Disability and sexual and reproductive health service utilisation in Uganda: an intersectional analysis of demographic and health surveys between 2006 and 2016

Background

The United Nations through universal health coverage, including sexual and reproductive health (SRH), pledges to include all people, leaving no one behind. However, people with disabilities continue to experience multiple barriers in accessing SRH services. Studies analysing the impacts of disability in conjunction with other social identities and health determinants reveal a complex pattern in SRH service use. Framed within a larger mixed methods study conducted in Uganda, we examined how disability, among other key social determinants of health (SDH), was associated with the use of SRH services.

Methods

We analysed data from repeated cross-sectional national surveys, the Uganda Demographic and Health Surveys (DHS) of 2006, 2011, and 2016. The three outcomes of interest were antenatal care visits, HIV testing, and modern contraception use. Our main exposure of interest was the type of disability, classified according to six functional dimensions: seeing, hearing, walking/climbing steps, remembering/concentrating, communicating, and self-care. We performed descriptive and multivariable logistic regression analyses, which controlled for covariates such as survey year, sex, age, place of residence, education, and wealth index. Interaction terms between disability and other factors such as sex, education, and wealth index were explored. Regression analyses were informed by an intersectionality framework to highlight social and health disparities within groups.

Results

From 2006 to 2016, 15.5-18.5% of study participants lived with some form of disability. Over the same period, the overall prevalence of at least four antenatal care visits increased from 48.3 to 61.0%, while overall HIV testing prevalence rose from 30.8 to 92.4% and the overall prevalence of modern contraception use increased from 18.6 to 34.2%. The DHS year, highest education level attained, and wealth index were the most consistent determinants of SRH service utilisation. People with different types of disabilities did not have the same SRH use patterns. Interactions between disability type and wealth index were associated with neither HIV testing nor the use of modern contraception. Women who were wealthy with hearing difficulty (Odds Ratio (OR) = 0.15, 95%CI 0.03 – 0.87) or with communication difficulty (OR = 0.17, 95%CI 0.03 – 0.82) had lower odds of having had optimal antenatal care visits compared to women without disabilities who were poorer.

Conclusion

This study provided evidence that SRH service use prevalence increased over time in Uganda and highlights the importance of studying SRH and the different disability types when examining SDH. The SDH are pivotal to the attainment of universal health coverage, including SRH services, for all people irrespective of their social identities.

Findings from a scoping review

OBJECTIVE

This scoping review aimed to identify how equity has been considered in large-scale infectious disease testing initiatives.

STUDY DESIGN AND SETTING

Large-scale testing interventions are instrumental for infectious disease control and a central tool for the coronavirus 19 (COVID-19) pandemic. We searched Web of Science: core collection, Embase and Medline in June 2021 and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations for scoping reviews. We critically analyzed the content of all included articles.

RESULTS

Our search resulted in 2448 studies of which 86 were included for data extraction after screening. Of the included articles, 80% reported on COVID-19 -related screening programs. None of the studies presented a formal definition of (in)equity in testing, however, 71 articles did indirectly include elements of equity through the justification of their target population. Of these 71 studies, 58% articles indirectly alluded to health equity according to the PROGRESS-Plus framework, an acronym used to identify a list of socially stratifying characteristics driving inequity in health outcomes.

CONCLUSION

The studies included in our scoping review did not explicitly consider equity in their design or evaluation which is imperative for the success of infectious disease testing programs.

How are large-scale One Health initiatives targeting infectious diseases and antimicrobial resistance evaluated? A scoping review

While One Health initiatives are gaining in popularity, it is unclear if and how they are evaluated when implementation at scale is intended. The main purpose of this scoping review was to describe how One Health initiatives targeting infectious diseases and antimicrobial resistance at a large scale are evaluated. Secondary objectives included identifying the main facilitators and barriers to the implementation and success of these initiatives, and how their impacts were assessed. Twenty-three studies evaluating One Health initiatives were eligible. Most studies included the human (n = 22) and animal (n = 15) sectors; only four included the environment sector. The types of evaluated initiative (non-exclusive) included governance (n = 5), knowledge (n = 6), protection (n = 17), promotion (n = 16), prevention (n = 9), care (n = 8), advocacy (n = 10) and capacity (n = 10). Studies used normative (n = 4) and evaluative (n = 20) approaches to assess the One Health initiatives, the latter including impact (n = 19), implementation (n = 8), and performance (n = 7) analyses. Structural and economic, social, political, communication and coordination-related factors, as well as ontological factors, were identified as both facilitators and barriers for successful One Health initiatives. These results identified a wide range of evaluation methods and indicators used to demonstrate One Health's added values, strengths, and limitations: the inherent complexity of the One Health approach leads to the use of multiple types of evaluation. The strengths and remaining gaps in the evaluation of such initiative highlight the relevance of comprehensive, mixed-method, context-sensitive evaluation frameworks to inform and support the implementation of One Health initiatives by stakeholders in different governance settings.

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Studies evaluating One Health initiatives were scarce.

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Only One Health initiatives related to infectious diseases were evaluated.

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Evaluations were mainly conducted using quantitative approaches.

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Involvement of the community was identified as a major facilitator.

Understanding and attenuating pandemic-related disruptions: a plan to reduce inequalities in child development

The Secretary General of the United Nations described the impact of COVID-19-related school closures as a "generational catastrophe." What will be the legacy of the 2020-2021 pandemic-related disruptions in 5, 10, 20 years from now, as regards education and well-being of children and youth? Addressing the disproportionate impact on those growing up in socio-economically disadvantaged areas or on those with pre-existing learning challenges is key to sustainable recovery. This commentary builds on the four literature reviews presented in this Special Section on a Pandemic Recovery Plan for Children and proposes strategies to understand and attenuate the impact of pandemic-related lockdown measures. Importantly, we need a monitoring strategy to assess indicators of child development in three areas of functioning: education and learning, health, and well-being (or mental health). Surveillance needs to begin in the critical prenatal period (with prenatal care to expectant parents), and extend to the end of formal high school/college education. Based on child development indicators, a stepped strategy for intervention, ranging from all-encompassing population-based health and education promotion initiatives to targeted prevention programs and targeted remedial/therapeutic interventions, can be offered. As proposed in the UN plan for recovery, ensuring healthy present and future generations involves a concerted and intensive intersectoral effort from the education, health, psychosocial services, and scientific communities.

Attitudes and Satisfaction toward the Taken Procedures to Tackle COVID-19 Pandemic in Palestine

Background

Since the beginning of the COVID-19 pandemic, there have been differences in the mitigation strategies implemented by governments worldwide. In addition, people's acceptance and adherence to these strategies, such as avoiding large gatherings and shelter in place, varied. The current study aims to assess the attitude and satisfaction with the procedures to tackle COVID-19 in Palestine.

Methods

This cross-sectional descriptive study was conducted in the Palestinian territories, including, Gaza Strip, West Bank, and East Jerusalem, between April 29, 2020, and June 5, 2020, using a validated online questionnaire. The questionnaire included three sections: socio-demographic characteristics, attitude towards the measures and behaviors to avoid COVID-19 infection and its consequences, and level of people satisfaction with the response of the community and local authorities to combat the COVID-19 pandemic. A convenience sampling method was used to select participants. Statistical analysis was performed using SPSS version 26.

Results

A total of 570 adults aged ≥18 years (56.3% males and 43.7% females) were included in the study. The mean positive attitude score (average % agree or strongly agree) was 94.22%; 95.24%, 95.18%, and 92.18% in the Gaza Strip, West Bank, and East Jerusalem, respectively. While, the mean satisfaction score was 44.26%, distributed as 47.16%, 46.1%, and 39.22% in the Gaza Strip, West Bank, and East Jerusalem, respectively. Additionally, there were statistically significant variations by most attitude and satisfaction variables across the governorates included in the study (p < 0.05). The current study demonstrated high levels of positive attitude but suboptimal level of satisfaction toward the taken procedures to tackle COVID-19 in Palestine.

Conclusions

Varied implementation strategies to improve the levels of satisfaction toward the approaches to combat the COVID-19 pandemic are recommended.

Preparedness and Readiness Strategies for Addressing the COVID-19 Pandemic in Fragile and Conflict Settings: Experiences of the Gaza Strip

The COVID-19 pandemic is a global public health threat of serious concern, especially in conflict settings that face fragility and lack adequate resources and capacities. Gaza suffers from a blockade imposed by the Israeli occupation, environmental deterioration, confiscation of lands, demolition of houses and hospitals, restrictions on movement, lack of control over natural resources, and financial constraints. Gaza's population is consequently living in a poor humanitarian situation with high unemployment rates, poverty, over-crowdedness, and a weak health system. This makes Gaza incredibly fragile and affects its ability to respond to the COVID-19 pandemic effectively. The pandemic is expected to deepen Gaza's systems' fragility, which is already overstretched beyond their limits. This will hinder its capacity to deal with the pandemic, and other pre-existing pressing humanitarian needs. Therefore, in this review, we comprehensively explored Gaza's policy failures and successes related to the COVID-19 preparedness and response by state and non-state actors and recommend potential solutions and alternatives. We have addressed critical issues including the health system, water, sanitation, hygiene, socio-economic, education, food security, and others. In Gaza, effectiveness in combating the COVID-19 pandemic can only come from committed political will, transparency from all regulators, strategic dialogue, comprehensive planning, and active international support.

Social inequalities in COVID-19 vaccine acceptance and uptake for children and adolescents in Montreal, Canada

Background

The success of current and prospective COVID-19 vaccine campaigns for children and adolescents will in part depend on the willingness of parents to accept vaccination. This study examined social determinants of parental COVID-19 vaccine acceptance and uptake for children and adolescents.

Methods

We used cross-sectional data from an ongoing COVID-19 cohort study in Montreal, Canada and included all parents of 2 to 18-year-olds who completed an online questionnaire between May 18 and June 26, 2021 (n = 809). We calculated child age-adjusted prevalence estimates of vaccine acceptance by parental education, race/ethnicity, birthplace, household income, and neighbourhood, and used multinomial logistic regression to estimate adjusted prevalence differences (aPD) and ratios (aPR). Social determinants of vaccine uptake were examined for the vaccine-eligible sample of 12 to 18 year-olds (n = 306).

Results

Intention to vaccinate children against COVID-19 was high, with only 12.4% of parents unlikely to have their child vaccinated. Parents with younger children were less likely to accept vaccination, as were those from lower-income households, racialized groups, and those born outside Canada. Children from households with annual incomes <$100,000 had 18.4 percent lower prevalence of being vaccinated/very likely vaccinated compared to household incomes ≥$150,000 (95% CI: 10.1 to 26.7). Racialized parents reported greater unwillingness to vaccinate vs. White parents (aPD = 10.3; 95% CI: 1.5, 19.1). Vaccine-eligible adolescents from the most deprived neighbourhood were half as likely to be vaccinated compared to those from the least deprived neighbourhood (aPR = 0.48; 95% CI: 0.18 to 0.77).

Interpretation.

This study identified marked social inequalities in COVID-19 vaccine acceptance and uptake for children and adolescents. Efforts are needed to reach disadvantaged and marginalized populations with tailored strategies that promote informed decision making and facilitate access to vaccination.

Seroprevalence of SARS-CoV-2 Antibodies Among Children in School and Day Care in Montreal, Canada

IMPORTANCE

Quebec prioritized in-person learning after the first wave of the COVID-19 pandemic, with school closures being implemented temporarily in selected schools or in hot-spot areas. Quebec's decision to keep most schools open was controversial, especially in Montreal, which was the epicenter of Canada's first and second waves; therefore, understanding the extent to which children were infected with SARS-CoV-2 provides important information for decisions about school closures.

OBJECTIVE

To estimate the seroprevalence of SARS-CoV-2 antibodies in children and teenagers in 4 neighborhoods of Montreal, Canada.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study (the Enfants et COVID-19: Étude de séroprévalence [EnCORE] study) enrolled a convenience sample of children aged 2 to 17 years between October 22, 2020, and March 22, 2021, in Montreal, Canada.

EXPOSURES

Potential exposure to SARS-CoV-2.

MAIN OUTCOMES AND MEASURES

The main outcome was seroprevalence of SARS-CoV-2 antibodies, collected using dried blood spots (DBSs) and analyzed with a research-based enzyme-linked immunosorbent assay (ELISA). Parents also completed an online questionnaire that included questions on self-reported COVID-19 symptoms and tests, along with sociodemographic questions.

RESULTS

This study included 1632 participants who provided a DBS sample from 30 day cares, 22 primary schools, and 11 secondary schools. The mean (SD) age of the children who provided a DBS sample was 9.0 (4.4) years; 801 (49%) were female individuals, with 354 participants (22%) from day cares, 725 (44%) from primary schools, and 553 (34%) from secondary schools. Most parents had at least a bachelor's degree (1228 [75%]), and 210 (13%) self-identified as being a racial or ethnic minority. The mean seroprevalence was 5.8% (95% CI, 4.6%-7.0%) but increased over time from 3.2% (95% CI, 0.7%-5.8%) in October to November 2020 to 8.4% (95% CI, 4.4%-12.4%) in March to April 2021. Of the 95 children with positive SARS-CoV-2 antibody results, 78 (82%) were not tested or tested negative with reverse transcription-polymerase chain reaction (RT-PCR) testing, and all experienced mild (49 [52%]) or no clinical symptoms (46 [48%]). The children of parents who self-identified as belonging to a racial and ethnic minority group were more likely to be seropositive compared with children of White parents (adjusted seroprevalence ratio, 1.9; 95% CI, 1.1-2.6).

CONCLUSIONS AND RELEVANCE

These results provide a benchmark of the seroprevalence status in Canadian children. The findings suggest that there was more transmission occurring in children compared with what was being detected by RT-PCR, although children experienced few or mild symptoms. It will be important to continue monitoring the serological status of children, particularly in the context of new COVID-19 variants of concern and in the absence of mass vaccination campaigns targeting young children.

Tree characteristics and environmental noise in complex urban settings - A case study from Montreal, Canada

Field studies have shown that dense tree canopies and regular tree arrangements reduce noise from a point source. In urban areas, noise sources are multiple and tree arrangements are rarely dense. There is a lack of data on the association between the urban tree canopy characteristics and noise in complex urban settings. Our aim was to investigate the spatial variation of urban tree canopy characteristics, indices of vegetation abundance, and environmental noise levels. Using Light Detection and Ranging point cloud data for 2015, we extracted the characteristics of 1,272,069 public and private trees across the island of Montreal, Canada. We distinguished needle-leaf from broadleaf trees, and calculated the percentage of broadleaf trees, the total area of the crown footprint, the mean crown centroid height, and the mean volume of crowns of trees that were located within 100m, 250m, 500m, and 1000m buffers around 87 in situ noise measurement sites. A random forest model incorporating tree characteristics, the normalized difference vegetation index (NDVI) values, and the distances to major urban noise sources (highways, railways and roads) was employed to estimate variation in noise among measurement locations. We found decreasing trends in noise levels with increases in total area of the crown footprint and mean crown centroid height. The percentages of increased mean squared error of the regression models indicated that in 500m buffers the total area of the crown footprint (29.2%) and the mean crown centroid height (12.6%) had a stronger influence than NDVI (3.2%) in modeling noise levels; similar patterns of influence were observed using other buffers. Our findings suggest that municipal initiatives designed to reduce urban noise should account for tree features, and not just the number of trees or the overall amount of vegetation.

How to navigate the application of ethics norms in global health research: reflections based on qualitative research conducted with people with disabilities in Uganda

BACKGROUND

As Canadian global health researchers who conducted a qualitative study with adults with and without disabilities in Uganda, we obtained ethics approval from four institutional research ethics boards (two in Canada and two in Uganda). In Canada, research ethics boards and researchers follow the research ethics norms of the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS2), and the National Guidelines for Research Involving Humans as Research Participants of Uganda (NGRU) in Uganda. The preparation and implementation of this qualitative research raised specific ethical issues related to research participant privacy and the importance of availability and management of financial resources.

MAIN BODY

Our field experience highlights three main issues for reflection. First, we demonstrate that, in a global health research context, methodological and logistic adjustments were necessary throughout the research implementation process to ensure the protection of study participants' privacy, especially that of people with disabilities, despite having followed the prescribed Canadian and Ugandan ethics norms. Data collection and management plans were adapted iteratively based on local realities. Second, securing financial support as a key aspect of financial management was critical to ensure privacy through disability-sensitive data collection strategies. Without adequate funding, the recruitment of research participants based on disability type, sex, and region or the hiring of local sign language interpreters would not have been possible. Third, although the TCPS2 and NGRU underscore the significance of participants' privacy, none of these normative documents clearly express this issue in the context of global health research and disability, nor broadly discuss the ethical issue related to financial availability and management.

CONCLUSIONS

Conducting research in resource limited settings and with study participants with different needs calls for a nuanced and respectful implementation of research ethics in a global health context. We recommend a greater integration in both the TCPS2 and NGRU of global health research, disability, and responsible conduct of research. This integration should also be accompanied by adequate training which can further guide researchers, be they senior, junior, or students, and funding agencies.

Modelling Spatiotemporal Patterns of Lyme Disease Emergence in Québec

Lyme disease is a growing public health problem in Québec. Its emergence over the last decade is caused by environmental and anthropological factors that favour the survival of Ixodes scapularis, the vector of Lyme disease transmission. The objective of this study was to estimate the speed and direction of human Lyme disease emergence in Québec and to identify spatiotemporal risk patterns. A surface trend analysis was conducted to estimate the speed and direction of its emergence based upon the first detected case of Lyme disease in each municipality in Québec since 2004. A cluster analysis was also conducted to identify at-risk regions across space and time. These analyses were reproduced for the date of disease onset and date of notification for each case of Lyme disease. It was estimated that Lyme disease is spreading northward in Québec at a speed varying between 18 and 32 km/year according to the date of notification and the date of disease onset, respectively. A significantly high risk of disease was found in seven clusters identified in the south-west of Québec in the sociosanitary regions of Montérégie and Estrie. The results obtained in this study improve our understanding of the spatiotemporal patterns of Lyme disease in Québec, which can be used for proactive, targeted interventions by public and clinical health authorities.

Implementation challenges of an integrated One Health surveillance system in humanitarian settings: A qualitative study in Palestine

Objectives

Several factors have changed interactions between people, animals, plants, and the environment - renewing the relevance of the One Health surveillance system in the fight against zoonotic diseases such as COVID-19. Therefore, this study aimed to explore barriers to implementing an integrated One Health surveillance system in Palestine.

Methods

This qualitative study was conducted from April 2020 until August 2020. Data were collected using semi-structured interview guides. Seven key stakeholders were interviewed during data collection. A thematic analysis was performed.

Results

Four overarching themes emerged explaining barriers to integrated implementation of the One Health surveillance system. They are lack of policy coherence, limited financial resources, poor governance and leadership, and lack of One Health training programmes.

Conclusion

Improved understanding of the transmission and effective control (including One Health approach) of zoonotic disease and better governance and leadership are critical in the diseases that threaten public health, such as the COVID-19.

The intersectional jeopardy of disability, gender and sexual and reproductive health: experiences and recommendations of women and men with disabilities in Northern Uganda

The 2030 Sustainable Development Goals committed to "Leave No One Behind" regardless of social identity. While access to sexual and reproductive health (SRH) services has improved globally, people with disabilities continue to face enormous barriers to SRH, infringing on their SRH rights (SRHR). Uganda adopted pro-disability legislation to promote the rights of people with disabilities. Despite these legal instruments, SRHR of people with disabilities continue to be violated and denied. To address this, we sought to understand and document how people with disabilities perceive the relationships between their use of SRH services, legislation, and health policy in three districts of the post-conflict Northern region of Uganda. Through an intersectionality-informed analysis, we interviewed 32 women and men with different types of impairments (physical, sensory and mental) and conducted two focus groups with 12 hearing and non-hearing disabled people as well as non-participant observations at seven health facilities. We found that disabled people's access to SHR services is shaped by the intersections of gender, disability, and violence, and that individuals with disabilities experienced discrimination across both private-not-for-profit and public health facilities. They also encountered numerous physical, attitudinal, and communication accessibility barriers. Despite policy implementation challenges, people with disabilities expected to exercise their rights and made concrete multi-level recommendations to redress situations of inequity and disadvantages in SRH service utilisation. Intersectionality revealed blind spots in policy implementation and service utilisation gaps. Universal health coverage can be operationalised in actionable measures where its universality meets with social justice.

The Association between Changes in Coronary Artery Calcium Scores, Dietary Intake, Physical Activity, and Depression Symptoms among the Population of Gaza Strip, Palestine

Background

This study aimed to identify the association between macronutrient intake, physical activity, and depressive symptoms and changes in coronary artery calcium score among the population of Gaza Strip.

Method

The study sample consisted of 269 individuals who underwent non-enhanced coronary computed tomography using 64-slice MDCT (Siemens, Germany) at Al-Shifa medical complex between September 2017 and January 2018. The study participants were divided into two groups; group one, consisting of coronary calcium calcification scoring (CAC) of greater than zero (CAC score > 0), and group two, CAC less than or equal to zero (CAC score ≤ 0). Data about macronutrient intake, physical activity, and depressive symptoms were collected using a validated self-administered questionnaire. Additionally, the participants' anthropometric characteristics and blood biochemical markers were measured.

Results

Out of 269 participants, 45-recorded CAC score > 0; 72% of them were males with a mean age of 52.6 ± 5.4 years. Significant differences between the two groups in terms of total energy, lipid intake, and carbohydrate were found (P-value of 0.020, 0.012, and 0.034, respectively). No significant differences were recorded in protein intake, physical activity, and depression. Multivariate logistic regression analysis under adjustment for possible confounding factors revealed that macronutrient intake, physical activity, and depressive symptoms were not associated with the development of CAC in two models.

Conclusion

Based on our findings, macronutrient intake, physical activity, and depressive symptoms are not associated with the development of CAC among the population of Gaza.

Seroprevalence of anti-SARS-CoV-2 antibodies among school and daycare children and personnel: protocol for a cohort study in Montreal, Canada

INTRODUCTION

Further evidence is needed to understand the contribution of schools and daycares for the spread of COVID-19 in the context of diverse transmission dynamics and continually evolving public health interventions. The Enfants et COVID-19: Étude de séroprévalence (EnCORE) study will estimate the seroprevalence and seroconversion of SARS-CoV-2 among school and daycare children and personnel. In addition, the study will examine associations between seroprevalence and sociodemographic characteristics and reported COVID-19 symptoms and tests, and investigates changes in health, lifestyle and well-being outcomes.

METHODS AND ANALYSIS

This study includes children and personnel from 62 schools and daycares in four neighbourhoods in Montreal, Canada. All children aged 2-17 years attending one of the participating schools or daycares and their parents are invited to participate, as well as a sample of personnel members. Participants respond to brief questionnaires and provide blood samples, collected via dried blood spot, at baseline (October 2020-March 2021) and follow-up (May-June 2021). Questionnaires include sociodemographic and household characteristics, reported COVID-19 symptoms and tests, potential COVID-19 risk factors and prevention efforts and health and lifestyle information. Logistic regression using generalised estimating equations will be used to estimate seroprevalence and seroconversion, accounting for school-level clustering.

ETHICS AND DISSEMINATION

This study was approved by the research ethics boards of the Université de Montréal (CERSES) and the Centre Hospitalier Universitaire Sainte-Justine. Results will contribute to our knowledge about SARS-CoV-2 transmission in schools and daycares and will be made available to study participants and their families, school and public health decision-makers and the research community.

Frequency, timing and risk factors for primary maternal cytomegalovirus infection during pregnancy in Quebec

INTRODUCTION

Maternal Cytomegalovirus (CMV) infection in the first trimester (T1) of pregnancy is a public health concern, as it increases the risk of severe neurodevelopmental outcomes associated with congenital infection compared to infections occurring later during pregnancy.

OBJECTIVES

To determine CMV seroprevalence in T1 of pregnancy, its trend, risk factors and the incidence rate of primary infection during pregnancy.

METHODS

Using the biobank of the prospective cohort "Grossesse en Santé de Québec" collected between April 2005 and March 2010 at the Québec-Laval Hospital, Québec, Canada, maternal CMV serology was determined using Abbott Architect Chemiluminescence microparticle immunoassays for immunoglobulin G(IgG), immunoglobulin M(IgM) titration and IgG avidity testing. Changepoint detection analysis was used to assess temporal trends. Risk factors associated with seropositivity were determined by multivariable logistic regression.

RESULTS

CMV seroprevalence in T1 of pregnancy was 23.4% (965/4111, 95% CI, 22.1-24.7%). The incidence rate for CMV primary infection during pregnancy was 1.8 (95% CI, 1.2-2.6) per 100 person-years. No changepoint was identified in the maternal CMV-seroprevalence trend. Multivariable analyses showed that T1 maternal CMV seropositivity was associated with having one child OR 1.3 (95% CI, 1.10-1.73) or two or more children OR 1.5 (95%CI, 1.1-2.1), ethnicity other than Caucasian OR 2.1 (95% CI, 1.1-3.8) and country of birth other than Canada and the USA OR 2.8 (95% CI, 1.5-4.9).

CONCLUSIONS

In this cohort, maternal seroprevalence in T1 of pregnancy and seroconversion rate were low. This information and identified risk factors could help guide the development and implementation of preventive actions and evidence-based health policies to prevent CMV infection during pregnancy.

Strong variations in urban allergenicity riskscapes due to poor knowledge of tree pollen allergenic potential

Exposure to allergenic tree pollen is an increasing environmental health issue in urban areas. However, reliable, well-documented, peer-reviewed data on the allergenicity of pollen from common tree species in urban environments are lacking. Using the concept of 'riskscape', we present and discuss evidence on how different tree pollen allergenicity datasets shape the risk for pollen-allergy sufferers in five cities with different urban forests and population densities: Barcelona, Montreal, New York City, Paris, and Vancouver. We also evaluate how tree diversity can modify the allergenic risk of urban forests. We show that estimates of pollen exposure risk range from 1 to 74% for trees considered to be highly allergenic in the same city. This variation results from differences in the pollen allergenicity datasets, which become more pronounced when a city's canopy is dominated by only a few species and genera. In an increasingly urbanized world, diverse urban forests offer a potentially safer strategy aimed at diluting sources of allergenic pollen until better allergenicity data is developed. Our findings highlight an urgent need for a science-based approach to guide public health and urban forest planning.

Learning from public health and hospital resilience to the SARS-CoV-2 pandemic: protocol for a multiple case study (Brazil, Canada, China, France, Japan, and Mali)

BACKGROUND

All prevention efforts currently being implemented for COVID-19 are aimed at reducing the burden on strained health systems and human resources. There has been little research conducted to understand how SARS-CoV-2 has affected health care systems and professionals in terms of their work. Finding effective ways to share the knowledge and insight between countries, including lessons learned, is paramount to the international containment and management of the COVID-19 pandemic. The aim of this project is to compare the pandemic response to COVID-19 in Brazil, Canada, China, France, Japan, and Mali. This comparison will be used to identify strengths and weaknesses in the response, including challenges for health professionals and health systems.

METHODS

We will use a multiple case study approach with multiple levels of nested analysis. We have chosen these countries as they represent different continents and different stages of the pandemic. We will focus on several major hospitals and two public health interventions (contact tracing and testing). It will employ a multidisciplinary research approach that will use qualitative data through observations, document analysis, and interviews, as well as quantitative data based on disease surveillance data and other publicly available data. Given that the methodological approaches of the project will be largely qualitative, the ethical risks are minimal. For the quantitative component, the data being used will be made publicly available.

DISCUSSION

We will deliver lessons learned based on a rigorous process and on strong evidence to enable operational-level insight for national and international stakeholders.

Community views on short birth interval in Northern Uganda: a participatory grounded theory

BACKGROUND

Short birth interval is associated with adverse perinatal, maternal, and infant outcomes, although evidence on actionable factors underlying short birth interval remains limited. We explored women and community views on short birth intervals to inform potential solutions to promote a culturally safe child spacing in Northern Uganda.

METHODS

Gendered fuzzy cognitive mapping sessions (n = 21), focus group discussions (n = 12), and an administered survey questionnaire (n = 255) generated evidence on short birth intervals. Deliberative dialogues with women, their communities, and service providers suggested locally relevant actions promote culturally safe child spacing.

RESULTS

Women, men, and youth have clear understandings of the benefits of adequate child spacing. This knowledge is difficult to translate into practice as women are disempowered to exercise child spacing. Women who use contraceptives without their husbands' consent risk losing financial and social assets and are likely to be subject to intra-partner violence. Women were not comfortable with available contraceptive methods and reported experiencing well-recognized side effects. They reported anxiety about the impact of contraception on the health of their future children. This fear was fed by rumors in their communities about the effects of contraceptives on congenital diseases. The women and their communities suggested a home-based sensitization program focused on improving marital relationships (spousal communication, mutual understanding, male support, intra-partner violence) and knowledge and side-effects management of contraceptives.

CONCLUSIONS

The economic context, gender power dynamics, inequality, gender bias in land tenure and ownership regulations, and the limited contraceptive supply reduce women's capacity to practice child spacing.

Communities and service providers address access to perinatal care in postconflict Northern Uganda: socialising evidence for participatory action

Objectives

Describe participatory codesign of interventions to improve access to perinatal care services in Northern Uganda.

Study design

Mixed-methods participatory research to codesign increased access to perinatal care. Fuzzy cognitive mapping, focus groups and a household survey identified and documented the extent of obstructions to access. Deliberative dialogue focused stakeholder discussions of this evidence to address the obstacles to access. Most significant change stories explored the participant experience of this process.

Setting

Three parishes in Nwoya district in the Gulu region, Northern Uganda.

Participants

Purposively sampled groups of women, men, female youth, male youth, community health workers, traditional midwives and service providers. Each of seven stakeholder categories included 5–8 participants in each of three parishes.

Results

Stakeholders identified several obstructions to accessing perinatal care: lack of savings in preparation for childbirth in facility costs, lack of male support and poor service provider attitudes. They suggested joining saving groups, practising saving money and income generation to address the short-term financial shortfall.

They recommended increasing spousal awareness of perinatal care and they proposed improving service provider attitudes. Participants described their own improved care-seeking behaviour and patient–provider relationships as short-term gains of the codesign.

Conclusion

Participatory service improvement is feasible and acceptable in postconflict settings like Northern Uganda. Engaging communities in identifying perinatal service delivery issues and reflecting on local evidence about these issues generate workable community-led solutions and increases trust between community members and service providers.

Impact of the coronavirus disease 2019 pandemic on the Palestinian family: A cross-sectional study

INTRODUCTION

The current study aims to understand and assess the consequences of the coronavirus disease 2019 pandemic on Palestinian families.

METHODS

This online community-based cross-sectional descriptive study was conducted between 19 April 2020 and 5 June 2020, using a validated questionnaire. The questionnaire comprised of three sections: sociodemographic characteristics, living conditions, and impact of the coronavirus disease 2019 pandemic. A convenience sampling method was used to select participants.

RESULTS

A total of 570 adults aged ⩾18 years participated in the study. Of them, 258 (45.3%), 120 (21%), and 192 (33.7%) were residing in the Gaza Strip, West Bank, and East Jerusalem, respectively. A large portion of participants (73.2%) reported that the containment measures of the coronavirus disease 2019 pandemic had caused an excessive burden on their families; 549 (96.3%) revealed that water supplies were not always available at home. However, paying attention to personal hygiene and home cleaning was more than usual before the announcement of the coronavirus disease 2019 pandemic. The mean times of going out of their homes have dropped significantly following the onset of the pandemic, p value = 0.001 (95% confidence interval). In addition, 192 (33.7%) participants reported that they changed to working remotely from home with 66 (11.6%) having lost their employment.

CONCLUSION

The coronavirus disease 2019 pandemic was associated with an additional burden on the Palestinian families. Moreover, we suggest discussing the obtained results with local and national stakeholders to ensure that they know to improve their actions.

Accounting for health inequities in the design of contact tracing interventions: A rapid review

Background

Contact tracing has been a central control measure for coronavirus disease 2019 (COVID-19) transmission. However, without consideration of the needs of specific populations, public health interventions can exacerbate health inequities.

Aim

The purpose of this rapid review was to determine if and how health inequities were included in the design of contact tracing interventions in epidemic settings.

Methods

A search of the electronic databases MEDLINE and Web of Science was conducted. The following inclusion criteria were applied for article selection: (1) described the design of contact tracing interventions, (2) published between 2013 and 2020 in English, French, Spanish, Chinese, or Portuguese, (3) and included at least 50% of empiricism, according to the Automated Classifier of Texts on Scientific Studies (ATCER) tool. Various tools were used to extract data.

Results

Following screening of the titles and abstracts of 230 articles, 39 met the inclusion criteria. Only seven references were retained after full text review. None of the selected studies considered health inequities in the design of contact tracing interventions.

Conclusions

The use of tools/concepts for incorporating health inequities, such as the REFLEX-ISS tool, and ‘proportionate universalism’ when designing contact tracing interventions, would enable practitioners, decision-makers, and researchers to better consider health inequities.

Assessing the reporting of Dengue, Chikungunya and Zika to the National Surveillance System in Colombia from 2014-2017: A Capture-recapture analysis accounting for misclassification of arboviral diagnostics

BACKGROUND

Chikungunya, dengue, and Zika are three different arboviruses which have similar symptoms and are a major public health issue in Colombia. Despite the mandatory reporting of these arboviruses to the National Surveillance System in Colombia (SIVIGILA), it has been reported that the system captures less than 10% of diagnosed cases in some cities.

METHODOLOGY/PRINCIPAL FINDINGS

To assess the scope and degree of arboviruses reporting in Colombia between 2014-2017, we conducted an observational study of surveillance data using the capture-recapture approach in three Colombian cities. Using healthcare facility registries (capture data) and surveillance-notified cases (recapture data), we estimated the degree of reporting by clinical diagnosis. We fit robust Poisson regressions to identify predictors of reporting and estimated the predicted probability of reporting by disease and year. To account for the potential misclassification of the clinical diagnosis, we used the simulation extrapolation for misclassification (MC-SIMEX) method. A total of 266,549 registries were examined. Overall arboviruses' reporting ranged from 5.3% to 14.7% and varied in magnitude according to age and year of diagnosis. Dengue was the most notified disease (21-70%) followed by Zika (6-45%). The highest reporting rate was seen in 2016, an epidemic year. The MC-SIMEX corrected rates indicated underestimation of the reporting due to the potential misclassification bias.

CONCLUSIONS

These findings reflect challenges on arboviruses' reporting, and therefore, potential challenges on the estimation of arboviral burden in Colombia and other endemic settings with similar surveillance systems.

Pro-equity legislation, health policy and utilisation of sexual and reproductive health services by vulnerable populations in sub-Saharan Africa: a systematic review

Twenty-five years ago, the International Conference on Population and Development highlighted the need to address sexual and reproductive health (SRH) rights on a global scale. The sub-Saharan Africa region continues to have the highest levels of maternal mortality and HIV, primarily affecting the most vulnerable populations. Recognising the critical role of policy in understanding population health, we conducted a systematic review of original primary research which examined the relationships between equity-focused legislation and policy and the utilisation of SRH services by vulnerable populations in sub-Saharan Africa. We searched nine bibliographic databases for relevant articles published between 1994 and 2019. Thirty-two studies, conducted in 14 sub-Saharan African countries, met the inclusion criteria. They focused on maternal health service utilisation, either through specific fee reduction/removal policies, or through healthcare reforms and insurance schemes to increase SRH service utilisation. Findings across most of the studies showed that health-related legislation and policy promoted an increase in service utilisation, over time, especially for antenatal care, skilled birth attendance and facility-based delivery. However, social health inequalities persisted among subgroups of women. Neither the reviewed studies nor the policies specifically addressed youth, people living with HIV and people with disabilities. In the era of the sustainable development goals, addressing health inequities in the context of social determinants of health becomes unavoidable. Systematic and rigorous quantitative and qualitative research, including longitudinal policy evaluation, is required to understand the complex relationships between policy addressing upstream social determinants of health and health service utilisation.

The Impact of Multiple Rounds of Indoor Residual Spraying on Malaria Incidence and Hemoglobin Levels in a High-Transmission Setting

BACKGROUND

Indoor residual spraying (IRS) is widely used as a vector control measure, although there are conflicting findings of its effectiveness in reducing malaria incidence. The objective of this study was to estimate the effect of multiple IRS rounds on malaria incidence and hemoglobin levels in a cohort of children in rural southeastern Uganda.

METHODS

The study was based upon a dynamic cohort of children aged 0.5-10 years enrolled from August 2011 to June 2017 in Nagongera Subcounty. Confirmed malaria infections and hemoglobin levels were recorded over time for each participant. After each of 4 rounds of IRS, malaria incidence, hemoglobin levels, and parasite density were evaluated and compared with pre-IRS levels. Analyses were carried out at the participant level while accounting for repeated measures and clustering by household.

RESULTS

Incidence rate ratios comparing post-IRS to pre-IRS incidence rates for age groups 0-3, 3-5, and 5-11 were 0.108 (95% confidence interval [CI], .078-.149), 0.173 (95% CI, .136-.222), and 0.226 (95% CI, .187-.274), respectively. The mean hemoglobin levels significantly increased from 11.01 (pre-IRS) to 12.18 g/dL (post-IRS).

CONCLUSIONS

Our study supports the policy recommendation of IRS usage in a stable and perennial transmission area to rapidly reduce malaria transmission.