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de Souza DC, Paul R, Mozun R, Sankar J, Jabornisky R, Lim E, Harley A, Al Amri S, Aljuaid M, Qian S, Schlapbach LJ, Argent A, Kissoon N. Quality improvement programmes in paediatric sepsis from a global perspective. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:695-706. [PMID: 39142743 DOI: 10.1016/s2352-4642(24)00142-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 05/28/2024] [Accepted: 06/04/2024] [Indexed: 08/16/2024]
Abstract
Sepsis is a major contributor to poor child health outcomes around the world. The high morbidity, mortality, and societal cost associated with paediatric sepsis render it a global health priority, as summarised in Paper 1 of this Series. Sepsis is characterised by a dysregulated host response to infection that manifests as organ failure, and children are uniquely susceptible to sepsis, as discussed in Paper 2. The focus of this third Series paper is quality improvement in paediatric sepsis. The 2017 WHO resolution on sepsis outlined key aims to reduce the burden of sepsis. As of 2024, only a small number of countries have implemented systematic, paediatric-focused quality improvement programmes to raise sepsis awareness, enhance recognition of sepsis, promote timely treatment, and provide long-term support for paediatric sepsis survivors. We examine programme successes and systematic barriers to quality improvement targeting paediatric sepsis. We highlight the need for programme design to consider the entire patient journey, starting with prevention, caregiver awareness, recognition at home, education of the health-care workforce, development of health-care systems, and establishment of long-term family and survivor support extending beyond the intensive care unit. Building on lessons learnt from existing quality improvement programmes, we outline implementation strategies and measures to enable benchmarking. Ultimately, quality improvement on a global scale can only be accelerated through a global learning platform focusing on paediatric sepsis.
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Affiliation(s)
- Daniela C de Souza
- Latin American Sepsis Institute, São Paulo, Brazil; Pediatric Intensive Care Unit, Hospital Universitário da Universidade de São Paulo, São Paulo, Brazil; Pediatric Intensive Care Unit, Hospital Sírio Libanês, São Paulo, Brazil.
| | - Raina Paul
- Children's Hospital of Orange County, Orange, CA, USA; Improving Pediatric Sepsis Outcomes Collaborative, Children's Hospital Association, Washington, DC, USA
| | - Rebeca Mozun
- Department of Intensive Care and Neonatology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jhuma Sankar
- All India Institute of Medical Sciences, New Delhi, India
| | - Roberto Jabornisky
- Universidad Nacional del Nordeste, Corrientes, Argentina; LARed Network, Montevideo, Uruguay; SLACIP Sociedad Latinoamericana de Cuidados Intensivos Pediátricos, Monterrey, Mexico
| | - Emma Lim
- Department of Paediatric Infectious Diseases, Immunology and Allergy, Great North Children's Hospital, Newcastle upon Tyne, UK; Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Amanda Harley
- Queensland Paediatric Sepsis Program, Brisbane, QLD, Australia; Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Samirah Al Amri
- Nursing Department, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Maha Aljuaid
- Nursing Department, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Suyun Qian
- Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Luregn J Schlapbach
- Department of Intensive Care and Neonatology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
| | | | - Niranjan Kissoon
- Global Child Health Department of Pediatrics and Emergency Medicine, British Columbia Women and Children's Hospital and the University of British Columbia, Vancouver, BC, Canada
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Bonnamy J, Levett-Jones T, Carr B, Lokmic-Tomkins Z, Maguire J, Catling C, Pich J, Fields L, Brand G. Australian and New Zealand nursing and midwifery educators' planetary health knowledge, views, confidence and teaching practices: A descriptive survey study. J Adv Nurs 2024. [PMID: 38973250 DOI: 10.1111/jan.16317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 06/18/2024] [Accepted: 06/23/2024] [Indexed: 07/09/2024]
Abstract
AIM To explore Australian and New Zealand nursing and midwifery educators' planetary health knowledge, views, confidence and teaching practices. DESIGN A cross-sectional survey design. METHODS An online survey was sent to Australian and New Zealand nursing and midwifery educators across the 45 Schools of Nursing and Midwifery between July and September 2023. The online survey consisted of 29 open- and closed-ended questions about nursing and midwifery educators' planetary health knowledge, views, confidence and teaching practices. RESULTS There was a total of 127 responses to the first open-ended question. A total of 97 nursing and midwifery educators then completed the remaining questions. While educators had mostly positive views about integrating planetary health into their teaching, they lacked the knowledge and/or confidence to do so effectively. CONCLUSION Australian and New Zealand nursing and midwifery educators acknowledge that planetary health should be included in nursing and midwifery curricula, but most reported a deficit in knowledge and/or confidence to integrate these complex concepts into their teaching. When considering planetary health, most educators focussed on climate change, which demonstrates their limited understanding of the concept of planetary health. IMPLICATIONS FOR THE PROFESSION All nurses and midwives need to understand how the health of the planet and human civilization are interconnected and be prepared to address complex global health challenges now and in the future. Across the world, key healthcare organizations have called upon nursing and midwifery educators to prepare the healthcare workforce to practice in a more sustainable way, including supporting decarbonization of healthcare. However, our study has demonstrated that nursing and midwifery educators do not feel ready to respond due to a lack of required knowledge and/or confidence. REPORTING METHOD We used the Consensus-Based Checklist for Reporting of Survey Studies (CROSS). PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution.
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Affiliation(s)
- James Bonnamy
- School of Nursing and Midwifery, Sub-Faculty of Health Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, Victoria, Australia
| | - Tracy Levett-Jones
- Health and Climate Initiative, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, Victoria, Australia
| | - Bethany Carr
- School of Nursing and Midwifery, Sub-Faculty of Health Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, Victoria, Australia
| | - Zerina Lokmic-Tomkins
- School of Nursing and Midwifery, Sub-Faculty of Health Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, Victoria, Australia
- Health and Climate Initiative, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, Victoria, Australia
| | - Jane Maguire
- School of Nursing & Midwifery, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Christine Catling
- Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Jacqueline Pich
- School of Nursing & Midwifery, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Lorraine Fields
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Gabrielle Brand
- School of Nursing and Midwifery, Sub-Faculty of Health Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, Victoria, Australia
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Qiu S, Qiu J. From individual resilience to collective response: reframing ecological emotions as catalysts for holistic environmental engagement. Front Psychol 2024; 15:1363418. [PMID: 38903457 PMCID: PMC11188184 DOI: 10.3389/fpsyg.2024.1363418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 05/27/2024] [Indexed: 06/22/2024] Open
Abstract
The ongoing international study on the mental health implications of climate change has prompted a deeper exploration of ecological emotions such as eco-anxiety, eco-worry and eco-grief, which are associated with environmental degradation and the escalating climate crisis. Although psychological and mental health literature has mainly presented preliminary conceptual analyses, the understanding of ecological emotions remains unclear. This narrative review aims to clarify the definition, highlight precipitating factors, and outline the effects of ecological emotions on mental health, emphasizing the need for thorough research to shift the nonclinical intervention approach from merely promoting individual resilience to encouraging collective engagement. Our analysis of the literature reveals that the existing theoretical framework, which predominantly focuses on bolstering individual resilience, provides only temporary relief for acute symptoms without addressing the foundational social and environmental factors that trigger these ecological emotions. We conclude that it is crucial to overcome the limitations of Western anthropocentrism's human-to-human interaction approach and embrace the unity of humans and nature to effectively manage the increasing ecological emotions. This perspective draws insights from the holistic and collective wisdom of indigenous cultures and traditional Chinese philosophy, offering a potential pathway toward maintaining a sustainable emotional balance amid the worsening global ecological turmoil.
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Affiliation(s)
- Shicun Qiu
- School of Foreign Languages, Sichuan University of Arts and Science, Dazhou, Sichuan, China
| | - Jiacun Qiu
- Business School, Guangdong Business and Technology University, Zhaoqing, Guangdong, China
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Pinho-Gomes AC, Woodward M. The association between gender equality and climate adaptation across the globe. BMC Public Health 2024; 24:1394. [PMID: 38790000 PMCID: PMC11127422 DOI: 10.1186/s12889-024-18880-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 05/17/2024] [Indexed: 05/26/2024] Open
Abstract
INTRODUCTION Climate change has a disproportionate impact on women in comparison to men, and women have a key role to play in climate adaptation. However, evidence is lacking on how gender inequalities may be associated with climate vulnerability and ability to respond at country level. METHODS This ecological study investigated the association between climate adaptation, measured by the Notre Dame Global Adaptation Initiative Country Index (ND-GAIN), and gender equality, measured by the Global Gender Gap Index (GGGI) developed by the World Economic Forum and the Gender Inequality Index (GII) developed by the United Nations. Simple linear regression was used to estimate the associations between the indices and their subdomains for 146 countries. RESULTS There was an approximately linear association between the GGGI and climate adaptation. Each 1% increase in gender equality was associated with a 0.6% increase in the ND-GAIN score (the slope was 0.59, with a 95% confidence interval [0.33 to 0.84]). This was driven by a negative association between gender equality and vulnerability (-0.41 [-0.62 to -0.20]), and a positive association between gender equality and readiness (0.77 [0.44 to 1.10]). The strongest associations between gender equality and climate adaptation were observed for the education domain of the GGGI. There was a strong negative linear association between the GII and climate adaptation, which explained most (86%) of the between-country variation in climate adaptation. Each 1% increase in gender inequality was associated with a 0.5% decrease in the ND-GAIN score (-0.54 [-0.57 to -0.50]). The association between gender inequality and readiness was stronger than the association with vulnerability (0.41 [0.37 to 0.44] for vulnerability versus - 0.67 [-0.72 to -0.61] for readiness). CONCLUSIONS Gender inequality, measured broadly across different domains of life, is associated with climate adaptation at country level, both in terms of vulnerability to impact and readiness to respond.
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Affiliation(s)
- Ana-Catarina Pinho-Gomes
- The George Institute for Global Health, Imperial College London, Scale Space, 58 Wood Lane, London, W12 7RZ, UK.
- Institute for Global Health, University College London, London, UK.
| | - Mark Woodward
- The George Institute for Global Health, Imperial College London, Scale Space, 58 Wood Lane, London, W12 7RZ, UK
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Azimi MN, Rahman MM. Unveiling the health consequences of air pollution in the world's most polluted nations. Sci Rep 2024; 14:9856. [PMID: 38684837 PMCID: PMC11058277 DOI: 10.1038/s41598-024-60786-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 04/26/2024] [Indexed: 05/02/2024] Open
Abstract
Air pollution poses a persuasive threat to global health, demonstrating widespread detrimental effects on populations worldwide. Exposure to pollutants, notably particulate matter with a diameter of 2.5 µm (PM2.5), has been unequivocally linked to a spectrum of adverse health outcomes. A nuanced understanding of the relationship between them is crucial for implementing effective policies. This study employs a comprehensive investigation, utilizing the extended health production function framework alongside the system generalized method of moments (SGMM) technique, to scrutinize the interplay between air pollution and health outcomes. Focusing on a panel of the top twenty polluted nations from 2000 to 2021, the findings yield substantial insights. Notably, PM2.5 concentration emerges as a significant factor, correlating with a reduction in life expectancy by 3.69 years and an increase in infant mortality rates by 0.294%. Urbanization is found to increase life expectancy by 0.083 years while concurrently decreasing infant mortality rates by 0.00022%. An increase in real per capita gross domestic product corresponds with an improvement in life expectancy by 0.21 years and a decrease in infant mortality rates by 0.00065%. Similarly, an elevated school enrollment rate is associated with a rise in life expectancy by 0.17 years and a decline in infant mortality rates by 0.00032%. However, a higher population growth rate is found to modestly decrease life expectancy by 0.019 years and slightly elevate infant mortality rates by 0.000016%. The analysis reveals that per capita greenhouse gas emissions exert a negative impact, diminishing life expectancy by 0.486 years and elevating infant mortality rates by 0.00061%, while per capita energy consumption marginally reduces life expectancy by 0.026 years and increases infant mortality rates by 0.00004%. Additionally, economic volatility shock presents a notable decrement in life expectancy by 0.041 years and an increase in infant mortality rates by 0.000045%, with inflationary shock further exacerbating adverse health outcomes by lowering life expectancy by 0.70 years and elevating infant mortality rates by 0.00025%. Moreover, the study scrutinizes the role of institutional quality, revealing a constructive impact on health outcomes. Specifically, the institutional quality index is associated with an increase in life expectancy by 0.66% and a decrease in infant mortality rates by 0.0006%. Extending the analysis to examine the nuanced dimensions of institutional quality, the findings discern that economic institutions wield a notably stronger positive influence on health outcomes compared to political and institutional governance indices. Finally, the results underscore the pivotal moderating role of institutional quality in mitigating the deleterious impact of PM2.5 concentration on health outcomes, counterbalancing the influence of external shocks, and improving the relationships between explanatory variables and health outcome indicators. These findings offer critical insights for guiding evidence-based policy implications, with a focus on fostering resilient, sustainable, and health-conscious societies.
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Affiliation(s)
- Mohammad Naim Azimi
- School of Business, University of Southern Queensland, Toowoomba, QLD, 4350, Australia.
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Francis DL, Reddy SSP, Logaranjani A, Chopra SS. Climate change and oral health: Assessing the impacts and developing strategies for adaptation. Oral Dis 2024. [PMID: 38438315 DOI: 10.1111/odi.14922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 02/25/2024] [Accepted: 02/26/2024] [Indexed: 03/06/2024]
Affiliation(s)
- Delfin Lovelina Francis
- Department of Public Health Dentistry, Saveetha Dental College & Hospitals, Saveetha University, SIMATS, Chennai, Tamil Nadu, India
| | | | - Anitha Logaranjani
- Department of Periodontology, Meenakshi Ammal Dental College & Hospitals, Chennai, Tamil Nadu, India
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Moodley Y, Asare K, Tanser F, Tomita A. Maternal exposure to heat and its association with miscarriage in rural KwaZulu-Natal, South Africa: A population-based cohort study. WOMEN'S HEALTH (LONDON, ENGLAND) 2024; 20:17455057241259171. [PMID: 39066467 PMCID: PMC11282531 DOI: 10.1177/17455057241259171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/21/2024] [Accepted: 05/16/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND We sought to improve the current understanding of how climate change impacts women's reproductive health in sub-Saharan Africa. OBJECTIVES We investigated the relationship between maternal heat exposure and miscarriage (pregnancy ending before 20 weeks gestation) in a South African setting. DESIGN Population-based cohort study. METHODS Our study involved data for pregnancies collected via a health and demographic surveillance system in rural KwaZulu-Natal, South Africa between 2012 and 2016. Data from the South African Weather Service were used to compute maternal exposure to heat during the following time windows for each pregnancy: during the month preceding conception (T1) and during the week preceding the study outcome (either a miscarriage or no miscarriage, T2). Heat exposure was operationalized as a continuous variable and defined as the number of days that a mother was exposed to a mean daily temperature of > 26.6°C (A "hot day," equivalent to a mean daily temperature of > 80°F) during T1 or T2. Binary logistic regression was used to investigate the relationship between maternal heat exposure and miscarriage. RESULTS A total of 105/3477 pregnancies included in our analysis ended in miscarriage (3.0%). Each additional hot day during T1 was associated with a 26% higher odds of miscarriage (odds ratio: 1.26; 95% confidence interval: 1.15-1.38). No significant associations were observed between maternal heat exposure during T2 and the odds of miscarriage (odds ratio: 0.94, 95% confidence interval: 0.73-1.20). The relationship between maternal heat exposure during T1 and the odds of miscarriage was J-shaped. CONCLUSION There is a clear relationship between maternal heat exposure during the month preceding conception and miscarriage in our sub-Saharan African setting. Given the lack of feasible strategies to reduce pregnancy loss associated with prevailing high temperatures in sub-Saharan Africa, progressive climate change will likely exacerbate existing challenges for women's reproductive health in this region.
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Affiliation(s)
- Yoshan Moodley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Faculty of Health and Environmental Sciences, Central University of Technology, Bloemfontein, South Africa
- Division of Health Systems and Public Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kwabena Asare
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa, KwaZulu-Natal, South Africa
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Frank Tanser
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Centre for Epidemic Response and Innovation, School for Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
- South African Centre for Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, South Africa
| | - Andrew Tomita
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
- KwaZulu-Natal Research Innovation and Sequencing Platform, University of KwaZulu-Natal, Congella, South Africa
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Barteit S, Sié A, Zabré P, Traoré I, Ouédraogo WA, Boudo V, Munga S, Khagayi S, Obor D, Muok E, Franke J, Schwarz M, Blass K, Su TT, Bärnighausen T, Sankoh O, Sauerborn R. Widening the lens of population-based health research to climate change impacts and adaptation: the climate change and health evaluation and response system (CHEERS). Front Public Health 2023; 11:1153559. [PMID: 37304117 PMCID: PMC10248881 DOI: 10.3389/fpubh.2023.1153559] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/05/2023] [Indexed: 06/13/2023] Open
Abstract
Background Climate change significantly impacts health in low-and middle-income countries (LMICs), exacerbating vulnerabilities. Comprehensive data for evidence-based research and decision-making is crucial but scarce. Health and Demographic Surveillance Sites (HDSSs) in Africa and Asia provide a robust infrastructure with longitudinal population cohort data, yet they lack climate-health specific data. Acquiring this information is essential for understanding the burden of climate-sensitive diseases on populations and guiding targeted policies and interventions in LMICs to enhance mitigation and adaptation capacities. Objective The objective of this research is to develop and implement the Change and Health Evaluation and Response System (CHEERS) as a methodological framework, designed to facilitate the generation and ongoing monitoring of climate change and health-related data within existing Health and Demographic Surveillance Sites (HDSSs) and comparable research infrastructures. Methods CHEERS uses a multi-tiered approach to assess health and environmental exposures at the individual, household, and community levels, utilizing digital tools such as wearable devices, indoor temperature and humidity measurements, remotely sensed satellite data, and 3D-printed weather stations. The CHEERS framework utilizes a graph database to efficiently manage and analyze diverse data types, leveraging graph algorithms to understand the complex interplay between health and environmental exposures. Results The Nouna CHEERS site, established in 2022, has yielded significant preliminary findings. By using remotely-sensed data, the site has been able to predict crop yield at a household level in Nouna and explore the relationships between yield, socioeconomic factors, and health outcomes. The feasibility and acceptability of wearable technology have been confirmed in rural Burkina Faso for obtaining individual-level data, despite the presence of technical challenges. The use of wearables to study the impact of extreme weather on health has shown significant effects of heat exposure on sleep and daily activity, highlighting the urgent need for interventions to mitigate adverse health consequences. Conclusion Implementing the CHEERS in research infrastructures can advance climate change and health research, as large and longitudinal datasets have been scarce for LMICs. This data can inform health priorities, guide resource allocation to address climate change and health exposures, and protect vulnerable communities in LMICs from these exposures.
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Affiliation(s)
- Sandra Barteit
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Pascal Zabré
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - I Traoré
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | - Valentin Boudo
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | | | - David Obor
- Kenya Medical Research Institute, Kisumu, Kenya
| | - Erick Muok
- Kenya Medical Research Institute, Kisumu, Kenya
| | | | | | - Klaus Blass
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Tin Tin Su
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- South East Asia Community Observatory (SEACO) and Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University, Bandar Sunway, Malaysia
| | - Till Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
- Harvard Center for Population and Development Studies, Cambridge, MA, United States
| | - Osman Sankoh
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- Statistics Sierra Leone, Freetown, Sierra Leone
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rainer Sauerborn
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
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Dorji T, Morrison-Saunders A, Blake D. Understanding How Community Wellbeing is Affected by Climate Change: Evidence From a Systematic Literature Review. ENVIRONMENTAL MANAGEMENT 2023:10.1007/s00267-023-01833-w. [PMID: 37209142 PMCID: PMC10199662 DOI: 10.1007/s00267-023-01833-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/07/2023] [Indexed: 05/22/2023]
Abstract
Social science studies view community wellbeing to be a cumulative construct of multiple dimensions which include social, economic, environmental, physical, political, health, education indicators and more. The study of community wellbeing is compounded by climate change as it increases the frequency of disasters affecting all dimensions of community wellbeing. It becomes crucial for communities to build community resilience and address the impact on community wellbeing in the context of Disaster Risk Reduction and sustainable development. This systematic literature aimed to understand how community wellbeing is affected by climate change. It analysed 23 papers from Scopus, Web of Science, ProQuest, and Google Scholar, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method, to address three research questions: (i) how do climate change scholars understand community wellbeing, (ii) how community wellbeing is affected by specific climate change factors/conditions and the nature of impact, and (iii) how the impact on community wellbeing as a result of climate change is being addressed. The study found that climate change scholars hold mixed and multiple views or understanding of community wellbeing and climate change led to mental stress decreasing community wellbeing. The solutions to improve community wellbeing in the context of climate change suggests that adaptation should be the main policy instrument supplemented by mitigation strategies and recommends building a vibrant research culture in wellbeing and climate studies, among others. This review provides insights into the complex relationship between community wellbeing and climate change and identifies areas for future research and policy development.
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Affiliation(s)
- Tashi Dorji
- Centre for People, Place & Planet, Edith Cowan University, Perth, WA, Australia.
| | - Angus Morrison-Saunders
- Centre for People, Place & Planet, Edith Cowan University, Perth, WA, Australia
- Research Unit for Environmental Sciences and Management, North-West University, Potchefstroom, South Africa
| | - Dave Blake
- Centre for People, Place & Planet, Edith Cowan University, Perth, WA, Australia
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Magalhães AR, Codeço CT, Svenning JC, Escobar LE, Van de Vuurst P, Gonçalves-Souza T. Neglected tropical diseases risk correlates with poverty and early ecosystem destruction. Infect Dis Poverty 2023; 12:32. [PMID: 37038199 PMCID: PMC10084676 DOI: 10.1186/s40249-023-01084-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 03/19/2023] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND Neglected tropical diseases affect the most vulnerable populations and cause chronic and debilitating disorders. Socioeconomic vulnerability is a well-known and important determinant of neglected tropical diseases. For example, poverty and sanitation could influence parasite transmission. Nevertheless, the quantitative impact of socioeconomic conditions on disease transmission risk remains poorly explored. METHODS This study investigated the role of socioeconomic variables in the predictive capacity of risk models of neglected tropical zoonoses using a decade of epidemiological data (2007-2018) from Brazil. Vector-borne diseases investigated in this study included dengue, malaria, Chagas disease, leishmaniasis, and Brazilian spotted fever, while directly-transmitted zoonotic diseases included schistosomiasis, leptospirosis, and hantaviruses. Environmental and socioeconomic predictors were combined with infectious disease data to build environmental and socioenvironmental sets of ecological niche models and their performances were compared. RESULTS Socioeconomic variables were found to be as important as environmental variables in influencing the estimated likelihood of disease transmission across large spatial scales. The combination of socioeconomic and environmental variables improved overall model accuracy (or predictive power) by 10% on average (P < 0.01), reaching a maximum of 18% in the case of dengue fever. Gross domestic product was the most important socioeconomic variable (37% relative variable importance, all individual models exhibited P < 0.00), showing a decreasing relationship with disease indicating poverty as a major factor for disease transmission. Loss of natural vegetation cover between 2008 and 2018 was the most important environmental variable (42% relative variable importance, P < 0.05) among environmental models, exhibiting a decreasing relationship with disease probability, showing that these diseases are especially prevalent in areas where natural ecosystem destruction is on its initial stages and lower when ecosystem destruction is on more advanced stages. CONCLUSIONS Destruction of natural ecosystems coupled with low income explain macro-scale neglected tropical and zoonotic disease probability in Brazil. Addition of socioeconomic variables improves transmission risk forecasts on tandem with environmental variables. Our results highlight that to efficiently address neglected tropical diseases, public health strategies must target both reduction of poverty and cessation of destruction of natural forests and savannas.
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Affiliation(s)
- Arthur Ramalho Magalhães
- Laboratory of Ecological Synthesis and Biodiversity Conservation (ECOFUN), Federal Rural University of Pernambuco, Recife, PE, Brazil
| | - Cláudia Torres Codeço
- Scientific Computation Program (PROCC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Jens-Christian Svenning
- Center for Ecological Dynamics in a Novel Biosphere (ECONOVO) & Center for Biodiversity Dynamics in a Changing World (BIOCHANGE), Department of Biology., Aarhus University, Aarhus, Denmark
| | - Luis E Escobar
- Department of Fish and Wildlife Conservation, Virginia Tech, Blacksburg, VA, USA
- Center for Emerging Zoonotic and Arthropod-Borne Pathogens, Virginia Tech, Blacksburg, VA, USA
| | - Paige Van de Vuurst
- Center for Emerging Zoonotic and Arthropod-Borne Pathogens, Virginia Tech, Blacksburg, VA, USA
- Translational Biology, Medicine and Health Program, Virginia Tech Graduate School, Blacksburg, VA, USA
| | - Thiago Gonçalves-Souza
- Laboratory of Ecological Synthesis and Biodiversity Conservation (ECOFUN), Federal Rural University of Pernambuco, Recife, PE, Brazil.
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11
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Greibe Andersen J, Kallestrup P, Karekezi C, Yonga G, Kraef C. Climate change and health risks in Mukuru informal settlement in Nairobi, Kenya - knowledge, attitudes and practices among residents. BMC Public Health 2023; 23:393. [PMID: 36841782 PMCID: PMC9958313 DOI: 10.1186/s12889-023-15281-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 02/15/2023] [Indexed: 02/27/2023] Open
Abstract
BACKGROUND Residents of informal settlements in Sub-Sahara Africa (SSA) are vulnerable to the health impacts of climate change. Little is known about the knowledge, attitudes and practices (KAP) of inhabitants of informal settlements in SSA regarding climate change and its health impacts. The aim of this study was to investigate how inhabitants of an informal settlement in SSA experience climate change and its health impacts and assess related knowledge, attitudes and practices. The study was conducted in Mukuru informal settlement in Nairobi City County, Kenya. METHODS A cross-sectional study was conducted in September 2021 using a structured, semi-closed KAP questionnaire. Inclusion criteria were ≥ 18 years of age and living in one of the three main sections in Mukuru: Kwa Njenga, Kwa Reuben or Viwandani. By spinning a pen at the geographic centre of each section, a random direction was selected. Then, in every second household one individual was interviewed, creating a representative mix of ages and genders of the local community. To assess participant characteristics associated with climate change knowledge multivariable logistic regression was used. Thematic content analysis was performed for qualitative responses. RESULTS Out of 402 study participants, 76.4% (n = 307) had heard of climate change before the interview, 90.8% (n = 365) reported that climate change was affecting their community, and 92.6% (n = 372) were concerned with the health-related impact of climate change. Having lived in Mukuru for more than 10 years and living in a dwelling close to the riverside were factors significantly associated with having heard of climate change before (aOR 3.1, 95%CI 1.7 - 5.8 and aOR 2.6, 95%CI 1.1 - 6.1, respectively) and experiencing a climate change related impact on the community (aOR 10.7, 95%CI 4.0 - 28.4 and aOR 7.7; 95%CI 1.7 - 34.0, respectively). Chronic respiratory conditions, vector-borne diseases, including infectious diarrhoea, malnutrition and cardiovascular diseases were identified by respondents as climate related health risks. CONCLUSIONS Most respondents were knowledgeable about climate change and were experiencing its (health-related) impact on their community. This study provides insights which may prove useful for policy makers, intervention planners and researchers to work on locally adapted mitigation and adaption strategies.
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Affiliation(s)
- Johanne Greibe Andersen
- Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark. .,Danish Non-communicable Diseases Alliance, Copenhagen, Denmark.
| | - Per Kallestrup
- Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark.,Danish Non-communicable Diseases Alliance, Copenhagen, Denmark
| | - Catherine Karekezi
- Kenya Diabetes Management and Information Centre, Nairobi, Kenya.,Non-communicable Diseases Alliance of Kenya, Nairobi, Kenya
| | - Gerald Yonga
- Non-communicable Diseases Alliance of Kenya, Nairobi, Kenya.,School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Christian Kraef
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany.,Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Khine MM, Langkulsen U. The Implications of Climate Change on Health among Vulnerable Populations in South Africa: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3425. [PMID: 36834118 PMCID: PMC9959885 DOI: 10.3390/ijerph20043425] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/08/2023] [Accepted: 02/11/2023] [Indexed: 06/18/2023]
Abstract
Climate change poses numerous threats to human life, including physical and mental health, the environment, housing, food security, and economic growth. People who already experience multidimensional poverty with the disparity in social, political, economic, historical, and environmental contexts are more vulnerable to these impacts. The study aims to identify the role of climate change in increasing multidimensional inequalities among vulnerable populations and analyze the strengths and limitations of South Africa's National Climate Change Adaptation Strategy. A systematic review was applied, and literature from Google, Google Scholar, and PubMed, as well as relevant gray literature from 2014-2022 were reviewed. Out of 854 identified sources, 24 were included in the review. Climate change has exacerbated multidimensional inequalities among vulnerable populations in South Africa. Though the National Climate Change Adaptation Strategy has paid attention to health issues and the needs of vulnerable groups, the adaptation measures appear to focus less on mental and occupational health. Climate change may play a significant role in increasing multidimensional inequalities and exacerbating health consequences among vulnerable populations. For an inclusive and sustainable reduction in inequalities and vulnerabilities to the impact of climate change, community-based health and social services should be enhanced among vulnerable populations.
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Affiliation(s)
| | - Uma Langkulsen
- Faculty of Public Health, Thammasat University, Pathum Thani, Bangkok 12120, Thailand
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Ezeruigbo CF, Ezeoha A. Climate change and the burden of healthcare financing in African households. Afr J Prim Health Care Fam Med 2023; 15:e1-e3. [PMID: 36744450 PMCID: PMC9900300 DOI: 10.4102/phcfm.v15i1.3743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 02/05/2023] Open
Abstract
Climate change is a mounting pressure on private health financing in Africa - directly because of increased disease prevalence and indirectly because of its negative impact on household income. The sources and consequences of the pressure constitute an important area of policy discourse, especially as it relates to issues of poverty and inequality. Relying on a panel dataset involving 49 African countries and the period 2000-2019, as well as a random effect regression analysis, this report shows that climate change has a positive and significant impact on the level of out-of-pocket health expenditure (OPHE) in Africa, and an increase in the level of greenhouse (CO2) emissions by 1% could bring about a 0.423% increase in the level of OPHE. Indirectly, the results show that, compared with the regional average, countries that have higher government health expenditure levels, above 1.7% regional average, and face higher climate change risk may likely record an increase in OPHE. Alternatively, countries with higher per capita income (above the regional annual average of $2300.00) are likely to record a drop in OPHE. Countries with lower climate change risk and a lower than the regional average age dependency (above the regional average of 80.4%) are also likely to record a drop in OPHE. It follows that there is a need for policy alignment, especially with regard to how climate change influences primary health care funding models in Africa.Contribution: The results of this research offer policymakers in-depth knowledge of how climate change erodes healthcare financing capacity of government and shifts the burden to households. This raises concerns on the quality of accessible healthcare and the link with poverty and inequality.
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Affiliation(s)
- Chinwe F. Ezeruigbo
- Department of Nursing, Faculty of Health Sciences and Technology, Ebonyi State University, Abakaliki, Nigeria
| | - Abel Ezeoha
- Department of Banking and Finance, Faculty of Management Sciences, Alex-Ekwueme Federal University, Abakaliki, Nigeria
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14
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Guihenneuc J, Ayraud-Thevenot S, Roschnik S, Dupuis A, Migeot V. Climate change and health care facilities: A risk analysis framework through a mapping review. ENVIRONMENTAL RESEARCH 2023; 216:114709. [PMID: 36343709 DOI: 10.1016/j.envres.2022.114709] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 10/12/2022] [Accepted: 10/30/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Climate change (CC) has been identified as the biggest global health threat of the 21st century. Although health care facilities (HCF) play a central role in the care of populations, there has been no comprehensive assessment of the impact of CC on HCF. The objective of our study was to highlight the components of HCFs affected by CC through a mapping review of the literature. METHODS To meet our objective, we first assessed the place of HCFs in relation to CC in the scientific literature and in the Intergovernmental Panel on Climate Change (IPCC) reports. Bibliometric data from the PubMed database were analyzed between 1979 and 2021 to assess the penetration of keywords on CC alone, and in relation to health and HCF in particular. Second, we analyzed the changes in HCF keywords in the IPCC reports. Finally, we conducted a mapping review in five databases, of the international scientific literature published between 1979 and 2019, and identified the components of HCF affected by CC using the Ishikawa diagram. RESULTS From the 2000s, the number of publications on CC and HCF increased gradually with 137 articles in 2005, and even more sharply since 2008 with 358 articles published and 813 in 2021. Even though CC is only recently present in the biomedical literature, all climatic events (warming and heatwaves, droughts, wildfires, storms, hurricanes and cyclones, floods and sea-level rise, and other indirect effects) have had an impact on at least one component of HCF. CONCLUSION HCFs are already impacted, in all their components, by CC. By enhancing our understanding of the impacts of CC on HCF, this work could contribute to the engagement of health professionals in the implementation of mitigation and adaptation actions, thereby limiting the consequences of CC on patient care.
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Affiliation(s)
- Jérémy Guihenneuc
- University of Poitiers, School of Medicine and Pharmacy, 6 rue de la Milétrie, TSA 51115, F-86073 Poitiers Cedex, France; University Hospital of Poitiers, Biology-Pharmacy-Public Health Department, 2 rue de la Milétrie, F-86021 Poitiers, France; INSERM, Clinical Investigation Center 1402, 2 rue de la Milétrie, F-86021 Poitiers, France; University of Poitiers, CNRS UMR7267, Ecologie & Biologie des Interactions, F-86000 Poitiers, France.
| | - Sarah Ayraud-Thevenot
- University of Poitiers, School of Medicine and Pharmacy, 6 rue de la Milétrie, TSA 51115, F-86073 Poitiers Cedex, France; University Hospital of Poitiers, Biology-Pharmacy-Public Health Department, 2 rue de la Milétrie, F-86021 Poitiers, France; INSERM, Clinical Investigation Center 1402, 2 rue de la Milétrie, F-86021 Poitiers, France; University of Poitiers, CNRS UMR7267, Ecologie & Biologie des Interactions, F-86000 Poitiers, France
| | - Sonia Roschnik
- Health Care Without Harm Europe, 1 rue de la Pépinière, Brussels 1000, Belgium
| | - Antoine Dupuis
- University of Poitiers, School of Medicine and Pharmacy, 6 rue de la Milétrie, TSA 51115, F-86073 Poitiers Cedex, France; University Hospital of Poitiers, Biology-Pharmacy-Public Health Department, 2 rue de la Milétrie, F-86021 Poitiers, France; INSERM, Clinical Investigation Center 1402, 2 rue de la Milétrie, F-86021 Poitiers, France; University of Poitiers, CNRS UMR7267, Ecologie & Biologie des Interactions, F-86000 Poitiers, France
| | - Virginie Migeot
- University of Poitiers, School of Medicine and Pharmacy, 6 rue de la Milétrie, TSA 51115, F-86073 Poitiers Cedex, France; University Hospital of Poitiers, Biology-Pharmacy-Public Health Department, 2 rue de la Milétrie, F-86021 Poitiers, France; INSERM, Clinical Investigation Center 1402, 2 rue de la Milétrie, F-86021 Poitiers, France; University of Poitiers, CNRS UMR7267, Ecologie & Biologie des Interactions, F-86000 Poitiers, France
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Vercillo S, Huggins C, Cochrane L. How is gender investigated in African climate change research? A systematic review of the literature. AMBIO 2022; 51:1045-1062. [PMID: 34669170 PMCID: PMC8847500 DOI: 10.1007/s13280-021-01631-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/03/2021] [Accepted: 09/12/2021] [Indexed: 05/21/2023]
Abstract
This systematic review analyzes all 260 studies published in the Web of Science on gender and climate change in Africa. While there is no strong methodological bias, comparative case studies and sex disaggregated analyses predominate from a limited set of countries. Many articles covered the agrarian sector by comparing women's and men's on-farm vulnerability to a changing climate based on their adaptation behaviours. Though this literature recognizes women's important conservation, farming, and food responsibilities, it oftentimes generalized these contributions without providing evidence. A number of themes were covered by a very limited number of articles, including coastal areas, conflict, education, energy, migration, urban areas, and water. Overall, more justice-oriented research is needed into the socioeconomic structures that intersect with social identities to make certain people, places, and institutions more vulnerable. Investigations into the power dynamics between (social) scientists and African institutions are also needed as most articles reviewed stem from North America and Europe and are locked beyond paywalls.
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Affiliation(s)
- Siera Vercillo
- School of Environment, Enterprise and Development, University of Waterloo, 200 University Avenue West, EV3-4301, Waterloo, ON N2L 3G5 Canada
| | - Chris Huggins
- School of International Development and Global Studies, University of Ottawa, Social Science Building (FSS) 8052, 120 University Private, Ottawa, ON K1N 6N5 Canada
| | - Logan Cochrane
- College of Public Policy, Hamad Bin Khalifa University, Qatar, UAE
- Global and International Studies, Carleton University, Ottawa, ON Canada
- Institute for Policy and Development Research, Hawassa University, Hawassa, Ethiopia
- Room 2118, Dunton Tower, 1125 Colonel by Drive, Ottawa, ON K1S5B6 Canada
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Barnwell G, Wood N. Climate justice is central to addressing the climate emergency’s psychological consequences in the Global South: a narrative review. SOUTH AFRICAN JOURNAL OF PSYCHOLOGY 2022. [DOI: 10.1177/00812463211073384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The United Nations has signalled a ‘code red’, marking climate change as an existential threat for humanity. The world is rapidly warming, and the consequences of climate change include an increase and intensification in flooding, droughts, wildfires, and other traumatic exposures. Although countries in the Global South have contributed least to global warming, they are the most vulnerable owing to historical inequities. The concept of ‘climate justice’ recognises that historical racial discrimination, class disenfranchisement, political misrecognition, and other social injustices make surviving climate change and thriving within it more challenging. This narrative review considers the psychological consequences of the climate emergency through a climate justice lens. The article discusses the unequal exposures to psychological adversities, socio-historical barriers to adaptations and, finally, institutional betrayal that complicates the experience of psychological distress. The review concludes by pragmatically discussing how psychology could support climate justice ends.
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Fox S. Synchronous Generative Development amidst Situated Entropy. ENTROPY (BASEL, SWITZERLAND) 2022; 24:89. [PMID: 35052115 PMCID: PMC8775003 DOI: 10.3390/e24010089] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/30/2021] [Accepted: 01/04/2022] [Indexed: 12/04/2022]
Abstract
The Sustainable Development Goals have been criticized for not providing sufficient balance between human well-being and environmental well-being. By contrast, joint agent-environment systems theory is focused on reciprocal synchronous generative development. The purpose of this paper is to extend this theory towards practical application in sustainable development projects. This purpose is fulfilled through three interrelated contributions. First, a practitioner description of the theory is provided. Then, the theory is extended through reference to research concerned with multilevel pragmatics, competing signals, commitment processes, technological mediation, and psychomotor functioning. In addition, the theory is related to human-driven biosocial-technical innovation through the example of digital twins for agroecological urban farming. Digital twins being digital models that mirror physical processes; that are connected to physical processes through, for example, sensors and actuators; and which carry out analyses of physical processes in order to improve their performance. Together, these contributions extend extant theory towards application for synchronous generative development that balances human well-being and environmental well-being. However, the practical examples in the paper indicate that counterproductive complexity can arise from situated entropy amidst biosocial-technical innovations: even when those innovations are compatible with synchronous generative development.
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Affiliation(s)
- Stephen Fox
- VTT Technical Research Centre of Finland, FI-02150 Espoo, Finland
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18
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Orievulu KS, Iwuji CC. Institutional Responses to Drought in a High HIV Prevalence Setting in Rural South Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:434. [PMID: 35010691 PMCID: PMC8744984 DOI: 10.3390/ijerph19010434] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 11/17/2022]
Abstract
In 2015, South Africa experienced one of the worst (El Niño-induced) droughts in 35 years. This affected economic activities, individual and community livelihoods and wellbeing especially in rural communities in northern KwaZulu-Natal. Drought's direct and indirect impacts on public health require urgent institutional responses, especially in South Africa's stride to eliminate HIV as a public health threat by 2030 in line with the UNAIDS goals. This paper draws on qualitative data from interviews and policy documents to discuss how the devastating effect of the 2015 drought experience in the rural Hlabisa sub-district of uMkhanyakude, a high HIV prevalence area, imposes an imperative for more proactive institutional responses to drought and other climate-related events capable of derailing progress made in South Africa's HIV/AIDS response. We found that drought had a negative impact on individual and community livelihoods and made it more difficult for people living with HIV to consistently engage with care due to economic losses from deaths of livestock, crop failure, food insecurity, time spent in search of appropriate water sources and forced relocations. It also affected government institutions and their interventions. Interviewed participants' reflections on drought-related challenges, especially those related to institutional and coordination challenges, showed that although current policy frameworks are robust, their implementation has been stalled due to complex reporting systems, and inadequate interdepartmental collaboration and information sharing. We thus argue that to address the gaps in the institutional responses, there is a need for more inclusive systems of drought-relief implementation, in which government departments, especially at the provincial and district levels, work with national institutions to better share data/information about drought-risks in order to improve preparedness and implementation of effective mitigation measures.
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Affiliation(s)
- Kingsley S. Orievulu
- Africa Health Research Institute, KwaZulu-Natal, Mtubatuba 3935, South Africa;
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK
- Centre for Africa-China Studies, University of Johannesburg, Johannesburg 2006, South Africa
| | - Collins C. Iwuji
- Africa Health Research Institute, KwaZulu-Natal, Mtubatuba 3935, South Africa;
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK
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De Boni L, Msimang V, De Voux A, Frean J. Trends in the prevalence of microscopically-confirmed schistosomiasis in the South African public health sector, 2011-2018. PLoS Negl Trop Dis 2021; 15:e0009669. [PMID: 34529659 PMCID: PMC8445405 DOI: 10.1371/journal.pntd.0009669] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 07/20/2021] [Indexed: 11/25/2022] Open
Abstract
Background Schistosomiasis, also known as bilharzia, is a chronic parasitic blood fluke infection acquired through contact with contaminated surface water. The illness may be mild or can cause significant morbidity with potentially serious complications. Children and those living in rural areas with limited access to piped water and services for healthcare are the most commonly infected. To address the prevalence of the disease in parts of South Africa (SA) effective national control measures are planned, but have not yet been implemented. This study aimed to estimate the prevalence and trends of public sector laboratory-confirmed schistosomiasis cases in SA over an eight-year (2011–2018) period, to inform future control measures. Methodology & principal findings This is a descriptive analysis of secondary data from the National Health Laboratory Service (NHLS). The study included all records of patients for whom microscopic examination detected Schistosoma species eggs in urine or stool specimens from January 2011 to December 2018. Crude estimates of the prevalence were calculated using national census mid-year provincial population estimates as denominators, and simple linear regression was used to analyse prevalence trends. A test rate ratio was developed to describe variations in testing volumes among different groups and to adjust prevalence estimates for testing variations. A total number of 135 627 schistosomiasis cases was analysed with the highest prevalence observed among males and individuals aged 5–19 years. We describe ongoing endemicity in the Eastern Cape Province, and indicate important differences in the testing between population groups. Conclusion While there was no overall change in the prevalence of schistosomiasis during the analysis period, an average of 36 people per 100 000 was infected annually. As such, this represents an opportunity to control the disease and improve quality of life of affected people. Laboratory-based surveillance is a useful method for reporting occurrence and evaluating future intervention programs where resources to implement active surveillance are limited. This is the first paper to describe the prevalence of human schistosomiasis in South Africa using nationally representative data. The prevalence remained consistent during the eight-year period, independent of increasing annual testing volumes. Groups with the highest burden included males and individuals aged 5–19 years. The schistosomiasis-endemic provinces of Limpopo, Mpumalanga and KwaZulu-Natal emerged as the highest-burdened areas, and ongoing endemicity in Eastern Cape Province was demonstrated. Western Cape Province likely reported cases imported from endemic provinces rather than being acquired by local transmission. In summary, schistosomiasis remains an important public health problem in South Africa that needs long-term sustainable, effective standardised interventions to reduce the burden. Passive laboratory-based surveillance is a practical tool for reporting prevalence, and could be used to monitor and evaluate future intervention programs.
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Affiliation(s)
- Liesl De Boni
- South African Field Epidemiology Training Programme, Johannesburg, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Veerle Msimang
- Centre for Emerging Zoonotic and Parasitic Diseases, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Alex De Voux
- South African Field Epidemiology Training Programme, Johannesburg, South Africa
| | - John Frean
- University of the Witwatersrand, Johannesburg, South Africa
- Centre for Emerging Zoonotic and Parasitic Diseases, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
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Opoku SK, Filho WL, Hubert F, Adejumo O. Climate Change and Health Preparedness in Africa: Analysing Trends in Six African Countries. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094672. [PMID: 33925753 PMCID: PMC8124714 DOI: 10.3390/ijerph18094672] [Citation(s) in RCA: 199] [Impact Index Per Article: 66.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/12/2021] [Accepted: 04/17/2021] [Indexed: 11/23/2022]
Abstract
Climate change is a global problem, which affects the various geographical regions at different levels. It is also associated with a wide range of human health problems, which pose a burden to health systems, especially in regions such as Africa. Indeed, across the African continent public health systems are under severe pressure, partly due to their fragile socioeconomic conditions. This paper reports on a cross-sectional study in six African countries (Ghana, Nigeria, South Africa, Namibia, Ethiopia, and Kenya) aimed at assessing their vulnerabilities to climate change, focusing on its impacts on human health. The study evaluated the levels of information, knowledge, and perceptions of public health professionals. It also examined the health systems’ preparedness to cope with these health hazards, the available resources, and those needed to build resilience to the country’s vulnerable population, as perceived by health professionals. The results revealed that 63.1% of the total respondents reported that climate change had been extensively experienced in the past years, while 32% claimed that the sampled countries had experienced them to some extent. Nigerian respondents recorded the highest levels (67.7%), followed by Kenya with 66.6%. South Africa had the lowest level of impact as perceived by the respondents (50.0%) when compared with the other sampled countries. All respondents from Ghana and Namibia reported that health problems caused by climate change are common in the two countries. As perceived by the health professionals, the inadequate resources reiterate the need for infrastructural resources, medical equipment, emergency response resources, and technical support. The study’s recommendations include the need to improve current policies at all levels (i.e., national, regional, and local) on climate change and public health and to strengthen health professionals’ skills. Improving the basic knowledge of health institutions to better respond to a changing climate is also recommended. The study provides valuable insights which may be helpful to other nations in Sub-Saharan Africa.
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Affiliation(s)
- Samuel Kwasi Opoku
- Research and Transfer Centre “Sustainable Development and Climate Change Management”, Hamburg University of Applied Sciences, Ulmenliet 20, D-21033 Hamburg, Germany; (S.K.O.); (F.H.)
| | - Walter Leal Filho
- Research and Transfer Centre “Sustainable Development and Climate Change Management”, Hamburg University of Applied Sciences, Ulmenliet 20, D-21033 Hamburg, Germany; (S.K.O.); (F.H.)
- Correspondence:
| | - Fudjumdjum Hubert
- Research and Transfer Centre “Sustainable Development and Climate Change Management”, Hamburg University of Applied Sciences, Ulmenliet 20, D-21033 Hamburg, Germany; (S.K.O.); (F.H.)
| | - Oluwabunmi Adejumo
- Institute for Entrepreneurship and Development Studies, Obafemi Awolowo University, Ile-Ife 220282, Osun State, Nigeria;
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Hove J, D’Ambruoso L, Twine R, Mabetha D, van der Merwe M, Mtungwa I, Khoza S, Kahn K, Witter S. Developing stakeholder participation to address lack of safe water as a community health concern in a rural province in South Africa. Glob Health Action 2021; 14:1973715. [PMID: 34538225 PMCID: PMC8462876 DOI: 10.1080/16549716.2021.1973715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/24/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Despite legislative and policy commitments to participatory water governance in South Africa, and some remarkable achievements, there has been limited progress to improve the water infrastructure servicing in marginalized rural communities. Around five million South Africans still do not have access to safe water. OBJECTIVE This paper seeks to understand and advance processes to engage multisectoral stakeholders to respond to lack of safe water as a community-nominated health priority in rural South Africa. METHOD We engaged representatives from Mpumalanga Department of Health (MDoH), rural communities, other government departments and non-governmental organisations (NGOs) to cooperatively generate, interpret and act on evidence addressing community-nominated priorities. A series of participatory workshops were conducted where stakeholders worked together as co-researchers to develop shared accounts of the problem, and recommendations to address it. Consensus on the problem, mapping existing planning and policy landscapes, and initiating constructive dialogue was facilitated through group discussions in a collective learning process. RESULTS Community stakeholders nominated lack of safe water as a local priority public health issue and generated evidence on causes and contributors, and health and social impacts. Together with government and NGO stakeholders, this evidence was corroborated. Stakeholders developed a local action plan through consensus and feasibility appraisal. Actions committed to behavioural change and reorganization of existing services, were relevant to the needs of the local community and were developed with consideration of current policies and strategies. A positive, collective reflection was made on the process. The greatest gain reported was the development of dialogue in 'safe spaces' through which mutual understanding, insights into the functioning of other sectors and learning by doing were achieved. CONCLUSION Our process reflected willingness and commitment among stakeholders to work together collectively addressing local water challenges. Location in an established public health observatory helped to create neutral, mediated spaces for participation.
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Affiliation(s)
- Jennifer Hove
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science (Achds) Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, UK
| | - Lucia D’Ambruoso
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science (Achds) Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, UK
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- National Health Service (NHS) Grampian, Scotland, UK
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Denny Mabetha
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science (Achds) Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, UK
| | - Maria van der Merwe
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science (Achds) Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, UK
- Independent Consultant, South Africa
| | - Ishmael Mtungwa
- Department of Health, Mpumalanga Provincial Government, Mbombela, South Africa
| | - Sonto Khoza
- Department of Health, Mpumalanga Provincial Government, Mbombela, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- International Network for the Demographic Evaluation of Populations and Their Health (Indepth), Accra, Ghana
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Scotland, UK
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Hrabok M, Delorme A, Agyapong VIO. Threats to Mental Health and Well-Being Associated with Climate Change. J Anxiety Disord 2020; 76:102295. [PMID: 32896782 DOI: 10.1016/j.janxdis.2020.102295] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 08/02/2020] [Accepted: 08/10/2020] [Indexed: 01/16/2023]
Abstract
Climate change is a contributor to extreme weather events and natural disasters. The mental health effects of climate change are multifaceted, with post-traumatic stress disorder and depression predominant. This paper aims to describe the impact of climate change on mental health conditions, including risk and protective factors related to the expression of mental health conditions post-disaster, as well as a discussion of our local experience with a devastating wildfire to our region within Canada. The risk of the development of mental health conditions post-disaster is not equally distributed; research has consistently demonstrated that specific risk factors (e.g., gender, socioeconomic status and education, pre-existing mental health symptomatology), are associated with increased vulnerability to mental health conditions following natural disasters. There are multiple strategies that must be undertaken by communities to enhance adjustment and coping post-disaster, including improved access to care, inter-agency cooperation, enhanced community resiliency, and adequate preparation.
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Affiliation(s)
- Marianne Hrabok
- Dission of Community Psychiatry, Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Aaron Delorme
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Vincent I O Agyapong
- Dission of Community Psychiatry, Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
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23
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Impact of Extreme Weather Events on Sub-Saharan African Child and Adolescent Mental Health: A Protocol for a Systematic Review. ATMOSPHERE 2020. [DOI: 10.3390/atmos11050493] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Sub-Saharan Africa (SSA) has been identified by the Intergovernmental Panel on Climate Change (IPCC) as being the most vulnerable region to climate change impacts. A major concern is the increase in extreme weather events (EWE) such as storms, floods, droughts, heatwaves, wildfires, and landslides in SSA and their potential to affect the health and well-being of children and adolescents. The objective of this systematic review is to examine the direct and indirect impacts of EWE on the mental health of children and adolescents living in SSA, in order to inform protective adaptation strategies and promote resilience. A meta-analysis will not be possible, since the assumption is that limited studies have been published on the EWE-associated mental health impacts on children and adolescents living in SSA and that those studies that are available are heterogenous. There is acknowledgement in the global literature of the need to highlight child and adolescent mental health more prominently in climate change health strategies and policies. It is vital that adaptation strategies are informed by research on risk prevention and promotion of resilience to ensure the mental health of children and adolescents is protected.
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24
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Slums, Space, and State of Health-A Link between Settlement Morphology and Health Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17062022. [PMID: 32204347 PMCID: PMC7143924 DOI: 10.3390/ijerph17062022] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/06/2020] [Accepted: 03/13/2020] [Indexed: 12/31/2022]
Abstract
Approximately 1 billion slum dwellers worldwide are exposed to increased health risks due to their spatial environment. Recent studies have therefore called for the spatial environment to be introduced as a separate dimension in medical studies. Hence, this study investigates how and on which spatial scale relationships between the settlement morphology and the health status of the inhabitants can be identified. To this end, we summarize the current literature on the identification of slums from a geographical perspective and review the current literature on slums and health of the last five years (376 studies) focusing on the considered scales in the studies. We show that the majority of medical studies are restricted to certain geographical regions. It is desirable that the number of studies be adapted to the number of the respective population. On the basis of these studies, we develop a framework to investigate the relationship between space and health. Finally, we apply our methodology to investigate the relationship between the prevalence of slums and different health metrics using data of the global burden of diseases for different prefectures in Brazil on a subnational level.
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25
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A population model for the 2017/18 listeriosis outbreak in South Africa. PLoS One 2020; 15:e0229901. [PMID: 32163438 PMCID: PMC7067559 DOI: 10.1371/journal.pone.0229901] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 02/18/2020] [Indexed: 11/24/2022] Open
Abstract
We introduce a compartmental model of ordinary differential equations for the population dynamics of listeriosis, and we derive a model for analysing a listeriosis outbreak. The model explicitly accommodates neonatal infections. Similarly as is common in cholera modeling, we include a compartment to represent the reservoir of bacteria. We also include a compartment to represent the incubation phase. For the 2017/18 listeriosis outbreak that happened in South Africa, we calculate the time pattern and intensity of the force of infection, and we determine numerical values for some of the parameters in the model. The model is calibrated using South African data, together with existing data in the open literature not necessarily from South Africa. We make projections on the future outlook of the epidemiology of the disease and the possibility of eradication.
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26
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Coates SJ, Enbiale W, Davis MDP, Andersen LK. The effects of climate change on human health in Africa, a dermatologic perspective: a report from the International Society of Dermatology Climate Change Committee. Int J Dermatol 2020; 59:265-278. [PMID: 31970754 DOI: 10.1111/ijd.14759] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 11/04/2019] [Accepted: 11/25/2019] [Indexed: 12/14/2022]
Abstract
Throughout much of the African continent, healthcare systems are already strained in their efforts to meet the needs of a growing population using limited resources. Climate change threatens to undermine many of the public health gains that have been made in this region in the last several decades via multiple mechanisms, including malnutrition secondary to drought-induced food insecurity, mass human displacement from newly uninhabitable areas, exacerbation of environmentally sensitive chronic diseases, and enhanced viability of pathogenic microbes and their vectors. We reviewed the literature describing the various direct and indirect effects of climate change on diseases with cutaneous manifestations in Africa. We included non-communicable diseases such as malignancies (non-melanoma skin cancers), inflammatory dermatoses (i.e. photosensitive dermatoses, atopic dermatitis), and trauma (skin injury), as well as communicable diseases and neglected tropical diseases. Physicians should be aware of the ways in which climate change threatens human health in low- and middle-income countries in general, and particularly in countries throughout Africa, the world's lowest-income and second most populous continent.
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Affiliation(s)
- Sarah J Coates
- Department of Dermatology, The University of California San Francisco, San Francisco, CA, USA
| | | | - Mark D P Davis
- Division of Clinical Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Louise K Andersen
- Department of Dermato-Venereology, Aarhus University Hospital, Aarhus, Denmark
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28
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Chersich MF, Wright CY. Climate change adaptation in South Africa: a case study on the role of the health sector. Global Health 2019; 15:22. [PMID: 30890178 PMCID: PMC6423888 DOI: 10.1186/s12992-019-0466-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/12/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Globally, the response to climate change is gradually gaining momentum as the impacts of climate change unfold. In South Africa, it is increasingly apparent that delays in responding to climate change over the past decades have jeopardized human life and livelihoods. While slow progress with mitigation, especially in the energy sector, has garnered much attention, focus is now shifting to developing plans and systems to adapt to the impacts of climate change. METHODS We applied systematic review methods to assess progress with climate change adaptation in the health sector in South Africa. This case study provides useful lessons which could be applied in other countries in the African region, or globally. We reviewed the literature indexed in PubMed and Web of Science, together with relevant grey literature. We included articles describing adaptation interventions to reduce the impact of climate change on health in South Africa. All study designs were eligible. Data from included articles and grey literature were summed thematically. RESULTS Of the 820 publications screened, 21 were included, together with an additional xx papers. Very few studies presented findings of an intervention or used high-quality research designs. Several policy frameworks for climate change have been developed at national and local government levels. These, however, pay little attention to health concerns and the specific needs of vulnerable groups. Systems for forecasting extreme weather, and tracking malaria and other infections appear well established. Yet, there is little evidence about the country's preparedness for extreme weather events, or the ability of the already strained health system to respond to these events. Seemingly, few adaptation measures have taken place in occupational and other settings. To date, little attention has been given to climate change in training curricula for health workers. CONCLUSIONS Overall, the volume and quality of research is disappointing, and disproportionate to the threat posed by climate change in South Africa. This is surprising given that the requisite expertise for policy advocacy, identifying effective interventions and implementing systems-based approaches rests within the health sector. More effective use of data, a traditional strength of health professionals, could support adaptation and promote accountability of the state. With increased health-sector leadership, climate change could be reframed as predominately a health issue, one necessitating an urgent, adequately-resourced response. Such a shift in South Africa, but also beyond the country, may play a key role in accelerating climate change adaptation and mitigation.
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Affiliation(s)
- Matthew F Chersich
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Caradee Y Wright
- Environment and Health Research Unit, South African Medical Research Council and Department of Geography, Geoinformatics and Meteorology, University of Pretoria, Pretoria, South Africa
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