the continuing lack of attention to HIV and AIDS among this at risk population, now estimated to make up 15% of the worlds population, is striking. However, the statistics, while too limited at this point to make definitive conclusions, increasingly suggest at least an equal HIV prevalence rate for people with disabilities as for their non-disabled peers.

Women’s Experience of Group Prenatal Care

Group prenatal care (GPNC) is an innovative alternative to individual prenatal care. In this longitudinal study we used ethnographic methods to explore African American and Hispanic women’s experiences of receiving GPNC in two urban clinics. Methods included individual, in-depth, semistructured interviews of women and group leaders in GPNC, participant observation of GPNC sessions, and medical record review. GPNC offered positive experiences and met many of women’s expressed preferences regarding prenatal care. Six themes were identified, which represented separate aspects of women’s experiences: investment, collaborative venture, a social gathering, relationships with boundaries, learning in the group, and changing self. Taken together, the themes conveyed the overall experience of GPNC. Women were especially enthusiastic about learning in groups, about their relationships with group leaders, and about having their pregnancy-related changes and fears normalized; however, there were also important boundaries on relationships between participants, and some women wished for greater privacy during physical examinations.