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Objectives: We sought to determine if trust in government institutions mediate the relationship between experiences of discrimination and health care utilization during the COVID-19 pandemic., Methods: We used data from Statistics Canada's Crowdsourcing Data: Impacts of COVID-19 on Canadians-Experiences of Discrimination. We used generalized linear latent and mixed models (Gllamm) with a binomial and logit link function as well as generalized structural equation modeling (GSEM) to determine if reported discrimination and trust were associated with difficulties in accessing health services, health care, and the likelihood of experiencing negative health impacts. We also examined if trust mediated the relationship between experiences of discrimination and these health outcomes. Our analytical sample consisted of 2568 individuals who self-identified as belonging to a visible minority group., Results: The multivariate results indicate that experiences of discrimination during COVID-19 were associated with higher odds of reporting difficulties in accessing general health services (OR = 1.99, p ≤ 0.01), receiving care (OR = 1.65, p ≤ 0.01), and higher likelihood of reporting negative health impacts (OR = 1.68, p ≤ 0.01). Our mediation analysis indicated that trust in public institutions explained a substantial portion of the association between reported discrimination and all the health outcomes, although the effects of experiencing discrimination remain significant and robust., Conclusion: The findings show that building and maintaining trust is important and critical in a pandemic recovery world to build back better., (© 2023. W. Montague Cobb-NMA Health Institute.)

Vaccine hesitancy is considered one of the ten threats to global health. In the context of the COVID-19 pandemic, vaccine hesitancy may undermine efforts toward controlling or preventing the disease. Nevertheless, limited research has examined vaccine hesitance, particularly in low- and middle-income countries (LMICs). It is thus imperative to examine how institutional trust and conspiracy belief in tandem influence the uptake of COVID-19 vaccines. Using data (n = 2059) from a cross-sectional study in Ghana, this study examines the association between institutional trust, conspiracy beliefs, and vaccine uptake among adults in Ghana using logistics regression. The regression model (model 3) adjusted for variables such as marital status, age, gender, employment, income, and political affiliations. The results show that individuals were significantly less likely to be vaccinated if they did not trust institutions (OR = .421, CI = .232-.531). Similarly, we found that individuals who believed in conspiracy theories surrounding the COVID-19 vaccine were less likely to be vaccinated (OR = .734, CI = .436-.867). We also found that not having a COVID-19-related symptom is associated with vaccine refusal (OR = .069, CI = .008-.618). Similarly, compared to those with a vaccine history, those without a vaccine history are less likely to accept the COVID-19 vaccine (OR = .286, CI = .108-.756). In conclusion, our results demonstrate the need for enhanced education to tackle conspiracy beliefs about the disease and enhance vaccine uptake. Given the role of trust in effecting attitudinal change, building trust and credibility among the institutions responsible for vaccinations ought to be prioritized., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Achore et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Monkeypox (MPOX) was declared a global public health emergency of international concern in July 2022. Vaccinations may be an essential strategy to prevent MPOX infections and reduce their impact on populations, especially among at-risk populations. However, less is known about the factors associated with people's willingness to accept the MPOX vaccine in resource-constrained settings. In this study, we examine the associations between self-rated health, previous vaccine uptake, and people's willingness to accept the MPOX vaccine using cross-sectional data from four major cities in Ghana. The data were analyzed using descriptive and logistic regression techniques. We found that the acceptance of the MPOX vaccine is generally low (approximately 32%) in Ghana. The regression analysis reveals that individuals who did not receive vaccines in the past are much less likely to get the MPOX vaccine (AOR:.28; 95% CI:.62-2.37). The association between self-rated health and vaccine acceptance (AOR: 1.22; 95% CI:.62-2.37) disappeared after we accounted for covariates. Based on these findings, we conclude that vaccine uptake history may be critical to people's uptake of the MPOX vaccine., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Braimah et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The main goal of this study was to examine the relationship between exposure to mass media health campaign massages and the uptake of non-communicable diseases (NCDs) screening services in Ghana and whether this relationship differs by place of residence. Available evidence suggests a general low uptake of NCDs screening in developing country settings. Unfortunately, many NCDs evolve very slowly and are consequently difficult to detect early especially in situations where people do not screen regularly and in settings where awareness is low. In this study, we contribute to understanding the potential role of the media in scaling up NCDs screening in developing countries. We fitted multivariate logistic regression models to a sample of 1337 individual surveys which were collected at the neighborhood level in three Ghanaian cities. Overall, the results show that exposure to mass media chronic NCD health campaign messages was significantly associated with increased likelihood of screening for NCDs. The results further highlight neighborhood-level disparities in the uptake of NCDs screening services as residents of low-income and deprived neighborhoods were significantly less likely to report being screened for NCDs. Other factors including social capital, knowledge about the causes of NCDs and self-rated health predicted the likelihood of chronic NCDs screening. The results demonstrate mass media can be an important tool for scaling up NCDs screening services in Ghana and similar contexts where awareness might be low. However, place-based disparities need to be addressed., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Konkor et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Informal water sellers (commonly known as water vendors) have emerged as part of urban water infrastructure systems in many low- and middle-income countries to meet the water needs of unserved urban populations. These vendors include water tanker operators, those who sell water from private standpipes and boreholes, and those who use hand carts, bicycles, tricycles to transport water around for sale. However, we know little about the embodied impacts of their work on their health and wellbeing. In this article, we consider how embodied experience can add to our understandings of water access and decent work in urban centers in Sub-Saharan Africa. The study examines health risks associated with informal water vending in three cities, Accra and Wa (Ghana) and Kisumu (Kenya), where close to 48%, 65%, and 26% of residents respectively rely on vendors for their drinking water needs. We used in-depth interviews to explore the lived experiences of 59 water vendors and perspectives of 21 local stakeholders. Water vendors were mostly exposed to injury, environmental pollution, stigma, and work-life balance. Vendors who transport water in containers using bicycles or hand-pushed carts and those who carry water around complained about harsh weather conditions, poor physical terrain, and abuse from customers. Female water vendors also complained about pregnancy complications, baldness and water related diseases. Female water vendors experience unique physical threats that may put them at greater risk for chronic health and safety impacts. Gaining a better understanding of the health risks faced by these water vendors will provide policy makers with greater insight into how water vendors can be better supported to provide more improved services to enhance greater access to safe water. Findings from this work are also important for contributing to social protection policies, promoting inclusive growth, and designing empowerment programs for women., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Collective agreement about the importance of centering equity in health research, practice, and policy is growing. Yet, responsibility for advancing equity is often situated as belonging to a vague group of 'others', or delegated to the leadership of 'equity-seeking' or 'equity-deserving' groups who are tasked to lead systems transformation while simultaneously navigating the violence and harms of oppression within those same systems. Equity efforts also often overlook the breadth of equity scholarship. Harnessing the potential of current interests in advancing equity requires systematic, evidence-guided, theoretically rigorous ways for people to embrace their own agency and influence over the systems in which they are situated. ln this article, we introduce and describe the Systematic Equity Action-Analysis (SEA) Framework as a tool that translates equity scholarship and evidence into a structured process that leaders, teams, and communities can use to advance equity in their own settings., Methods: This framework was derived through a dialogic, critically reflective and scholarly process of integrating methodological insights garnered over years of equity-centred research and practice. Each author, in a variety of ways, brought engaged equity perspectives to the dialogue, bringing practical and lived experience to conversation and writing. Our scholarly dialogue was grounded in critical and relational lenses, and involved synthesis of theory and practice from a broad range of applications and cases., Results: The SEA Framework balances practices of agency, humility, critically reflective dialogue, and systems thinking. The framework guides users through four elements of analysis (worldview, coherence, potential, and accountability) to systematically interrogate how and where equity is integrated in a setting or object of action-analysis. Because equity issues are present in virtually all aspects of society, the kinds of 'things' the framework could be applied to is only limited by the imagination of its users. It can inform retrospective or prospective work, by groups external to a policy or practice setting (e.g., using public documents to assess a research funding policy landscape); or internal to a system, policy, or practice setting (e.g., faculty engaging in a critically reflective examination of equity in the undergraduate program they deliver)., Conclusions: While not a panacea, this unique contribution to the science of health equity equips people to explicitly recognize and interrupt their own entanglements in the intersecting systems of oppression and injustice that produce and uphold inequities., (© 2023. The Author(s).)

Knowledge of infectious diseases and self-action are vital to disease control and prevention. Yet, little is known about the factors associated with knowledge of and self-action to prevent the coronavirus disease (COVID-19). This study accomplishes two objectives. Firstly, we examine the determinants of COVID-19 knowledge and preventive knowledge among women in four sub-Saharan African countries (Kenya, Nigeria, the Democratic Republic of Congo, and Burkina Faso). Secondly, we explore the factors associated with self-action to prevent COVID-19 infections among these women. Data for the study are from the Performance for Monitoring Action COVID-19 Survey, conducted in June and July 2020 among women aged 15-49. Data were analysed using linear regression technique. The study found high COVID-19 knowledge, preventive knowledge, and self-action among women in these four countries. Additionally, we found that age, marital status, education, location, level of COVID-19 information, knowledge of COVID-19 call centre, receipt of COVID-19 information from authorities, trust in authorities, and trust in social media influence COVID-19 knowledge, preventive knowledge, and self-action. We discuss the policy implications of our findings., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Braimah et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Gender-based violence resulting from water, sanitation and hygiene (WASH) insecurity is a major public health problem. WaSH gender-based (WaSH-GBV) is a spatio-temporal experience and has disproportionate health and wellbeing impacts on women and girls. However, the global community of WaSH practitioners and policymakers is yet to adequately address women's vulnerability to violence in relation to WaSH access. Informed by the feminist political ecology of health framework, we conducted in-depth interviews (n = 27, 16 women and 11 men) with Ghanaian immigrants to Canada to explore perceptions of WaSH experiences over lifecourse. Results revealed that participants' perceptions and experiences of GBV are both socially and context dependent, organized around four dimensions: structural, physical, psychological, and sexual. These muti-scalar dimensions of diasporans' WaSH experiences and perceptions in Ghana are discussed along with their implications for policy and practice, specifically in enhancing health equity and water security., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Global health surveillance reports show Africa's epidemiologic transition from one dominated by higher burdens of nutritional, maternal, and communicable diseases to one increasingly dominated by non-communicable diseases (NCDs). Debates on the increasing cases of NCDs in the African context have focused on individualistic risk factors to the neglect of other similar important determinants such as the living environment. Drawing on theoretical tenets of the protection motivation theory and using cross-sectional data, we examined neighborhood risk perceptions and self-rated risk of developing NCDs in Ghana. The dependent variable 'self-rated risk of developing NCDs' was measured as a binary outcome and the focal independent variable - perceived neighborhood health risk - as an index. We fitted multivariate multilevel regression models to a sample of 1376 individuals across 9 neighborhoods. Results show that respondents who perceived their neighborhoods as risky were more likely to rate their risk of developing NCDs high. A unit increase in neighborhood violence was associated with 8% likelihood of self-rated risk of developing NCDs. However, a unit increase in the aesthetic quality of respondent's neighborhood was associated with lower likelihood of self-rated risk of developing NCDs. Engaging in regular physical activity, and non-tobacco use were associated with a lower likelihood of perceived NCDs risk. We suggest policy agendas intended for reducing the burden of NCDs in Ghana and other LMICs could incorporate programs that target improving environmental characteristics to minimize risks and offer people the opportunity to make healthy choices., Competing Interests: Declaration of competing interest None., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Access to safe drinking water is critical in improving health and well-being. It is estimated that >40% of urban households in Ghana do not have access to safe drinking water. Although the willingness and ability of community members to collectively take local initiatives are essential to curtailing inequities in water access in Ghana, the determinant of collective action is less explored. This paper explores determinants of collective action in water-insecure neighbourhoods and examines how perceived inequities in access to water and trust mediate the relationship between lack of access to water and collective action in urban Ghana. The results show that the urban poor OR = 12.047 (p = 0.000) were more likely to participate in water-related collective action compared to wealthy individuals. Primary decision-makers were 1.696 times more likely to participate in collective (p = 0.02). We also found that perceived inequities OR = 0.381 (p = 0.00) significantly predict participation in collective action to address water insecurity. Water service providers should be subjected to a rigid state-level framework that ensures inclusivity, fairness and justice in their distribution systems., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Research suggests that experiences of water insecurity may negatively impact the psycho-emotional wellbeing of water-insecure households. This paper examines how perceived inequalities in water access mediate the relationship between water insecurity and psycho-emotional distress. Data were collected among 1192 men and women in Ghana who are active water collectors within their households. We employed a binary logistics regression to identify the determinants of psycho-emotional distress. Sobel test was used to test the indirect effect of water insecurity and psycho-emotional distress through perceived inequalities. The results show that wealth (OR = 6.6, CI = 2.784-14.076), number of people in a household (OR = 1.07, CI = 1.002-1.145) and perceived inequalities (OR = 4.6, CI = 2.737-7.907) are significant predictors of psycho-emotional distress. Sobel test indicated that the point estimate (PE) of the indirect effect between water insecurity and psycho-emotional distress through perceived inequality is -0.136 (p = 0.000), meaning households were less likely to experience psycho-emotional distress if they felt that safe water facilities were equally distributed. The findings suggest that the distribution of water resources in cities with water challenges, no matter how scarce those resources are, has a profound effect on psycho-emotional distress. In resources constrained cities, there is a need for holistic water-related interventions that make inclusivity and fairness their primary focus., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background : The term 'last mile' has been used across disciplines to refer to populations who are farthest away, most difficult to reach, or last to benefit from a program or service. However, last mile research lacks a shared understanding around its conceptualization. Objectives : This project used a concept mapping process to answer the questions: what is last mile research in global health and, how can it be used to make positive change for health equity in the last mile? Methods : Between July and December 2019, a five-stage concept mapping exercise was undertaken using online concept mapping software and an in-person consensus meeting. The stages were: establishment of an expert group and focus prompt; idea generation; sorting and rating; initial analysis and final consensus meeting. Results : A group of 15 health researchers with experience working with populations in last mile contexts and who were based at the Matariki Network institutions of Queen's University, CAN and Dartmouth College, USA took part. The resulting concept map had 64 unique idea statements and the process resulted in a map with five clusters. These included: (1) Last mile populations; (2) Research methods and approaches; (3) Structural and systemic factors; (4) Health system factors, and (5) Broader environmental factors. Central to the map were the ideas of equity, human rights, health systems, and contextual sensitivity. Conclusion : This is the first time 'last mile research' has been the focus of a formal concept mapping exercise. The resulting map showed consensus about who last mile populations are, how research should be undertaken in the last mile and why last mile health disparities exist. The map can be used to inform research training programs, however, repeating this process with researchers and members from different last mile populations would also add further insight.

Water insecurity is a key public health and developmental challenge for many communities across the world. Using a meta-ethnographic synthesis, this study examines how households cope with water insecurity, as well as the socio-economic consequences and determinants of water insecurity coping strategies. A systematized keyword search was conducted in various electronic databases (PubMed, CINAHL EBSCOHost, Embase Ovid, Science Direct, Medline, Global Health, SCOPUS, Google and Google scholar). Out of 1352 potential articles, 21 studies were selected for review. Households employed nine key coping strategies. These strategies include water storage, construction of alternative water source, water sharing and borrowing from social networks, buying water from private vendors, water management and reuse, illegal connections to public water networks, water harvesting, fetching water from distant sources, and water treatment to improve the quality. Some of these coping strategies had far-reaching health and economic consequences, including the risk of water contamination, adverse psychosocial health, and impacts on household savings. We found that poor households, due to their over-reliance on short term labour-intensive and time-consuming coping strategies, are further economically disadvantaged by water insecurity. From a policy perspective, we recommend that investments in effective and efficient water supply infrastructure are needed to help alleviate the day-to-day hassles of water users. While policymakers are looking for long term solutions to these problems, some of the coping strategies identified in this synthesis, such as water conservation, water reuse, and purification of water before consumption, could be encouraged as supplementary strategies to meet households' immediate water needs., (Copyright © 2020 Elsevier GmbH. All rights reserved.)

Inadequate access to water, sanitation and hygiene (WaSH) exposes many vulnerable populations, especially women and girls, to preventable diseases around the world. This paper reports findings from a photovoice project that explored water-related risk perceptions and health outcomes among women in Nyanchwa, Kenya. Thirteen women in four age categories were recruited for this study in July 2016 using the 'snowball' technique. From the results, inadequate access to WaSH was associated with increased water collection burden on women and children; environmental pollution; poor educational outcomes; loss of time due to water collection and poor sanitation infrastructure. Some barriers to change identified include financial barriers and inadequate government support. The identified risks and barriers are important considerations for the design, evaluation and mainstreaming of WaSH programs in resource constrained settings., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Introduction: There is a growing literature demonstrating the benefits of engaging knowledge-users throughout the research process. We engaged a multi-stakeholder team to undertake a hackathon as part of an integrated knowledge translation (iKT) process to develop nonpharmacological interventions to enhance the economic lives of people with systemic lupus erythematosus (SLE). The aims of this research were to (1) increase understanding of the economic challenges of living with SLE through stakeholder engagement at a research hackathon; (2) investigate possible interventions to improve the economic lives of individuals affected by SLE in Canada; and (3) document the outcomes of the Waterlupus hackathon., Methods: Waterlupus was held at the University of Waterloo in May 2019, attended by lupus advocacy organization representatives, researchers, physicians, individuals with lived experience and students. We conducted participant observation with participants' understanding and consent; notes from the hackathon were qualitatively analyzed to document hackathon outcomes., Results: At the conclusion of the 28-hour hackathon event, five teams pitched nonpharmacological interventions to address the economic challenges of living with SLE. The winning team's pitch focussed on increasing accessibility of affordable sun-protective clothing. Other Waterlupus outcomes include increased awareness of SLE among participants, and professional and informal networking opportunities., Conclusion: This paper contributes to a limited literature on health hackathons. The successful outcomes of Waterlupus emphasize the value of hackathons as an iKT tool. Research about how knowledge-users perceive hackathons is an important next step., Competing Interests: There are no conflicts of interest to disclose.

Water security is critical to the health and well-being of people around the world, especially among populations experiencing water stresses and rapid urbanization in low- to middle-income countries (LMICs). Recent research suggests water insecurity is associated with negative mental health outcomes. Despite global improvement in access to safe water across the world, the World Health Organization (WHO) reports that access to safe water in urban areas has not changed significantly or has stagnated in certain countries. In most African cities, entrepreneurial water vendors have stepped up to fill supply gaps in the formal delivery system by selling vended water. As part of a larger research program that aims to assess and analyze public perceptions around vended water, this paper explores the links connecting water insecurity and emotional distress among urban slum dwellers who mostly use vended water in Accra, Ghana. We used a parallel mixed-methods approach. Our quantitative results show that water-insecure households (OR = 2.23, p = 0.01) were more likely to report emotional distresses compared to water-secure households. However, households with improved sanitation (OR = 0.28, p = 0.01) and those willing to participate for improved water and sanitation (OR = 0.28, p = 0.01) were less likely to report emotional distress. Our qualitative results offered support for the quantitative results, as participants not only hold various perceptions regarding the safety and quality of vended water but expressed emotional distresses such as fear of contamination, discomfort, worry over arbitrary change in prices, and anxiety. The implications of the results for policy and practice, specifically to ensuring access to safe water, are discussed.

Research has shown that inadequate access to water, sanitation, and hygiene (WASH) affects women and girls in several ways, including lowering their participation in the labour market and community activities and contributing to psychosocial stress and poor educational outcomes. There is growing awareness that addressing the gender inequalities related to WASH that many women and girls face on a daily basis must go beyond focusing on delivery of infrastructure and facilities alone and include attention to issues of empowerment. Yet there is limited exploration of how the concept of empowerment is defined and applied in the WASH sector and thus limited information on how it could be measured. This study used concept mapping to uncover the meaning and key dimensions of empowerment in WASH among 34 and 24 stakeholders in Asutifi North District, Ghana, and Banfora Commune, Burkina Faso, respectively. The study was part of initial steps toward choosing indicators for developing an Empowerment in WASH Index. In Ghana and Burkina Faso, 42 and 29 items were generated, respectively. These items were thought to empower men and women in WASH at the household and community levels. In both case studies, 7 clusters were generated and named by participants, and themes related to sharing of information, sociocultural norms, participation, and accessibility of WASH services were associated with empowerment. Some themes were unique to each case study site. Participants also showed a multidimensional and multilevel understanding of empowerment. Concept mapping created an effective balance between individual and group contributions and facilitated accessible, rapid, and contextually relevant data collection. The findings can be used to generate domains of empowerment in future quantitative research as well as inform the design of the Empowerment in WASH Index., Competing Interests: Authors declare no conflict of interest., (© 2020 The Authors.)

Medical geography and global health share a fundamental concern for health equity. Both fields operate within similar multiple intersecting funding, academic, health systems, and development landscapes to produce scholarship. Both reflect complex interactions and partnerships between people, communities and institutions of unequal power. The Canadian Coalition of Global Health Research Principles for Global Health Research evolved from deep concern about the absence of standards for how Canadians engage in this field. They can serve as a broadly relevant framework to guide how to integrate equity considerations into everyday research, knowledge translation, and practice activities. Comprised of six principles (authentic partnering, inclusion, shared benefits, commitment to the future, responsiveness to causes of inequities, and humility), they are an aspirational and reflective frame that can elevate equity as a central procedural goal and outcome. In this commentary, we describe each of the six principles and offer examples of how they are being applied to guide research practices, inform knowledge translation science and build capacity. We invite collective reflection about moving our field toward more meaningful health equity research and action, using the CCGHR Principles for Global Health Research to spark dialogue about how to align our practices with desire for a more equitable world., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Aim: This paper examined the association between wealth and health insurance status and the use of traditional medicine (TM) among older persons in Ghana., Background: There have been considerable efforts by sub-Saharan African countries to improve access to primary health care services, partly through the implementation of risk-pooling community or national health insurance schemes. The use of TM, which is often not covered under these insurance schemes, remains common in many countries, including Ghana. Understanding how health insurance and wealth influence the use of TM, or otherwise, is essential to the development of equitable health care policies., Methods: The study used data from the first wave of the World Health Organisation's Study of Global Ageing and Adult Health conducted in Ghana in 2008. Descriptive statistics and negative loglog regression models were fitted to the data to examine the influence of insurance and wealth status on the use of TM, controlling for theoretically relevant factors., Findings: Seniors who had health insurance coverage were also 17% less likely to frequently seek treatment from a TM healer relative to the uninsured. For older persons in the poorest income quintile, the odds of frequently seeking treatment from TM increased by 61% when compared to those in the richest quintile. This figure was 46%, 62% and 40% for older persons in poorer, middle and richer income quintiles, respectively, compared to their counterparts in the richest income quintile., Conclusion: The findings indicate that TM was primarily used by the poor and persons who were not enrolled in the National Health Insurance Scheme. TM continues to be a vital health care resource for the poor and uninsured older adults in Ghana.

Access to water, sanitation and hygiene (WaSH) is a major challenge in sub-Saharan Africa (SSA). Women and girls suffer the main burden of a lack of access to WaSH because they are primarily responsible for collecting water for their homes. However, they are often excluded from WaSH decision-making and implementation processes. This research sought to explore women's experiences in participating in WaSH decision-making through a case study in Nyanchwa, Kenya. Twelve (12) key informant interviews were conducted with community leaders and members regarding challenges and possible measures for enhancing women and girls' participation in WaSH decision-making. From this research, it is evident that economic challenges and cultural factors such as male dominance, greatly inhibit women and girls' participation in WaSH decision-making and implementation processes. Other factors such as time constraints and low literacy rates also emerged. The paper concludes with a call for collaboration among women's groups to enhance collective action for improved access to WaSH. This will undoubtedly lead to enhanced community health and wellbeing (Sustainable Development Goal 3, SDG3) through the empowerment of women (Sustainable Development Goal 5, SDG5).

About 22% of childhood deaths in developing countries are attributable to diarrhea. In poor resource settings, diarrhea morbidities are correlated with poverty and socio-contextual factors. Diarrhea rates in Ghana are reported to be high, with cases estimated at 113,786 among children under-five years in 2011. This study analyzed the trends of diarrhea morbidity outcomes in the Jasikan District of Ghana. A retrospective analysis of records on diarrhea data for a five years' period (January 2012 to December 2016) was undertaken. There was a total of 17740 diarrhea case reports extracted from District Health Information Management System (DHIMS) II database in an Excel format which was then exported to Stata version 14 for data cleaning, verification, and analysis. Excel version 2016 was used to plot the actual observed cases by years to assess trends and seasonality. There was a period incidence rate of 272.02 per 1000 persons with a decreasing annual growth rate of 1.85%. Declines for diarrhea generally occurred from November to December and increased from January upwards, evidence that most cases of diarrhea in this study were reported in the harmattan season. High incidence of diarrhea was found to be common among under-five children and among females. Decreasing trend of diarrhea incidence which was identified in this research within the five years' period understudied shows that, by the year 2020, there will be a sharp decline in the incidence rate of diarrhea reported cases in Jasikan District, given improvements in the external environmental conditions in the district, all things being equal.

Purpose: This study explores the relationships between neighborhood structural differences such as socioeconomic status (SES), income inequality, and ethnic diversity on women's mental health in Accra, Ghana., Methods: The study used secondary data from the 2009 Women Health Survey Accra II, linked with the 2010 sub-metro level census figures on income inequality. The analytical sample consists of 2814 women nested within 195 enumeration areas (clusters) in the Accra Metropolitan Area (AMA). Multilevel binary logit and complimentary log-log models were used to analyze the data., Results: Results suggest that social capital and neighborhood socioeconomic structural factors such SES, ethnic diversity, and housing ownership were associated with depressive symptoms, feeling downhearted, and self-reported health., Conclusions: These findings suggest that policies and programs that improve the physical and economic conditions of deprived neighborhoods, as well as civic initiatives that improve social capital and cohesion, may be important for promoting collective actions and improving health outcomes in urban settings like Accra.

This study uses a cross-sectional survey (n = 557) with a retrospective design to examine relationships between improvement in access to safe water supply (i.e. extension of municipal piped water) and a range of social outcomes including water insecurity, household time savings and allocation, and household water expenditure in Usoma, Kenya. Data were collected in July 2016, about 3 years after the intervention, using a modified version of the Household Water Insecurity Access Scale (HWIAS). Having assessed the validity and reliability of the modified HWIAS, we examine how differences in levels of access to safe water influence reported levels of water insecurity as well as amount of money and time savings, post the water intervention. Findings suggest that higher levels of access reduce risk of water insecurity. Households with piped water on premises scored 2.95 points less on the water insecurity scale compared to households with access to unimproved sources. As anticipated, time saved on water collection was re-directed to income generating activities, while money saved was spent primarily on food. Important gender differences were reported, with female headed households having 1.15 points less on the HWIAS than male headed households. This study establishes an innovative approach to evaluating water interventions that can be used in program design and evaluation. The study also emphasises the need for universal access to safe water as envisioned in the Sustainable Development Goals (SDGs)., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: This paper explores daily experiences and coping resources related to the lack of access to safe water and adequate sanitation in Usoma, a lakeshore community in Western Kenya., Methods: A qualitative approach that involved 10 focus group discussions and 9 key informant interviews with community leaders, volunteers and professionals was used to explore the research objectives. Data were collected from June to August 2013., Results: Daily practices and experiences around water and sanitation, such as water collection, open defecation and shared toilets, were a major concern to residents. In the absence of safe water, residents used social networks and support, financial resources and the nearby Lake Victoria as coping resources., Conclusion and Implication for Practice: Findings from this study are important for mobilizing resources in vulnerable settings as a first step towards designing community-based interventions. For public health practice, practitioners must work with - and collaborate across - sectors to enhance and strengthen social networks and cohesion, and protect the natural environment while working toward addressing water-related challenges in deprived settings.

The lack of access to safe water and adequate sanitation has implications for the psychosocial well-being of individuals and households. To review the literature on psychosocial impacts, we completed a scoping review of the published literature using Medline, Embase, and Scopus. Fifteen studies met the inclusion criteria and were reviewed in detail. Of the included studies, six were conducted in India, one in Nepal, one in Mexico, one in Bolivia, two in Ethiopia, one in Zimbabwe, one in South Africa, and two in Kenya. Four interrelated groups of stressors emerged from the review: physical stressors, financial stressors, social stressors, and stressors related to (perceived) inequities. Further, gender differences were observed, with women carrying a disproportionate psychosocial burden. We argue that failure to incorporate psychosocial stressors when estimating the burden or benefits of safe water and sanitation may mask an important driver of health and well-being for many households in low- and middle-income countries. We propose further research on water-related stressors with particular attention to unique cultural norms around water and sanitation, short and long term psychosocial outcomes, and individual and collective coping strategies. These may help practitioners better understand cumulative impacts and mechanisms for addressing water and sanitation challenges.

Problem: While caesarean sections in developing contexts act as a marker for access to skilled care, little is known about the health outcomes of caesarean sections. With calls for a more in depth understanding of women's perceptions of this procedure in resource poor settings, this paper explores women's perceptions and experiences of caesarean birth in the context of Ghana's Maternal Exemption Policy of the National Health Insurance Scheme in the Upper West Region., Methods: A qualitative study using 10 focus group discussions and 30 in depth interviews of mothers and pregnant women were conducted. The results were thematically analysed., Findings: Drawing on theories of feminist geography and embodiment, the results suggest most women perceive caesarean section birth as highly problematic, acting as a long term disease, which hinders their ability to engage in economic activities and care for their children. In the context of the Maternal Exemption Policy, caesarean section birth restricts a woman's ability to secure further health insurance for themselves and newborn child, leaving long term access to health care uncertain. Findings also suggest long term repercussions of caesarean sections may go beyond the physical health of the mother and child to include other socio-cultural and contextual challenges., Discussion: Accordingly, caesarean sections position women in a multifaceted situation of vulnerability. This underscores the need for context appropriate maternal health programmes in developing countries., (Copyright © 2016 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Recent years have witnessed an increase in the use of community based participatory research (CBPR) tools for understanding environment and health issues and facilitating social action. This paper explores the application and utility of photovoice for understanding water, sanitation, and hygiene (WASH) behaviours and catalysing community led solutions to change behaviours. Between June and August 2013, photovoice was conducted with eight (8) women in Usoma, a lakeshore community in Western Kenya with a follow-up community meeting (baraza) in May 2014 to discuss findings with the community members and government officials. In the first part of the study, photovoice one-on-one interviews were used to explore local perceptions and practices around water-health linkages and how the ecological and socio-political environment shapes these perceptions and practices. This paper, which is the second component of the study, uses photovoice group discussions to explore participants' experiences with and (re)action to the photographs and the photovoice project. The findings illustrate that photovoice was an effective CBPR methodology for understanding behaviours, creating awareness, facilitating collective action, and engaging with local government and local health officials at the water-health nexus.

As part of a knowledge, attitudes, practices and empowerment (KAPE) project implemented by the United Nations University Institute for Water, Environment and Health (UNU-INWEH) in the Lake Victoria Basin, this paper reports findings from a photovoice study with women in Usoma, a lakeshore community in Western Kenya. Drawing on ecosocial and political ecology theory, findings reveal that access to water, perceptions and practices were shaped by ecological and broader structural factors. Further, collective actions to improve access were constrained by institutional and economic structures, thus (re)enforcing inequalities., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Globally, an estimated 748 million people remain without access to improved sources of drinking water and close to 1 billion people practice open defecation (WHO/UNICEF, 2014). The lack of access to safe water and adequate sanitation presents significant health and development challenges to individuals and communities, especially in low and middle income countries. Recent research indicates that aside from financial challenges, the lack of social capital is a barrier to collective action for community based water and sanitation initiatives (Levison et al., 2011; Bisung and Elliott, 2014). This paper reports results of a case study on the relationships between elements of social capital and participation in collective action in the context of addressing water and sanitation issues in the lakeshore village of Usoma, Western Kenya. The paper uses household data (N=485, 91% response rate) collected using a modified version of the social capital assessment tool (Krishna and Shrader, 2000). Findings suggest that investment in building social capital may have some contextual benefits for collective action to address common environmental challenges. These findings can inform policy interventions and practice in water and sanitation delivery in low and middle income countries, environmental health promotion and community development., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

In recent years, there has been considerable interest in social capital theory in both research and policy arenas. Social capital has been associated with many aspects of improvements in health, environment and development. This paper assesses the theoretical support for a social capital based analysis of environment and health issues with a focus on the water-health nexus in low and middle income countries. We review conceptualisation of social capital by Pierre Bourdieu in relation to his concepts of "fields" and "habitus" as well as other conceptualisations of social capital by James Coleman and Robert Putnam. We integrate these authors' ideas with ecosocial analysis of social and geographical patterns of access to safe water, adequate sanitation and hygiene and the resulting health impacts. Further, we develop a conceptual framework for linking social capital and health through the water-health nexus. The framework focuses on the role of social capital in improving water-related knowledge, attitudes and practices as well as facilitating collective action towards improving access to water and sanitation. The proposed framework will facilitate critical engagement with the pathways through which social processes and interactions influence health within the context of access to water, sanitation and hygiene in low and middle income countries., (Copyright © 2014 Elsevier Ltd. All rights reserved.)