Search

As COVID-19 spread rapidly during the early months of the pandemic, many communities around the globe anxiously waited for a vaccine. At the start of the pandemic, it was widely believed that Africa would be a significant source of infection, and thus, vaccinating African communities became a primary goal among local and global health authorities. However, when the COVID-19 vaccine became available in March 2021 in Sierra Leone, many people viewed it with scepticism and hesitation. While much literature has focused on access and distribution-related challenges for vaccination in the region, a growing number of studies discuss vaccine hesitancy as driving low vaccine uptake. Shifting attention to understanding the determinants of vaccine hesitancy remains fundamental to increasing vaccination rates, as negative vaccine perceptions tend to delay or prevent vaccination. This study sought to do this by assessing, through semi-structured qualitative interviews, vaccine-related attitudes and experiences of residents of Sierra Leone's Kono District. In contrast to studies that utilise "knowledge-deficit" models of belief, however, this study drew upon the vaccine anxieties framework (Leach and Fairhead, 2007), which views vaccines as being imbued with personal, historical, and political meaning. Findings suggest that important bodily, social, and political factors, including fear of side effects, the spread of misinformation prompted by poor messaging strategies, and distrust of government and international actors, influenced people's COVID-19 vaccine attitudes and behaviours. It is hoped that the study's findings will inform future policies and interventions related to vaccine uptake in Africa and globally.

The COVID-19 pandemic has prompted a re-examination of public health preparedness with an emphasis on lessons learned following the West African Ebola epidemic. However, much of this work focuses on technological solutions rather than social learning. Drawing upon anthropological work, this paper examines how Sierra Leoneans prepared for COVID-19 through a lens of "embodied epidemic memory." Findings reveal that while people felt more empowered to respond to COVID-19 due to their past experiences, traumatic memories from the Ebola outbreak also sparked logics of fear and avoidance, driven by mistrust toward the state and its healthcare system. As a result, people avoided healthcare facilities, and rumors concerning government corruption threatened mitigation efforts. While local populations should be better leveraged for their existing epidemic expertise, greater attention is needed to the "higher hanging fruit" of preparedness: restoring trust in the government's ability to respond to epidemics., (© 2024 The Authors. Medical Anthropology Quarterly published by Wiley Periodicals LLC on behalf of American Anthropological Association.)

Background: Previous research has shown that cocaine-associated deaths occur more frequently in hot weather, which has not been described for other illicit drugs or combinations of drugs. The study objective was to evaluate the relation between temperature and risk of death related to cocaine, opioids and amphetamines in British Columbia, Canada., Methods: We extracted data on all deaths with cocaine, opioid or amphetamine toxicity recorded as an underlying or contributing cause from BC vital statistics for 1998-2017. We used a time-stratified case-crossover design to estimate the effect of temperature on the risk of death associated with acute drug toxicity during the warmer months (May through September). Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated for each 10°C increase in the 2-day average maximum temperature at the residential location., Results: We included 4913 deaths in the analyses. A 10°C increase in the 2-day average maximum temperature was associated with an OR of 1.43 (95% CI 1.11-1.86) for deaths with only cocaine toxicity recorded ( n = 561), an OR of 1.15 (95% CI 0.99-1.33) for deaths with opioids only ( n = 1682) and an OR of 1.11 (95% CI 0.60-2.04) for deaths with amphetamines only ( n = 133). There were also elevated effects when toxicity from multiple drugs was recorded. Sensitivity analyses showed differences in the ORs by sex, by climatic region, and when the location of death was used instead of the location of residence., Interpretation: Increasing temperatures were associated with higher odds of death due to drug toxicity, especially for cocaine alone and combined with other drugs. Targeted interventions are necessary to prevent death associated with toxic drug use during hot weather., Competing Interests: Competing interests: None declared., (© 2023 CMA Impact Inc. or its licensors.)

The concept of "fatherhood" in many African countries has traditionally been understood in terms of instrumental support to one's family, most notably, financial provision. However, in Sierra Leone and elsewhere, this narrow understanding of fatherhood is changing as a result of shifting demographic trends and responses to recent crises such as the Ebola pandemic and the aftermath of a civil war. Very little is understood about how male former children associated with armed forces and armed groups (CAAFAG) are navigating fatherhood and understanding their roles as fathers, particularly as many have grown up without fathers or parents themselves and experienced violence. Our study builds upon previous ethnographic research in Sierra Leone, and uses a phenomenological approach to understand 1) the meaning and importance of fatherhood to former child soldiers in Sierra Leone, 2) what fatherhood looks like normatively and ideally, with attention to norms about nurturing care as well as violence, and 3) how ideals of fatherhood may or may not be in tension with socioeconomic circumstances. We find that CAAFAG fathers in Sierra Leone are committed to providing emotional support, encouragement, and a loving upbringing in addition to striving to provide financially. CAAFAG fathers experienced the greatest tension between their ideals of fatherhood and their socio-economic circumstances in terms of financial support, such as paying school fees. In other words, fathers felt inhibited in becoming the types of fathers they hoped to be due to their experiences in a post-conflict, resource-constrained environment., Competing Interests: 6.1.Competing Interests The authors declare that they have no competing interests.

Globally, millions of unintended pregnancies result in unsafe abortions each year. In Sierra Leone, abortion-related complications are a major driver of maternal mortality. Despite these costs, women continue to seek unsafe abortions, yet how individuals understand the risks and benefits of pregnancy termination remains under-researched. This study seeks to understand perceptions of abortion by women and men experiencing unplanned pregnancy and to highlight factors that inform their abortion trajectories. Findings indicate that abortion was contemplated in response to anxieties regarding caring for a child, interruptions to schooling, and stigma associated with extra-marital pregnancy. While many women and men preferred not to abort-due to cultural values tied to parenthood-others faced obstacles stemming from lack of knowledge of and access to services. Findings can be used to inform interventions to support women and men in realising their fertility preferences in the face of unplanned pregnancy.

Western North America experienced an unprecedented extreme heat event (EHE) in 2021, characterized by high temperatures and reduced air quality. There were approximately 740 excess deaths during the EHE in the province of British Columbia, making it one of the deadliest weather events in Canadian history. It is important to understand who is at risk of death during EHEs so that appropriate public health interventions can be developed. This study compares 1,614 deaths from 25 June to 02 July 2021 with 6,524 deaths on the same dates from 2012 to 2020 to examine differences in the prevalence of 26 chronic diseases between the two groups. Conditional logistic regression was used to estimate the odds ratio (OR) for each chronic disease, adjusted for age, sex, and all other diseases, and conditioned on geographic area. The OR [95% confidence interval] for schizophrenia among all EHE deaths was 3.07 [2.39, 3.94], and was larger than the ORs for other conditions. Chronic kidney disease and ischemic heart disease were also significantly increased among all EHE deaths, with ORs of 1.36 [1.18, 1.56] and 1.18 [1.00, 1.38], respectively. Chronic diseases associated with EHE mortality were somewhat different for deaths attributed to extreme heat, deaths with an unknown/pending cause, and non-heat-related deaths. Schizophrenia was the only condition associated with significantly increased odds of EHE mortality in all three subgroups. These results confirm the role of mental illness in EHE risk and provide further impetus for interventions that target specific groups of high-risk individuals based on underlying chronic conditions., Competing Interests: The authors declare no conflicts of interest relevant to this study., (© 2023 The Authors. GeoHealth published by Wiley Periodicals LLC on behalf of American Geophysical Union.)

Exposure to biomass smoke has been associated with a wide range of acute and chronic health outcomes. Over the past decades, the frequency and intensity of wildfires has increased in many areas, resulting in longer smoke episodes with higher concentrations of fine particulate matter (PM 2.5 ). There are also many communities where seasonal open burning and residential wood heating have short- and long-term impacts on ambient air quality. Understanding the acute and chronic health effects of biomass smoke exposure requires reliable estimates of PM 2.5 concentrations during the wildfire season and throughout the year, particularly in areas without regulatory air quality monitoring stations. We have developed a machine learning approach to estimate PM 2.5 across all populated regions of Canada from 2010 to 2019. The random forest machine learning model uses potential predictor variables integrated from multiple data sources and estimates daily mean (24-hour) PM 2.5 concentrations at a 5 km × 5 km spatial resolution. The training and prediction datasets were generated using observations from National Air Pollution Surveillance (NAPS) network. The Root Mean Squared Error (RMSE) between predicted and observed PM 2.5 concentrations was 2.96 μg/m 3 for the entire prediction set, and more than 96 % of the predictions were within 5 μg/m 3 of the NAPS PM 2.5 measurements. The model was evaluated using 10-fold, leave one-region-out, and leave-one-year-out cross-validations. Overall, CanOSSEM performed well but performance was sensitive to removal of large wildfire events such as the Fort McMurray interface fire in May 2016 or the extreme 2017 and 2018 wildfire seasons in British Columbia. Exposure estimates from CanOSSEM will be useful for epidemiologic studies on the acute and chronic health effects associated with PM 2.5 exposure, especially for populations affected by biomass smoke where routine air quality measurements are not available., 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., (Crown Copyright © 2022. Published by Elsevier B.V. All rights reserved.)

Globally, over 13% of children and adolescents are affected by mental disorders, yet relatively little scholarship addresses how risk factors, symptoms, and nosology vary by culture and context, especially in young children living in post-conflict and low-resource settings. To address this gap, we conducted a qualitative study to identify and describe the most salient mental health problems facing children aged 6 to 10 years in Sierra Leone, as well as the thoughts, feelings, and behaviors related to these problems. Free list interviews ( N  = 200) and semi-structured interviews ( N  = 66) were conducted among caregivers, children, and other relevant key informants to explore risk factors and locally meaningful concepts of distress. Our findings indicate that children are faced with a variety of challenges in their social environments that contribute to distress, including hunger, unmet material needs, and excessive work. Our research identifies five contextually defined mental health problems faced by young children: gbos gbos (angry, destructive behavior), poil at (sad, disruptive behavior), diskoraj (sad, withdrawn), wondri (excessive worry), and fred fred (abnormal fear). The manifestations of these distress concepts are described in detail and contextualized according to Sierra Leone's history of war and current backdrop of poverty and insecurity. Implications are discussed for locally relevant diagnosis and treatment as well as for the wider literature on global child mental health.

Background: Residential wood burning is a major source of fine particulate matter (PM 2.5 ) during winter and a leading contributor to air pollution. Exposure to woodsmoke PM 2.5 is associated with many health effects, so it is important to characterize the magnitude and spatial variability in exposures. However, high infrastructure and maintenance costs of regulatory monitoring stations limit their spatial resolution and make monitoring infeasible for many small communities where woodsmoke may be prevalent., Methods: Mobile monitoring was conducted with a nephelometer and multi-wavelength aethalometer, capable of identifying woodsmoke PM 2.5 , to capture spatially resolved data. This Combined Aethalometer and Nephelometer for Assessment of Woodsmoke (CANAW) method was evaluated in three pairs of communities in British Columbia, Canada. Measurements were also taken at fixed-site monitoring stations. Light scattering measured by a nephelometer (B sp ) was compared with gravimetric filter-based and beta-attenuation measures of PM 2.5 . The difference in absorbance of 370 nm and 880 nm wavelengths as measured by an aethalometer (delta C), was compared with the chemical woodsmoke tracer levoglucosan., Results: Fixed site measurements of B sp and delta C were comparable with established methods of monitoring PM 2.5 and woodsmoke, respectively. Correlations in each tested relationship across all locations were high (r ≥ 0.93 in all cases). Mobile monitoring captured high spatial variation in woodsmoke PM 2.5 and maps of average concentrations during monitoring were created to identify woodsmoke hotspots., Conclusion: Following the successful implementation of the mobile CANAW method, training materials were created and tested with lay volunteers along with an online mapping application. Volunteers were able to effectively operate the equipment, collect valuable data on woodsmoke concentrations, and map spatial patterns across their communities using the application. The CANAW method is a valuable option for advancing cost-effective data collection for residential woodsmoke in otherwise unmonitored communities, and to add spatial context to existing monitoring networks., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Globally, millions of unintended pregnancies occur each year resulting in a host of social, economic, and health-related problems. Improving knowledge of and access to family planning services is an effective way to prevent unintended pregnancy, and research suggests that men's involvement promotes greater contraceptive uptake. To explore this issue, we assess contraceptive knowledge, attitudes, and behaviors among Sierra Leonean men who experienced an unplanned pregnancy. Findings indicate that men's participation in family planning was limited due to barriers including inadequate knowledge about contraception, poor access to services, and gender norms that consider family planning a woman's responsibility. As a result, men often resorted to a pattern of control that put the onus of contraceptive use on women and blamed women when they became pregnant, without considering their own role in pregnancy prevention. We suggest that family planning policies and interventions both engage men and address the barriers to their participation in reproductive health., (© 2022 The Population Council, Inc.)

Background: British Columbia, Canada, was impacted by a record-setting heat dome in early summer 2021. Most households in greater Vancouver do not have air conditioning, and there was a 440% increase in community deaths during the event. Readily available data were analyzed to inform modifications to the public health response during subsequent events in summer 2021 and to guide further research., Methods: The 434 community deaths from 27 June through 02 July 2021 (heat dome deaths) were compared with all 1,367 community deaths that occurred in the same region from 19 June through 09 July of 2013-2020 (typical weather deaths). Conditional logistic regression was used to examine the effects of age, sex, neighborhood deprivation, and the surrounding environment. Data available from homes with and without air conditioning were also used to illustrate the indoor temperatures differences., Results: A combined index of material and social deprivation was most predictive of heat dome risk, with an adjusted odds ratio of 2.88 [1.85, 4.49] for the most deprived category. Heat dome deaths also had lower greenness within 100 m than typical weather deaths. Indoor temperatures in one illustrative home without air conditioning ranged between 30°C and 40°C., Conclusions: Risk of death during the heat dome was associated with deprivation, lower neighborhood greenness, older age, and sex. High indoor temperatures likely played an important role. Public health response should focus on highly deprived neighborhoods with low air conditioning prevalence during extreme heat events. Promotion of urban greenspace must continue as the climate changes., Competing Interests: Funding for publication of this study was provided by the BC Climate Preparedness and Adaptation Strategy., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The Environmental Epidemiology. All rights reserved.)

Background: As smoking prevalence has decreased in Canada, particularly during pregnancy and around children, and technological improvements have lowered detection limits, the use of traditional tobacco smoke biomarkers in infant populations requires re-evaluation., Objective: We evaluated concentrations of urinary nicotine biomarkers, cotinine and trans-3'-hydroxycotinine (3HC), and questionnaire responses. We used machine learning and prediction modeling to understand sources of tobacco smoke exposure for infants from the CHILD Cohort Study., Methods: Multivariable linear regression models, chosen through a combination of conceptual and data-driven strategies including random forest regression, assessed the ability of questionnaires to predict variation in urinary cotinine and 3HC concentrations of 2017 3-month-old infants., Results: Although only 2% of mothers reported smoking prior to and throughout their pregnancy, cotinine and 3HC were detected in 76 and 89% of the infants' urine (n = 2017). Questionnaire-based models explained 31 and 41% of the variance in cotinine and 3HC levels, respectively. Observed concentrations suggest 0.25 and 0.50 ng/mL as cut-points in cotinine and 3HC to characterize SHS exposure. This cut-point suggests that 23.5% of infants had moderate or regular smoke exposure., Significance: Though most people make efforts to reduce exposure to their infants, parents do not appear to consider the pervasiveness and persistence of secondhand and thirdhand smoke. More than half of the variation in urinary cotinine and 3HC in infants could not be predicted with modeling. The pervasiveness of thirdhand smoke, the potential for dermal and oral routes of nicotine exposure, along with changes in public perceptions of smoking exposure and risk warrant further exploration., (© 2021. The Author(s).)

Background: The modular British Columbia Asthma Prediction System (BCAPS) is designed to reduce information burden during wildfire smoke events by automatically gathering, integrating, generating, and visualizing data for public health users. The BCAPS framework comprises five flexible and geographically scalable modules: (1) historic data on fine particulate matter (PM 2.5 ) concentrations; (2) historic data on relevant health indicator counts; (3) PM 2.5 forecasts for the upcoming days; (4) a health forecasting model that uses the relationship between (1) and (2) to predict the impacts of (3); and (5) a reporting mechanism. Methods: The 2018 wildfire season was the most extreme in British Columbia history. Every morning BCAPS generated forecasts of salbutamol sulfate (e.g., Ventolin) inhaler dispensations for the upcoming days in 16 Health Service Delivery Areas (HSDAs) using random forest machine learning. These forecasts were compared with observations over a 63-day study period using different methods including the index of agreement (IOA), which ranges from 0 (no agreement) to 1 (perfect agreement). Some observations were compared with the same period in the milder wildfire season of 2016 for context. Results: The mean province-wide population-weighted PM 2.5 concentration over the study period was 22.0 μg/m 3 , compared with 4.2 μg/m 3 during the milder wildfire season of 2016. The PM 2.5 forecasts underpredicted the severe smoke impacts, but the IOA was relatively strong with a population-weighted average of 0.85, ranging from 0.65 to 0.95 among the HSDAs. Inhaler dispensations increased by 30% over 2016 values. Forecasted dispensations were within 20% of the observed value in 71% of cases, and the IOA was strong with a population-weighted average of 0.95, ranging from 0.92 to 0.98. All measures of agreement were correlated with HSDA population, where BCAPS performance was better in the larger populations with more moderate smoke impacts. The accuracy of the health forecasts was partially dependent on the accuracy of the PM 2.5 forecasts, but they were robust to over- and underpredictions of PM 2.5 exposure. Conclusions: Daily reports from the BCAPS framework provided timely and reasonable insight into the population health impacts of predicted smoke exposures, though more work is necessary to improve the PM 2.5 and health indicator forecasts., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Henderson, Morrison, McLean, Ding, Yao, Shaddick and Buckeridge.)

In recent decades, global health researchers and policy makers have advocated for men's increased involvement in pregnancy and childbirth with the goal of improving maternal health outcomes. By "involvement," these actors generally refer to narrow-largely Western-definitions of participation: accompanying women to antenatal and postpartum care visits, engaging in childbirth education, or being present during delivery. However, such approaches often fail to account for the culturally valid and gendered ways in which men already are involved in supporting women's reproductive health. This study is based on participant observation, semi-structured interviews, and life histories conducted among 106 fathers in eastern Sierra Leone over the course of 2013-2016. Findings demonstrate that in Sierra Leone, where pregnancy and childbirth are considered to belong to the domain of women, men's primary role is to supply the material resources for a safe and healthy birth: a nutritious diet, transportation to healthcare facilities, medicines and supplies in the case of emergency, and the items to wash and dress the baby. While evidence suggests that gender norms are shifting to include other forms of intimate and emotional involvement, it is important to recognize existing forms of material support as valuable and essential forms of care. By restricting male involvement to biomedical notions of care, global health programs and policies risk discounting other types of socially meaningful support. Rather than disparaging young, African men for falling short of what Western organizations and researchers perceive to be "correct" behaviors, this paper attempts to highlight men's own understandings of involvement, so as to provide a more complete picture of the gendered nature of reproductive health in this context., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Smoke from burning biomass is an important source of fine particulate matter (PM 2.5 ), but the health risks may not be fully captured by the Canadian Air Quality Health Index (AQHI). In May 2018, the province of British Columbia launched an evidence-based amendment (AQHI-Plus) to improve AQHI performance for wildfire smoke, but the AQHI-Plus was not developed or tested on data from the residential woodsmoke season. This study assesses how the AQHI and AQHI-Plus are associated with acute health outcomes during the cooler seasons of 2010-2017 in British Columbia, Canada. Monthly and daily patterns of temperature and PM 2.5 concentrations were used to identify Local Health Areas (LHAs) that were impacted by residential woodsmoke. The effects of the AQHI and AQHI-Plus on five acute health outcomes (including non-accidental mortality, outpatient physician visits, and medical dispensations for cardiopulmonary conditions) were estimated using generalized linear mixed effect models with Poisson distributions adjusted for long- and short-term temperature trends. Values of the Akaike information criterion (AIC) were compared to evaluate whether the AQHI or AQHI-Plus was better fitted to each health outcome. Eleven LHAs were categorized as woodsmoke-impacted. In these LHAs, the AQHI and AQHI-Plus associations with acute health outcomes were sensitive to temperature adjustments. After temperature adjustments, the most consistent associations were observed for the two asthma-specific outcomes where the AQHI-Plus was better fitted than the AQHI. The improved performance of the AQHI-Plus for susceptible populations with asthma is consistent between communities impacted by residential woodsmoke and wildfire smoke. Implications : Canada's Air Quality Health Index (AQHI) is a three pollutant index used to communicate the short term health impact of degraded air quality. As fine particulate matter (PM 2.5 ) is the lowest weighted pollutant in the AQHI, the index is poorly reflective of woodsmoke impacts. The present analysis found that an AQHI amendment developed for improved sensitivity to PM 2.5 during wildfire seasons (AQHI-Plus) is also more predictive of acute asthma-related health outcomes in communities impacted by residential woodsmoke. The BC Ministry of Environment and Climate Change Strategy has piloted the AQHI-Plus year-round. Other jurisdictions should consider whether their air quality indices are reflective of the risks posed by woodsmoke.

Previous research has associated snowfall with risk of myocardial infarction (MI). Most studies have been conducted in regions with harsh winters; it remains unclear whether snowfall is associated with risk of MI in regions with milder or more varied climates. A case-crossover design was used to investigate the association between snowfall and death from MI in British Columbia, Canada. Deaths from MI among British Columbia residents between October 15 and March 31 from 2009 to 2017 were identified. The day of each death from MI was treated as the case day, and each case day was matched to control days drawn from the same day of the week during the same month. Daily snowfall amount was assigned to case and control days at the residential address, using weather stations within 15 km of the residence and 100 m in elevation. In total, 3,300 MI case days were matched to 10,441 control days. Compared with days that had no snowfall, odds of death from MI increased 34% (95% confidence interval: 0%, 80%) on days with heavy snowfall (≥5 cm). In stratified analysis of deaths from MI as a function of both maximum temperature and snowfall, risk was significantly increased on snowfall days when the temperature was warmer., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

In much of the literature on Sierra Leone, young men have been recognized for perpetrating violence or resisting authority. This characterization extended into the Ebola crisis, as young men were depicted as "resisting" public health measures. In contrast, little scholarship has focused on men's roles as caregivers during the epidemic. This article draws on ethnographic research conducted between 2014 and 2016 in eastern Sierra Leone to demonstrate how men contributed to caregiving. Findings reveal that when men were unable to care via established means, they improvised new ways to care for their families, which included: paid labor in Ebola treatment facilities; protecting their families from risk of infection; and hands-on nurturing. By focusing on these diverse types of male caregiving, this article challenges the ways in which "care" and "women" are often neatly linked and calls for a rethinking of stereotypes associating African men with violence., (© 2019 by the American Anthropological Association.)

Following an extreme heat event in 2009, a Heat Alert and Response System (HARS) was implemented for the greater Vancouver area of British Columbia (BC), Canada. This system has provided a framework for guiding public health interventions and assessing population response and adaptation to extreme heat in greater Vancouver, but no other parts of BC were covered by HARS. The objective of this study was to identify evidence-based heat alert thresholds for the Southwest, Southeast, Northwest, and Northeast regions to facilitate the introduction of HARS across BC. This was done based on a national approach that considers high temperatures on two consecutive days and the intervening overnight low, referred to as the high-low-high approach. Daily forecast and observed air temperatures and daily mortality counts for May through September of 2004 through 2016 were obtained. For each date (day t ), day t-2 forecasts were used to assign high temperatures for day t and day t+1 and the overnight low. A range of high-low-high threshold combinations was assessed for each region by finding associations with daily mortality using time-series models and other considerations. The following thresholds were established: 29-16-29 °C in the Southwest; 35-18-35 °C in the Southeast; 28-13-28 °C in the Northwest; and 29-14-29 °C in the Northeast. Heat alert thresholds for all regions in BC provide health authorities with information on dangerously hot temperature conditions and inform the activation of protective public health interventions.

Mammographic breast density is an established risk factor for breast cancer and significantly reduces the sensitivity of mammography, yet its use within breast cancer screening programs in Australia is limited. We provide a contemporary snapshot of the role of breast density measurement in screening for breast cancer and review the recent evidence for an increasing role of breast density measurement as: a predictor of breast cancer risk, a predictor of 'masking', and a biomarker to monitor effectiveness of intervention strategies for primary prevention or improved breast cancer outcomes.

The goal of this study was to assess morbidity, mortality, and health-seeking behaviours during the 2014 Ebola outbreak in Monrovia, Liberia. This study examined commonly reported symptoms of illness, pre-clinical diagnostic practices, typical healthcare-seeking strategies, and health resources available to populations, in order to identify salient needs and gaps in healthcare that would inform local emergency response efforts. Semi-structured interviews were conducted with household members in four Monrovia neighbourhoods. Researchers used a multi-stage cluster approach to recruit participants. Within 555 households sampled, 505 individuals were reported sick (69%) or recently sick (38%) or deceased (7%). Common self-diagnoses included malaria, hypertension, influenza, typhoid, and Ebola. The most cited health-seeking strategy was to purchase medications from the private sector. Respondents also obtained healthcare from community members known to have medical experience. Findings suggest that non-formal healthcare systems played an important role in managing morbidity during the West African Ebola virus disease (EVD) outbreak. Lay community members engaged in complex assessments of health symptoms and sought biomedical care at rates perhaps higher than anticipated during the response. This study highlights how informal networks of healthcare providers can play an important role in preventing and curbing future emerging disease outbreaks.

Background: Most excess deaths that occur during extreme hot weather events do not have natural heat recorded as an underlying or contributing cause. This study aims to identify the specific individuals who died because of hot weather using only secondary data. A novel approach was developed in which the expected number of deaths was repeatedly sampled from all deaths that occurred during a hot weather event, and compared with deaths during a control period. The deaths were compared with respect to five factors known to be associated with hot weather mortality. Individuals were ranked by their presence in significant models over 100 trials of 10,000 repetitions. Those with the highest rankings were identified as probable excess deaths. Sensitivity analyses were performed on a range of model combinations. These methods were applied to a 2009 hot weather event in greater Vancouver, Canada., Results: The excess deaths identified were sensitive to differences in model combinations, particularly between univariate and multivariate approaches. One multivariate and one univariate combination were chosen as the best models for further analyses. The individuals identified by multiple combinations suggest that marginalized populations in greater Vancouver are at higher risk of death during hot weather., Conclusions: This study proposes novel methods for classifying specific deaths as expected or excess during a hot weather event. Further work is needed to evaluate performance of the methods in simulation studies and against clinically identified cases. If confirmed, these methods could be applied to a wide range of populations and events of interest.

Background: Industrial plants emit air pollutants like fine particles (PM2.5), sulfur dioxide (SO2) and nitrogen dioxide (NO2) that may affect the health of individuals living nearby., Objective: To assess the effects of community exposure to air emissions of PM2.5, SO2, and NO2 from pulp mills, oil refineries, metal smelters, on respiratory hospital admissions in young children in Quebec (QC) and British Columbia (BC), Canada., Methods: We assessed QC, BC and pooled associations between the following estimates of exposure and hospital admissions for asthma and bronchiolitis in children aged 2-4years for the years 2002-2010: i) Crude emission exposures at the residential postal codes of children, calculated by multiplying estimated daily emissions of PM2.5, SO2, or NO2 from all nearby (<7.5km) pulp mills, oil refineries, metal smelters emitting yearly ≥50t and their total emissions, by the percent of the day each postal code was downwind; ii) Daily levels of these pollutants at central ambient monitoring stations nearby the industries and the children's residences., Results: Seventy-one major industries were selected between QC and BC, with a total of 2868 cases included in our analyses. More cases were exposed to emissions from major industries in QC than in BC (e.g. 2505 admissions near SO2 industrial emitters in QC vs 334 in BC), although air pollutant levels were similar. Odds ratios (ORs) for crude refinery and smelter emissions were positive in QC but more variable in BC. For example with PM2.5 in QC, ORs were 1.13 per 0.15t/day (95% CI: 1.00-1.27) and 1.03 (95% CI: 0.99-1.07) for refinery and smelter emissions, respectively. Pooled results of QC and BC for crude total SO2 emissions from all sources indicated a 1% increase (0-3%) in odds of hospital admissions per 1.50t/day increase in exposure. Associations with measured pollutant levels were only seen in BC, with SO2 and NO2., Conclusion: Hospital admissions for wheezing diseases in young children were associated with community exposure to industrial air pollutant emissions. Future work is needed to better assess the risk of exposure to complex mixture of air pollutants from multiple industrial sources., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

The Canadian Healthy Infant Longitudinal Development birth cohort was designed to elucidate interactions between environment and genetics underlying development of asthma and allergy. Over 3600 pregnant mothers were recruited from the general population in four provinces with diverse environments. The child is followed to age 5 years, with prospective characterization of diverse exposures during this critical period. Key exposure domains include indoor and outdoor air pollutants, inhalation, ingestion and dermal uptake of chemicals, mold, dampness, biological allergens, pets and pests, housing structure, and living behavior, together with infections, nutrition, psychosocial environment, and medications. Assessments of early life exposures are focused on those linked to inflammatory responses driven by the acquired and innate immune systems. Mothers complete extensive environmental questionnaires including time-activity behavior at recruitment and when the child is 3, 6, 12, 24, 30, 36, 48, and 60 months old. House dust collected during a thorough home assessment at 3-4 months, and biological specimens obtained for multiple exposure-related measurements, are archived for analyses. Geo-locations of homes and daycares and land-use regression for estimating traffic-related air pollution complement time-activity-behavior data to provide comprehensive individual exposure profiles. Several analytical frameworks are proposed to address the many interacting exposure variables and potential issues of co-linearity in this complex data set.

Despite growing support for supervision after task sharing trainings in humanitarian settings, there is limited research on the experience of trainees in apprenticeship and other supervision approaches. Studying apprenticeships from trainees' perspectives is crucial to refine supervision and enhance motivation for service implementation. The authors implemented a multi-stage, transcultural adaptation for a pilot task sharing training in Haiti entailing three phases: 1) literature review and qualitative research to adapt a mental health and psychosocial support training; 2) implementation and qualitative process evaluation of a brief, structured group training; and 3) implementation and qualitative evaluation of an apprenticeship training, including a two year follow-up of trainees. Structured group training revealed limited knowledge acquisition, low motivation, time and resource constraints on mastery, and limited incorporation of skills into practice. Adding an apprenticeship component was associated with subjective clinical competency, increased confidence regarding utilising skills, and career advancement. Qualitative findings support the added value of apprenticeship according to trainees.

The British Columbia Asthma Monitoring System (BCAMS) tracks forest fire smoke exposure and asthma-related health outcomes, identifying excursions beyond expected daily counts. Weekly reports during the wildfire season support public health and emergency management decision-making. We evaluated BCAMS by identifying excursions for asthma-related physician visits and dispensations of the reliever medication salbutamol sulfate and examining their corresponding smoke exposures. A disease outbreak detection algorithm identified excursions from 1 July to 31 August 2014. Measured, modeled, and forecasted concentrations of fine particulate matter (PM2.5) were used to assess exposure. We assigned PM2.5 levels to excursions by choosing the highest value within a seven day window centred on the excursion day. Smoky days were defined as those with PM2.5 levels ≥ 25 µg/m3. Most excursions (57%-71%) were assigned measured or modeled PM2.5 concentrations of 10 µg/m3 or higher. Of the smoky days, 55.8% and 69.8% were associated with at least one excursion for physician visits and salbutamol dispensations, respectively. BCAMS alerted most often when measures of smoke exposure were relatively high. Better performance might be realized by combining asthma-related outcome metrics in a bivariate model.

Background: The West African Ebola epidemic has demonstrated that the existing range of medical and epidemiological responses to emerging disease outbreaks is insufficient, especially in post-conflict contexts with exceedingly poor healthcare infrastructures. In this context, community-based responses have proven vital for containing Ebola virus disease (EVD) and shifting the epidemic curve. Despite a surge in interest in local innovations that effectively contained the epidemic, the mechanisms for community-based response remain unclear. This study provides baseline information on community-based epidemic control priorities and identifies innovative local strategies for containing EVD in Liberia., Methodology/principal Findings: This study was conducted in September 2014 in 15 communities in Monrovia and Montserrado County, Liberia--one of the epicenters of the Ebola outbreak. Findings from 15 focus group discussions with 386 community leaders identified strategies being undertaken and recommendations for what a community-based response to Ebola should look like under then-existing conditions. Data were collected on the following topics: prevention, surveillance, care-giving, community-based treatment and support, networks and hotlines, response teams, Ebola treatment units (ETUs) and hospitals, the management of corpses, quarantine and isolation, orphans, memorialization, and the need for community-based training and education. Findings have been presented as community-based strategies and recommendations for (1) prevention, (2) treatment and response, and (3) community sequelae and recovery. Several models for community-based management of the current Ebola outbreak were proposed. Additional findings indicate positive attitudes towards early Ebola survivors, and the need for community-based psychosocial support., Conclusions/significance: Local communities' strategies and recommendations give insight into how urban Liberian communities contained the EVD outbreak while navigating the systemic failures of the initial state and international response. Communities in urban Liberia adapted to the epidemic using multiple coping strategies. In the absence of health, infrastructural and material supports, local people engaged in self-reliance in order to contain the epidemic at the micro-social level. These innovations were regarded as necessary, but as less desirable than a well-supported health-systems based response; and were seen as involving considerable individual, social, and public health costs, including heightened vulnerability to infection.

Objectives: Poison control centres provide information on the management of poisoning incidents. The British Columbia (BC) Drug and Poison Information Centre recently implemented an electronic database system for recording case information, making it easier to use case data as a potential source of population-based information on health services usage and health status. This descriptive analysis maps poisoning case rates in BC, highlighting differences in patient age, substance type, medical outcome, and caller location., Methods: There were 50,621 human exposure cases recorded during 2012 and 2013. Postal code or city name was used to assign each case to a Health Service Delivery Area (HSDA). Case rates per 1,000 person-years were calculated, including crude rates, age-standardized rates, age-specific rates, and rates by substance type, medical outcome, and caller location., Results: The lowest case rate was observed in Richmond, a city where many residents do not speak English as a first language. The highest rate was observed in the Northwest region, where the economy is driven by resource extraction. Pharmaceutical exposures were elevated in the sparsely populated northern and eastern areas. Calls from health care facilities were highest in the Northwest region, where there are many remote Aboriginal communities., Conclusions: Case rates were generally highest in the primarily rural northern and eastern areas of the province. Considering these results alongside contextual factors informs further investigation and action: addressing cultural and language barriers to accessing poison centre services, and developing a public health surveillance system for severe poisoning events in rural and remote communities.

A rich Haitian ethnopsychology has been described, detailing concepts of personhood, explanatory models of illness, and links between mind and body. However, little research has engaged explicitly with mental illness, and that which does focuses on the Kreyòl term fou (madness), a term that psychiatrists associate with schizophrenia and other psychoses. More work is needed to characterize potential forms of mild-to-moderate mental illness. Idioms of distress provide a promising avenue for exploring common mental disorders. Working in Haiti's Central Plateau, we aimed to identify idioms of distress that represent cultural syndromes. We used ethnographic and epidemiologic methods to explore the idiom of distress reflechi twòp (thinking too much). This syndrome is characterized by troubled rumination at the intersection of sadness, severe mental disorder, suicide, and social and structural hardship. Persons with "thinking too much" have greater scores on the Beck Depression Inventory and Beck Anxiety Inventory. "Thinking too much" is associated with 8 times greater odds of suicidal ideation. Untreated "thinking too much" is sometimes perceived to lead to psychosis. Recognizing and understanding "thinking too much" may allow early clinical recognition and interventions to reduce long-term psychosocial suffering in Haiti's Central Plateau.

Suicide is a complex global public health problem, yet few studies have examined local socio-cultural explanatory models and other contextual factors surrounding suicide in low-and-middle-income countries. Such research is critical, as suicide frequency and etiology, as well as care-seeking in the case of distress, differ contextually and by sub-groups within a population. This is the first study of its kind to explore the dual perspectives of both healthcare workers and community members regarding suicide in Haiti. We conducted semi-structured, in-depth interviews between May and June 2011 with eight biomedical healthcare workers and 16 lay community members. Qualitative data analysis, drawing on interpretive phenomenological analysis, addressed themes including perceived suicide frequency, veracity of suicidal ideation claims, perceived causal factors, religious constructs related to suicide, and support resources for suicidality. Compared to community members, healthcare workers underestimated the frequency of suicide and were less likely to interpret suicide-related claims as representing true intent. Religious perspectives influenced attitudes toward suicide, albeit in different ways: Christian concern with the afterlife resulted in suicide being unacceptable and sinful, while Vodou explanatory frameworks displaced blame and stigma away from suicidal individuals. Healthcare workers' failure to recognize suicide as a serious problem suggests that the formal health system is currently ill-equipped to respond to suicide-related needs. Religious practice and community supports in rural Haiti may serve as essential resources for prevention programs., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: This study examined patterns, determinants, and costs of seeking care for mild to moderate psychiatric distress in order to determine optimal approaches for expanding mental health care in rural Haiti., Methods: A cross-sectional, zone-stratified household survey of 408 adults was conducted in Haiti's Central Plateau. Multivariable logistic regression models were built to assess determinants of first-choice and lifetime health service use by provider type., Results: Thirty-two percent of respondents endorsed God as their first choice for care if suffering from mental distress, and 29% of respondents endorsed clinics and hospitals as their first choice. Forty-seven percent of respondents chose potential providers on the basis of anticipated efficacy. Suicidal individuals were 7.6 times (95% confidence interval [CI]=1.4-42.0) as likely to prefer community-based providers (herbal healer, church priest or pastor, or Vodou priest) over hospitals or clinics. Depression severity was associated with increased odds (adjusted odds ratio [AOR]=1.8, CI=1.5-2.3) of ever having been to an herbal healer. Having a household member with mental health problems was associated with increased odds of ever having been to church pastors or priests (AOR=5.8, CI=2.8-12.0) and decreased odds of ever having been to hospitals or clinics (AOR=.3, CI=.1-.8). Median actual service costs were US $1 for hospitals or clinics, $6 for herbal healers, and $120 for Vodou priests., Conclusions: Three out of four rural Haitians said they would seek community resources over clinical care if suffering from mental distress. Therefore, isolated clinical interventions may have limited impact because of less frequent use. Efforts to expand mental health care should consider differential provider costs when selecting community resources for task shifting.

Background: Since the 2010 earthquake in Haiti, there has been increased international attention to mental health needs throughout the country. The present study represents one of the first epidemiologic studies of depression symptomatology, suicidal ideation, and associated factors in Haiti's Central Plateau., Methods: We conducted a cross-sectional, zone-stratified household survey of 408 adults in Haiti's Central Plateau. Depression symptomatology was assessed with a culturally-adapted Kreyòl version of the Beck Depression Inventory (BDI). Multivariable linear and logistic regression models were built using backward elimination, with the outcomes being continuous BDI scores and endorsing suicidal ideation, respectively., Results: The mean BDI score was 20.4 (95% confidence interval [CI]: 19.3-21.5), and 6.13% (N = 25) of participants endorsed current suicidal ideation. Factors associated with BDI scores were: continuous age (adjusted beta [aβ]: 0.14, CI: 0.06-0.22), female gender (aβ: 2.1, CI: 0.18-4.0), suicidal ideation (aβ: 11.1, CI: 7.3-14.9), death in family (aβ: 2.7, CI: 0.57-4.9), and prior life-threatening illness (aβ: 2.6, CI: 0.77-4.5). Education was a risk factor for depression among women but not among men, and employment was a risk factor for both genders. Factors associated with endorsing suicidal ideation were: BDI score (ten point change) (adjusted odds ratio [aOR]: 2.5, CI: 1.7-3.6), lack of care if sick (aOR: 5.5, CI: 1.1-28.6), alcohol use (aOR: 3.3, CI: 1.3-8.2), and ever having been to a Vodou priest (aOR: 3.2, CI: 1.1-9.5)., Conclusions: A large proportion of Haiti's Central Plateau may be experiencing high levels of depression symptomatology and/or current suicidal ideation. Screening could be conducted in biomedical, religious, and Vodou healing contexts. For prevention, poverty reduction and improved healthcare access are key elements. For treatment, general psychiatric services, psychosocial services for the medically ill and their families, and substance abuse interventions should be explored. Paradoxical associations related to education and employment require further exploration.

Background: Epimorphic regeneration results in the restoration of lost tissues and structures from an aggregation of proliferating cells known as a blastema. Among amniotes the most striking example of epimorphic regeneration comes from tail regenerating lizards. Although tail regeneration is often studied in the context of ecological costs and benefits, details of the sequence of tissue-level events are lacking. Here we investigate the anatomical and histological events that characterize tail regeneration in the leopard gecko, Eublepharis macularius., Results: Tail structure and tissue composition were examined at multiple days following tail loss, revealing a conserved pattern of regeneration. Removal of the tail results in a consistent series of morphological and histological events. Tail loss is followed by a latent period of wound healing with no visible signs of regenerative outgrowth. During this latent period basal cells of the epidermis proliferate and gradually cover the wound. An additional aggregation of proliferating cells accumulates adjacent to the distal tip of the severed spinal cord marking the first appearance of the blastema. Continued growth of the blastema is matched by the initiation of angiogenesis, followed by the re-development of peripheral axons and the ependymal tube of the spinal cord. Skeletal tissue differentiation, corresponding with the expression of Sox9, and muscle re-development are delayed until tail outgrowth is well underway., Conclusions: We demonstrate that tail regeneration in lizards involves a highly conserved sequence of events permitting the establishment of a staging table. We show that tail loss is followed by a latent period of scar-free healing of the wound site, and that regeneration is blastema-mediated. We conclude that the major events of epimorphic regeneration are highly conserved across vertebrates and that a comparative approach is an invaluable biomedical tool for ongoing regenerative research.

Reptiles (lizards, snakes, turtles and crocodylians) are becoming increasing popular as models for developmental investigations. In this review the leopard gecko, Eublepharis macularius, is presented as a reptilian model for embryonic studies. We provide details of husbandry, breeding and modifications to two popular histological techniques (whole-mount histochemistry and immunohistochemistry). In addition, we provide a summary of basic reptilian husbandry requirements and discuss important details of embryonic nutrition, egg anatomy and sex determination.