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Gut 2004;53:392-400. doi: 10.1136/gut.2003.018572 Background: Interleukin 18 (IL-18) is a cytokine with pleiotropic activity that augments T helper 1 responses and cytotoxic activity of natural killer cells. Methods: To assess [...]

Balancing the numerous benefits that may accrue from pesticide use on cotton, farmers face health hazards. Pesticide-induced acute symptoms significantly increased the cost-of-illness in a survey of 280 smallholder cotton growers in two districts of Zimbabwe. Cotton growers lost a mean of Z$180 in Sanyati and Z$316 per year in Chipinge on pesticide-related direct and indirect acute health effects. These values are equivalent to 45% and 83% of annual household pesticide expenditures in the two districts. The time spent recuperating from illnesses attributed to pesticides averaged 2 days in Sanyati and 4 days in Chipinge during the 1998/1999 growing season. These pesticide health cost estimates represent lower bounds only; they omit chronic pesticide health effects as well as suffering and other non-monetary costs. Acute pesticide symptoms were determined in large part by pesticide use practices, notably the lack of protective clothing. Yet many smallholder farmers misunderstood pesticide health hazards, and so did little to protect themselves. Despite the use of simple color codes, 22% of smallholder cotton growers in Sanyati and 58% in Chipinge did not know how the four colored triangles communicated increasing degrees of pesticide toxicity. Better farmer education in exposure averting strategies is needed. Likewise, fuller accounting for hidden health costs in future would allow farmers to make more informed decisions about agricultural pest management. Keywords: Pesticide; Occupational health; Cost-of-illness; Agriculture; Cotton; Zimbabwe

Climatic variability and soil fertility decline present a fundamental challenge for smallholder farmers to determine the optimum management practices in the production of maize. Optimizing genotype (G) and management (M) of maize under different environmental conditions (E) and their interactions are essential for enhancing maize productivity in the smallholder sector of Malawi where maize is the main staple food. Here, we evaluated over seven seasons, the performance of four commercial maize genotypes [including hybrids and one open pollinated variety (OPV)] managed under different Conservation Agriculture (CA) and conventional practices (CP) across on-farm communities of central and southern Malawi. Our results revealed significant G×E and E×M interactions and showed that hybrids such as DKC 80-53 and PAN 53 outyielded the other hybrid and the OPV in most of the environments while the OPV ZM523 had greater yields in environments with above-average rainfall and shorter in-season dry spells. These environments received a maximum of 1250 mm to 1500 mm of rainfall and yet the long-term averages were 855 mm and 1248 mm, respectively. Despite yielding lower, the OPV ZM523 also exhibited higher yield stability across environments compared to the hybrid MH 30, possibly due to its resilience to drought, heat stress, and low soil fertility conditions which are often prevalent in the target communities. Conservation Agriculture-based practices outyielded CP across the genotypes and environments. However, amongst the CA-based systems, intercropping of maize with pigeonpea [Cajanus cajan (L.) Millsp] and cowpea (Vigna unguiculata Walp.) performed less than monocropping maize and then rotating it with a legume probably due to competition for moisture between the main and the companion crops in the intercrop. The key findings of this study suggest the need to optimize varietal and management options for particular environments to maximize maize productivity in Malawi. This means that smallholder farmers in Malawi should adopt hybrids and CA-based systems for enhanced yields but could also consider OPVs where the climate is highly variable. Further rigorous analysis that includes more abiotic stress factors is recommended for a better understanding of yield response.

In this analysis we examine through an intersectionality lens how key social determinants of health (SDOH) are associated with health conditions among under-five children (

Abstract Agriculture is exposed to climate change. This is particularly the case for developing countries like Nigeria, which suffer from persistent food insecurity today while also facing substantial population growth and a high exposure to the adverse consequences of global warming. Climate-smart agriculture (CSA) practices seek to mitigate agriculture’s contribution to climate change while building resilience and adaptation to the impacts of climate change and increasing the production of food crops. CSA is an approach to identify production systems that can best respond to the impacts of climate change and to adjust these systems to suit local conditions. In this study, we use descriptive statistics to characterize socio-economic characteristics of smallholder farmers in four states in Nigeria and identify the major needs, practices and constrains to CSA. Our results reveal that the mean farmer is an adult (40 years) male that has 10 members in their household and 12 years of farming experience, cultivating an area of 3 ha. The majority (87.2%) of farmers has adopted at least one climate resilient trait in crops. Farmers greatest needs on climate smart adaptation, mitigation and profitability were solutions to reduce in-season crop loss (56%), increase water use efficiency (42%) and increase productivity (54%), respectively. Our study intends to provide to a better understanding of the needs and motivations of local farming communities and a better understanding of their motivation to engage in CSA to develop and deploy more tailored initiatives for improving the resilience and productivity of smallholder farming systems.

Abstract Background The connection between healthy housing status and health is well established. The quality of housing plays a significant role in infectious and non-communicable as well as vector-borne diseases. The global burden of disease attributable to housing is considerable with millions of deaths arising from diarrheal and respiratory diseases annually. In sub-Saharan Africa (SSA), the quality of housing remains poor although improvements have been documented. There is a general dearth of comparative analysis across several countries in the sub-region. We assess in this study, the association between healthy housing and child morbidity across six countries in SSA. Methods We use the Demographic and Health Survey (DHS) data for six countries where the most recent survey collected health outcome data on child diarrhoea, acute respiratory illness, and fever. The total sample size of 91,096 is used in the analysis (representing 15, 044 for Burkina Faso, 11, 732 for Cameroon, 5, 884 for Ghana, 20, 964 for Kenya, 33, 924 for Nigeria, and 3,548 for South Africa). The key exposure variable is healthy housing status. We control for various factors associated with the three childhood health outcomes. These include quality housing status, residency (rural/urban), age of the head of the household, mother’s education, mother’s BMI status, marital status, mother’s age, and religious status. Others include the child’s gender, age, whether the child is from multiple or single births, and breastfeeding status. Inferential analysis using survey-weighted logistic regression is employed. Results Our findings indicate that housing is an important determinant of the three outcomes investigated. Compared to unhealthier housing, healthy housing status was found to be associated with reduced odds of diarrhoea in Cameroon [Healthiest: aOR = 0.48, 95% CI, (0.32,0.71), healthier: aOR = 0.50, 95% CI,(0.35,0.70), Healthy: aOR = 0.60, 95% CI, (0.44,0.83), Unhealthy: aOR = 0.60, 95% CI, (0.44,0.81)], Kenya [Healthiest: aOR = 0.68, 95% CI, (0.52,0.87), Healtheir: aOR = 0.79, 95% CI, (0.63,0.98), Healthy: aOR = 0.76, 95% CI, (0.62,0.91)], South Africa[Healthy: aOR = 0.41, 95% CI, (0.18, 0.97)], and Nigeria [Healthiest: aOR = 0.48, 95% CI,(0.37,0.62), Healthier: aOR = 0.61, 95% CI,(0.50,0.74), Healthy: aOR = 0.71, 95%CI, (0.59,0.86), Unhealthy: aOR = 0.78, 95% CI, (0.67,0.91)], and reduced odds of Acute Respiratory Infection in Cameroon [Healthy: aOR = 0.72, 95% CI,(0.54,0.96)], Kenya [Healthiest: aOR = 0.66, 95% CI, (0.54,0.81), Healthier: aOR = 0.81, 95% CI, (0.69,0.95)], and Nigeria [Healthiest: aOR = 0.69, 95% CI, (0.56,0.85), Healthier: aOR = 0.72, 95% CI, (0.60,0.87), Healthy: aOR = 0.78, 95% CI, (0.66,0.92), Unhealthy: aOR = 0.80, 95% CI, (0.69,0.93)] while it was associated with increased odds in Burkina Faso [Healthiest: aOR = 2.45, 95% CI, (1.39,4.34), Healthy: aOR = 1.55, 95% CI, (1.09,2.20)] and South Africa [Healthy: aOR = 2.36 95% CI, (1.31, 4.25)]. In addition, healthy housing was significantly associated with reduced odds of fever among children in all countries except South Africa [Healthiest: aOR = 2.09, 95% CI, (1.02, 4.29)] where children living in the healthiest homes had more than double the odds of having fever. In addition, household-level factors such as the age of the household head, and place of residence were associated with the outcomes. Child-level factors such as breastfeeding status, age, and sex, and maternal-level factors such as education, age, marital status, body mass index (BMI), and religion were also associated with the outcomes. Conclusions The dissimilarity of findings across similar covariates and the multiple relations between healthy housing and under 5 morbidity patterns show unequivocally the heterogeneity that exists across African countries and the need to account for different contexts in efforts to seek an understanding of the role of healthy housing in child morbidity and general health outcomes.

Background: The Covid-19 pandemic has placed a significant burden on psychosocial health and wellbeing of childcare providers. The need to support childcare managers has been recognized. However, there is to date little research specifically on how best to support the mental health needs of childcare providers, and no studies on their own experiences and views about what might be most helpful. We set out to address this research gap by qualitatively exploring the psychosocial experiences of childcare providers in Korogocho and Viwandani informal settlements in Nairobi, Kenya. Methods: We collected data through key informant interviews with thirty-two childcare providers who were recruited purposively from Korogocho and Viwandani informal settlements. We analysed the data using framework analysis. Results: We organized the results into six psychosocial support domains derived from themes identified during coding and analysis. As such, experiences and views about psychosocial support were diverse, ranging from self or individual; family and friends; colleagues, peers and teams; organizational; media and the wider public to specialized psychological support services. Colleagues and teams were most childcare centres' first line of support. Notably, like psychosocial support from self, family, organization, media and specialized support services, there were several caveats. Particularly, peer support was described to be a burden to other childcare providers. Conclusions: There is a need to strengthen psychosocial support from colleagues and teams, as it was the most preferred support. Further, there is a need for preparedness and response plans concerning the psychosocial consequences in an outbreak. As such, organisations, governments and other health and wellbeing actors ought to put measures in place to curb not only the physical health of individuals but also their psychosocial wellbeing as well. We recommend that psychosocial support structures of all nature by key actors in organisations should be kept operating during and beyond a crisis. More research is needed to fully unpack the structural, systemic and individual barriers to accessing psychosocial support during and beyond a pandemic.

Introduction Global morbidity from enteric infections and diarrhoea remains high in children in low-income and middle-income countries, despite significant investment over recent decades in health systems and water and sanitation infrastructure. Other types of societal development may be required to reduce disease burden. Ecological research on the influence of household and neighbourhood societal development on pathogen transmission dynamics between humans, animals and the environment could identify more effective strategies for preventing enteric infections.Methods and analysis The ‘enteric pathome’—that is, the communities of viral, bacterial and parasitic pathogens transmitted from human and animal faeces through the environment is taxonomically complex in high burden settings. This integrated cohort-exposure assessment study leverages natural socioeconomic spectrums of development to study how pathome complexity is influenced by household and neighbourhood infrastructure and hygiene conditions. We are enrolling under 12-month-old children in low-income and middle-income neighbourhoods of two Kenyan cities (Nairobi and Kisumu) into a ‘short-cohort’ study involving repeat testing of child faeces for enteric pathogens. A mid-study exposure assessment documenting infrastructural, behavioural, spatial, climate, environmental and zoonotic factors characterises pathogen exposure pathways in household and neighbourhood settings. These data will be used to inform and validate statistical and agent-based models (ABM) that identify individual or combined intervention strategies for reducing multipathogen transmission between humans, animals and environment in urban Kenya.Ethics and dissemination The protocols for human subjects’ research were approved by Institutional Review Boards at the University of Iowa (ID-202004606) and AMREF Health Africa (ID-ESRC P887/2020), and a national permit was obtained from the Kenya National Commission for Science Technology and Innovation (ID# P/21/8441). The study was registered on Clinicaltrials.gov (Identifier: NCT05322655) and is in pre-results stage. Protocols for research on animals were approved by the University of Iowa Animal Care and Use Committee (ID 0042302).

Urbanization is rapidly increasing across Africa, including in Nairobi, Kenya. Many people, recent migrants and long-term residents, live within dense and dynamic urban informal settlements. These contexts are fluid and heterogeneous, and deepening the understanding of how vulnerabilities and marginalization are experienced is important to inform pointed action, service delivery and policy priorities. The aim of this paper is to explore vulnerabilities and marginalization within Korogocho and Viwandani informal settlements in Nairobi and generate lessons on the value of a spectrum of community based participatory research approaches for understanding health and well-being needs and pinpointing appropriate interventions. In the exploratory stages of our ARISE consortium research, we worked with co-researchers to use the following methods: social mapping, governance diaries, and photo voice. Social mapping (including the use of Focus Group Discussions) identified key vulnerable groups: marginalized and precarious child heads of households (CHHs), Persons with disability who face multiple discrimination and health challenges, and often isolated older adults; and their priority needs, including health, education, water and sanitation. The governance diaries generated an understanding of the perceptions of the particularly vulnerable and marginalized informal settlement residents regarding the various people and institutions with the power to influence health and wellbeing; while photo voice highlighted the lived experiences of vulnerability and marginality. Understanding and responding to fluid and intersecting marginalities and vulnerabilities within growing urban informal settlements is particularly critical to achieving inclusive urbanization, where no one is left behind, a theme central to the Sustainable Development Goals and Kenya’s Vision 2030.

Over the past two decades, Higher Education Institutions (HEIs) in South Africa have been formulating e-learning policies to assist them to realise the full potential of using ICTs in teaching and learning. E-learning policies serve as guiding frameworks that create enabling environments for embedding ICTs in teaching and learning. The development of e-learning policies has attracted various stakeholders and actors with varied interests, views, priorities, influence and power. Consequently, stakeholder engagement is now an essential factor in the policy process. The efficacy of an e-learning policy can therefore be judged based on the multiple perspectives that it includes and the inclusion of those it affects in the policy-making process. In light of this background, this paper examined stakeholder engagement that characterised the e-learning policy formulation process at a University of Technology in South Africa (UoT). How stakeholders were engaged in the policy-making process using stakeholder engagement as its analytical framework, the stakeholders and actors involved in the policy formulation process and the nature of the dialogue that informed the policy formulation process were examined. The qualitative study gathered evidence using semi-structured interviews and document analysis. The study's findings show that the policy-making process at the UoT followed a bureaucratic process dominated by one actor, the policy delegate. Key stakeholders were excluded during the policy formulation process and were only consulted at the drafting stage. As a result, stakeholder engagement in the policy formulation process was low, resulting in key stakeholders and actors lacking policy ownership. Our findings also show that the exclusion of key stakeholders in the policy formulation process resulted in a policy that exclusively focuses on the Learner Management System and overlooks other technologies that play a crucial role in teaching and learning. These findings suggest the need to include all critical stakeholders and actors affected and interested in the e-learning policy at every stage of the policy formulation process.

Social accountability for water, sanitation and hygiene (WASH) services is a critical component to realising child rights to WASH services by the urban poor, more so in childcare centres. Despite the existence of discrete social accountability mechanisms (SAMs) in informal settlements, informal SAMs rarely form part of strategic approaches to addressing social accountability challenges in access to WASH services in childcare centres. The main objective of the study was to explore informal social accountability mechanisms for WASH in childcare centres in Korogocho and Viwandani informal settlements in Nairobi City County, Kenya. This qualitative study was an ethnography, where we administered governance diaries to 24 participants (parents and childcare managers) for 4 months. Data generated were analysed using a framework analysis derived from a principal-stewardship framework. Parents and centre managers, who are key actors for WASH services in childcare centres in informal settlements, relied on using informal SAMs. We identified three SAMs; (i) discretionary behaviours (rewards and sanctions, interpretation of rules and guidelines and peer mentorship); (ii) norms and values; and (iii) facilitative behaviours. The SAMs were interrelated and operated in synergy for access to WASH service by children in childcare centres. The SAMs for WASH used by parents and childcare owners in childcare centres encountered the following challenges; unrealistic expectations, negligence, conflicting expectations, conflicting agenda and administrative cultures, and tensions over performance standards and monitoring. Identified strategies for strengthening the SAMs included consistency in adhering to rules and guidelines for WASH service provision, and collaboration with strong WASH actors. Data from this study suggest it is valuable to examine and understand SAMs as this then offers clear pathways to mitigate problems and enact change in the WASH service delivery for improved global agenda of SDG 4 and SDG 6. Further, there is potential for joint advocacy for improved WASH services throughout the informal settlement. While SAMs are often conceptualised as a formal process or an intervention, this study shows that existing daily informal SAMs play an important role in promoting or maintaining WASH service delivery. Therefore, WASH stakeholders need to revisit, co-develop and evaluate informal SAMs for WASH service delivery.

Abstract Background The growing urban population imposes additional challenges for health systems in low- and middle-income countries (LMICs). We explored the economic burden and inequities in healthcare utilisation across slum, non-slum and levels of wealth among urban residents in LMICs. Methods This scoping review presents a narrative synthesis and descriptive analysis of studies conducted in urban areas of LMICs. We categorised studies as conducted only in slums, city-wide studies with measures of wealth and conducted in both slums and non-slums settlements. We estimated the mean costs of accessing healthcare, the incidence of catastrophic health expenditures (CHE) and the progressiveness and equity of health expenditures. The definitions of slums used in the studies were mapped against the 2018 UN-Habitat definition. We developed an evidence map to identify research gaps on the economics of healthcare access in LMICs. Results We identified 64 studies for inclusion, the majority of which were from South-East Asia (59%) and classified as city-wide (58%). We found severe economic burden across health conditions, wealth quintiles and study types. Compared with city-wide studies, slum studies reported higher direct costs of accessing health care for acute conditions and lower costs for chronic and unspecified health conditions. Healthcare expenditures for chronic conditions were highest amongst the richest wealth quintiles for slum studies and more equally distributed across all wealth quintiles for city-wide studies. The incidence of CHE was similar across all wealth quintiles in slum studies and concentrated among the poorest residents in city-wide studies. None of the definitions of slums used covered all characteristics proposed by UN-Habitat. The evidence map showed that city-wide studies, studies conducted in India and studies on unspecified health conditions dominated the current evidence on the economics of healthcare access. Most of the evidence was classified as poor quality. Conclusions Our findings indicated that city-wide and slums residents have different expenditure patterns when accessing healthcare. Financial protection schemes must consider the complexity of healthcare provision in the urban context. Further research is needed to understand the causes of inequities in healthcare expenditure in rapidly expanding and evolving cities in LMICs.

IntroductionOne of the major challenges that persons with disabilities (PWDs) are facing globally is unemployment. The challenge is attributed to systems that are not built with inclusivity in mind by employers. As such, the work of inclusion is not inviting PWDs to do more but to make a difference through social support. Most research on inclusion in the employment of PWDs in low-income settings has been concentrated upon the labor “supply” side, and to the best of our knowledge, no specific studies moved toward inclusion in employment issues from the employers’ perspective in informal settlements. Notably, our research question is: “what would it take to socially support employed PWD in informal settlements building from the perspectives of employers.”MethodsThis paper used data from in-depth interviews with 38 service providers in the education, health, water, sanitation, and solid waste management sectors and two sub-county officials in two informal settlements in Nairobi, Kenya. The service providers were employers or entrepreneurs who had hired PWDs in their workspaces and the sub-county officials that had vast experiences with employed PWDs. Data from transcripts were analyzed by the research team using content analysis.ResultsThe social support offered to employed PWDs included listening to them with a concern; identifying their strengths and obstacles; planning for them based on their qualities, knowledge, and experience and linking them with existing opportunities; creating specific opportunities and facilitating their access to opportunities; gradual withdrawal of support by support group; and, lastly, compromise by employers with PWD inclusion strategies. Study participants described how misdirected and inadequate resources, dissatisfaction and unhappiness, and conflicts at the workplace associated with non-inclusion were constraints to social support. Employment matters affecting PWDs are complex and require multi-pronged context-specific social support approaches. Essential to the functioning of an inclusive workplace for PWDs were communication, coordination, sharing of the workload, and supporting individual PWD.ConclusionInclusion of PWDs in the labor market is about generating a supportive workplace where people are valued and appreciated without judgement for what they can contribute. Notably, in the absence of jobs for everyone and high unemployment rates among every segment of the population, there is a need for an awareness creation, mobilization, and sensitization of employers and investors around the competencies of PWDs and their need to socially support on an impartial basis. On the other hand, employment centers could establish stations in low-income areas to advise and support PWDs on career opportunities that are disability-friendly and partner with employers to avail information about the capabilities of PWDs. Conversely, the government should provide some tax-related benefits to employers to upsurge employer incentives for hiring PWDs and empower employers on benefits and positive culture of employing PWDs. At all times, employers should be hands-on and involve diverse stakeholders to implement current policies and frameworks in different work contexts across the country and beyond.

Table of Contents Abstract Introduction Case report Results Discussion Conclusion References Abstract A review of 880 aviary bird case files, including pathology, biopsy, and clinical findings was conducted at the [...]

Challenges of soil degradation and changing climate pose major threats to food security in many parts of the world, and new approaches are required to close yield and nutrition gaps through enhanced agronomic efficiency. Combined use of mineral fertilizers, organic inputs, improved germplasm and adaptation of these practices to local contexts through improved agronomy can promote efficiency whilst building stocks of soil organic matter (SOM). Within this framework, recent attention has turned to the nature of plant-soil interactions to increase response to mineral fertilizer inputs through utilisation of nutrients from SOM that are replenished through management. This utilisation has been shown in barley and maize to vary with genotype and to be related to root physiological traits associated with rhizodeposition. The identification of candidate genes associated with rhizodeposition takes this a step closer towards the possibility of breeding for sustainability. Here we discuss this potential and feasibility in the context of maize cropping systems, and explore the potential for a combined approach that optimises utilisation of SOM nutrients together with enhanced biological nitrification inhibition to further improve agronomic efficiency.

IntroductionIt is widely acknowledged that vulnerable populations are hit very hard, both in the short and long term, when their health and wellbeing needs are not met. Despite the efforts at different levels to protect and promote their health and wellbeing, older persons, people with disabilities and children heads of households, continue to face significant social, economic and cultural difficulties in relation to health and wellbeing inequities. While rights to health and wellbeing are constitutionally guaranteed, and strategies can be advanced to reduce vulnerable situations, challenges persists and yet societies, communities, and individual factors that engender vulnerability are understudied and remain poorly understood. Situating our findings and understandings within CLUVA social vulnerability framework, allows us to adapt a conceptual framework for understanding vulnerability to health and wellbeing challenges across different groups in informal urban space. We used CLUVA social vulnerability framework to explore and uncover drivers of vulnerability to health and wellbeing challenges among the vulnerable and marginalized groups using the governance diaries approach.MethodsThis was an ethnographic study, using governance diaries with 24 participants in Korogocho and Viwandani informal settlements in Nairobi, Kenya. The governance diaries approach involved bi-weekly governance in-depth interviews (IDIs) with study participants for 4 months, complemented with observations, reflections, participant diaries and informal discussions. We used framework analysis methodology.ResultsWe identified several interlinked drivers and grouped them as individual, community, societal and structural level factors.DiscussionA comprehensive view of drivers at different levels will help actors engage in more expansive and collaborative thinking about strategies that can effectively reduce health and wellbeing challenges.ConclusionThe factors identified come together to shape functioning and capabilities of vulnerable groups in informal settlements. Beyond applying a more comprehensive concept of understanding health and wellbeing challenges, It is important to understand the drivers of vulnerability to health and wellbeing challenges from the perspective of marginalized and vulnerable populations. Particularly for local urban planning, the information should blend routine data with participatory assessment within different areas and groups in the city.

IntroductionBeyond several interests and speculations on the relationship between formal and informal actors and their networks in support of vulnerable populations, most studies do not conclusively establish whether the two types of support are substitutes or complements. While informal care and formal care may be substitutes in general, they are complements among the vulnerable groups. Despite how some studies have described complementarity, further insights on the synergy between formal and informal actors and networks are needed to pinpoint how to maximize policy and interventions to alleviate the challenges facing vulnerable groups in informal settlements.MethodsWe conducted an ethnography using governance diaries with 24 participants in Korogocho and Viwandani informal settlements in Nairobi, Kenya. The governance diaries approach involved conducting bi-weekly governance in-depth interviews (IDIs) with study participants for 4 months, complemented with observations, reflections, participant diaries and informal discussions. We used framework analysis approach.FindingsInformal actors identified include family, neighbors, friends, community groups and community members, and their direct networks. Formal actors on the other hand included government institutions, individuals and authorities that make policies and rules and their desired and possible networks. Both the formal and informal actors and their networks had complementary roles that were beneficial to the vulnerable populations living and working in informal settlements. The complementarities between formal and informal actors and networks in supporting vulnerable groups were portrayed in roles and responsibilities to the vulnerable groups; rules, regulations and governance in supporting vulnerable groups; knowledge, skills and dynamic workforces among formal and informal actors and their networks; information flow on health and wellbeing to the vulnerable populations; transition of actors in supporting vulnerable groups; availability, access and involvement of formal and informal actors and networks to support vulnerable groups. The complementarities allowed for maximum support of the vulnerable populations than otherwise.ConclusionWe conclude that informal social support is needed regardless of the availability of formal social support. Moreover, a combination of formal and informal actors and related networks are essential to support vulnerable persons. Formal actors should establish, support, or maintain the informal actors and related networks through goodwill and sundry incentives as a vital dimension of building with local community structures and enhancing inclusion, participation and ownership of policy and program interventions by marginalized and vulnerable groups.

Climate change is an increasingly important theme in Africa, where a large majority of its people depend on livestock and agricultural activities for livelihood. Concurrently, the topic of health of migrants and people on the move is rapidly raising both in the health debate and migration governance agenda in the Region. The link with climate change from the perspective of health and migration experts needs to be systematically addressed. Objectives: The article aims to contribute to the discourse on the interrelation of climate change, migration, and health by providing contributions of experts in the field of health and migration directly working with migrant and refugee communities in Africa. Methods: A webinar was conducted to collect and discuss first-hand experience with 25 participants from a postgraduate online course on health and migration funded by the Austrian Government and implemented in a co-operation of the Center for Health and Migration, Austria, with Makerere University, Uganda, the International Organization for Migration – UN Migration, and Lancet-Migration. As a result from the discussions, two cases from Sudan and Zimbabwe were selected to be further analysed with desk research to illustrate and underpin the points made. Results: All webinar participants reported to encounter climate change effects on health and migration in their professional practice. In their experience, climate change aggravates issues of health and migration by fueling forced migration and displacement, increasing health care needs, and deteriorating access to health care. Specific health challenges were identified for mental health problems caused by effects of climate change-induced migration, which remain widely undiagnosed and untreated, and the special affectedness of women and girls, with their mental, sexual and reproductive health severely deteriorated in insecure environments. The case studies from Sudan and Zimbabwe underline these observations. Conclusions: The interplay of effects of climate change, (internal) migration, and health is reported by a community of experts in the field of health and migration who are residing in Africa and working with migrant communities. Webinars prove to be an easy to implement tool to collect first hand evidence from practice experts, to foster exchange of experiences, and to get people engaged in further collaboration and discussion.

BackgroundAccountability strategies are expected to enhance access to water, sanitation and hygiene (WASH) service delivery in low-and middle-income countries (LMIC). Conventional formal social accountability mechanisms (SAMs) for WASH service delivery have been inadequate to meet the needs of residents in informal settlements in LMICs. This has prompted growing interest in alternative informal SAMs (iSAMs) in Nairobi's informal settlements. To date, iSAMs have shown a limited effect, often due to implementation failures and poor contextual fit. In childcare centers in Nairobi's informal settlements, co-creation of the iSAMs process, where parents, childcare managers, researchers and other WASH stakeholders, contribute to the design and implementation of iSAMs, is an approach with the potential to meet urgent WASH needs. However, to our knowledge, no study has documented (1) co-creating iSAMs processes for WASH service delivery in childcare centers and (2) self-evaluation of the co-creation process in the informal settlements.MethodsWe used a qualitative approach where we collected data through workshops and focus group discussions to document and inform (a) co-creation processes of SAMs for WASH service delivery in childcare centers and (b) self-evaluation of the co-creation process. We used a framework approach for data analysis informed by Coleman's framework.ResultsStudy participants co-created an iSAM process that entailed: definition; action and sharing information; judging and assessing; and learning and adapting iSAMs. The four steps were considered to increase the capability to meet WASH needs in childcare centers. We also documented a self-evaluation appraisal of the iSAM process. Study participants described that the co-creation process could improve understanding, inclusion, ownership and performance in WASH service delivery. Negative appraisals described included financial, structural, social and time constraints.ConclusionWe conclude that the co-creation process could address contextual barriers which are often overlooked, as it allows understanding of issues through the ‘eyes' of people who experience service delivery issues. Further, we conclude that sustainable and equitable WASH service delivery in childcare centers in informal settlements needs research that goes beyond raising awareness to fully engage and co-create to ensure that novel solutions are developed at an appropriate scale to meet specific needs. We recommend that actors should incorporate co-creation in identification of feasible structures for WASH service delivery in childcare centers and other contexts.

IntroductionA range of community engagement initiatives to advance health and wellbeing are currently taking place in informal settlements in low and middle income countries (LMICs), including community and stakeholder meetings, use of radio, film, TV programs and other information, education and communication materials (IECs) organized by different stakeholders. While these initiatives tend to focus on unidirectional flow of information to communities, the need to incorporate initiatives focusing on bi or multi-directional flow of information have been identified. Despite the extensive body of literature on community engagement, the role of Community Advisory Committees (CACs) in advancing health and wellbeing in informal settlements is still a puzzle, occasioned by considerable ambiguity. A community advisory committee is a dedicated group of volunteers to support health and wellbeing needs of their community using a community approach. Researchers and project implementers work in partnership with CACs to successfully implement their activities within the target community.MethodsIn this paper, using in-depth interviews, we document the roles of CACs in advancing health and wellbeing in Korogocho and Viwandani informal settlements in Nairobi, Kenya.ResultsStudy participants described the role of CAC in advancing health and wellbeing through education and awareness creation, advisory roles in research and implementation goals, protecting community interests and acting as gatekeepers and collaborators to community partners. Identified barriers to achieving CAC roles include lack of finance and other field resources, being labeled as organization staff and low involvement by some upcoming and emerging local leaders on issues which involve the CAC constituents. Enablers of CACs in their roles include possession of appropriate skills and values by members; involvement of the community in the selection of members, regular consultative and advisory meetings, representativeness in the composition of CAC membership and knowledge about the community.ConclusionWe conclude that CACs play key roles in advancing health and wellbeing in informal settlements and that existing CACs mechanisms and operations need to be given due consideration by researchers, project implementers and local authorities right from project conceptualization. CACs need recognition beyond consultations and placations during research and project implementation to a veritable social structure for community's social viability and survival as well as partners in development for inclusive urbanization process. While CACs have contributed in advancing health and wellbeing in informal settlements, there is need for a long-term strategy to optimize their impact and reduce puzzles around their roles.