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Arctic terrestrial invertebrate biodiversity is generally poorly known, but the archipelago of Svalbard has one of the most up-to-date inventories of its terrestrial and freshwater faunas of any Arctic region, offering a baseline for long term monitoring of invertebrate communities in space and time. Since the most recent review of the Svalbard invertebrate fauna was produced in 2014, knowledge of this fauna has developed and this inventory is here critically revised and updated. Our aims are (1) to critically review the inventory based on current taxonomic knowledge, (2) publish the complete species inventory, including cross-referencing to the relevant publications, in an open access data archive (GBIF), and (3) highlight the particular advantages that working in Svalbard may bring for scientists working on terrestrial, freshwater, and cryospheric environments. The inventory contains a total 1091 valid species names or interim names. A gap analysis in the Barcode of Life Data Systems reveals that 50% of the species currently documented from Svalbard lack COI (Cytochrome c oxidase subunit 1) barcode reference sequences in this database. Gaps in our knowledge of the Svalbard fauna and how these may be resolved are discussed.

BackgroundData dashboards are published tools that present visualizations; they are increasingly used to display data about behavioral health, social determinants of health, and chronic and infectious disease risks to inform or support public health endeavors. Dashboards can be an evidence-based approach used by communities to influence decision-making in health care for specific populations. Despite widespread use, evidence on how to best design and use dashboards in the public health realm is limited. There is also a notable dearth of studies that examine and document the complexity and heterogeneity of dashboards in community settings. ObjectiveCommunity stakeholders engaged in the community response to the opioid overdose crisis could benefit from the use of data dashboards for decision-making. As part of the Communities That HEAL (CTH) intervention, community data dashboards were created for stakeholders to support decision-making. We assessed stakeholders’ perceptions of the usability and use of the CTH dashboards for decision-making. MethodsWe conducted a mixed methods assessment between June and July 2021 on the use of CTH dashboards. We administered the System Usability Scale (SUS) and conducted semistructured group interviews with users in 33 communities across 4 states of the United States. The SUS comprises 10 five-point Likert-scale questions measuring usability, each scored from 0 to 4. The interview guides were informed by the technology adoption model (TAM) and focused on perceived usefulness, perceived ease of use, intention to use, and contextual factors. ResultsOverall, 62 users of the CTH dashboards completed the SUS and interviews. SUS scores (grand mean 73, SD 4.6) indicated that CTH dashboards were within the acceptable range for usability. From the qualitative interview data, we inductively created subthemes within the 4 dimensions of the TAM to contextualize stakeholders’ perceptions of the dashboard’s usefulness and ease of use, their intention to use, and contextual factors. These data also highlighted gaps in knowledge, design, and use, which could help focus efforts to improve the use and comprehension of dashboards by stakeholders. ConclusionsWe present a set of prioritized gaps identified by our national group and list a set of lessons learned for improved data dashboard design and use for community stakeholders. Findings from our novel application of both the SUS and TAM provide insights and highlight important gaps and lessons learned to inform the design of data dashboards for use by decision-making community stakeholders. Trial RegistrationClinicalTrials.gov NCT04111939; https://clinicaltrials.gov/study/NCT04111939

Abstract Dysbiosis of the human oral microbiota has been reported to be associated with oral cavity squamous cell carcinoma (OSCC) while the host-microbiota interactions with respect to the potential impact of pathogenic bacteria on host genomic and epigenomic abnormalities remain poorly studied. In this study, the mucosal bacterial community, host genome-wide transcriptome and DNA CpG methylation were simultaneously profiled in tumors and their adjacent normal tissues of OSCC patients. Significant enrichment in the relative abundance of seven bacteria species (Fusobacterium nucleatum, Treponema medium, Peptostreptococcus stomatis, Gemella morbillorum, Catonella morbi, Peptoanaerobacter yurli and Peptococcus simiae) were observed in OSCC tumor microenvironment. These tumor-enriched bacteria formed 254 positive correlations with 206 up-regulated host genes, mainly involving signaling pathways related to cell adhesion, migration and proliferation. Integrative analysis of bacteria-transcriptome and bacteria-methylation correlations identified at least 20 dysregulated host genes with inverted CpG methylation in their promoter regions associated with enrichment of bacterial pathogens, implying a potential of pathogenic bacteria to regulate gene expression, in part, through epigenetic alterations. An in vitro model further confirmed that Fusobacterium nucleatum might contribute to cellular invasion via crosstalk with E-cadherin/β-catenin signaling, TNFα/NF-κB pathway and extracellular matrix remodeling by up-regulating SNAI2 gene, a key transcription factor of epithelial-mesenchymal transition (EMT). Our work using multi-omics approaches explored complex host-microbiota interactions and provided important insights into genetic and functional basis in OSCC tumorigenesis, which may serve as a precursor for hypothesis-driven study to better understand the causational relationship of pathogenic bacteria in this deadly cancer.

Establishing a robust One Health (OH) governance is essential for ensuring effective coordination and collaboration among human, animal, and environmental health sectors to prevent and address complex health challenges like zoonoses or antimicrobial resistance. This study conducted a mixed-methods environmental scan to assess to what extent Mexico displays a OH governance and identify opportunities for improvement. Through documentary analysis, the study mapped OH national-level governance elements: infrastructure, multi-level regulations, leadership, multi-coordination mechanisms (MCMs), and financial and OH-trained human resources. Key informant interviews provided insights into enablers, barriers, and recommendations to enhance a OH governance. Findings reveal that Mexico has sector-specific governance elements: institutions, surveillance systems and laboratories, laws, and policies. However, the absence of a OH governmental body poses a challenge. Identified barriers include implementation challenges, non-harmonised legal frameworks, and limited intersectoral information exchange. Enablers include formal and ad hoc MCMs, OH-oriented policies, and educational initiatives. Like other middle-income countries in the region, institutionalising a OH governance in Mexico, may require a OH-specific framework and governing body, infrastructure rearrangements, and policy harmonisation. Strengthening coordination mechanisms, training OH professionals, and ensuring data-sharing surveillance systems are essential steps toward successful implementation, with adequate funding being a relevant factor.

ABSTRACTDespite self-congratulatory rhetoric, Canada compromised COVID-19 vaccine equity with policies impeding a proposed global waiver of vaccine intellectual property (IP) rules. To learn from Canada’s vaccine nationalism we explore the worldview – a coherent textual picture of the world – in a sample of Government of Canada communications regarding global COVID-19 vaccine sharing. Analysed documents portray risks and disparities as unrelated to the dynamics and power relations of the Canadian and international economies. Against this depoliticised backdrop, economic growth fueled by strict IP rules and free trade is advanced as the solution to inequities. Global vaccine access and distribution are pursued via a charity-focused public-private-partnership approach, with proposals to relax international IP rules dismissed as unhelpful. Rather than a puzzling lapse by a good faith ‘middle power’, Canada’s obstruction of global COVID-19 vaccine equity is a logical and deliberate extension of dominant neoliberal economic policy models. Health sector challenges to such models must prioritise equity in global pandemic governance via politically assertive and less conciliatory stances towards national governments and multilateral organisations. Mobilisation for health equity should transform the overall health-damaging macroeconomic model, complementing efforts based on specific individual health determinants or medical technologies.

Abstract Background Youth experiencing homelessness (YEH) suffer from poorer physical and mental health outcomes than stably housed youth. Additionally, YEH are forced to navigate fragmented health and social service systems on their own, where they often get lost between systems when transitioning or post-discharge. Inevitably, YEH require support with health system navigation and healthcare coordination. The aim of this study is to understand interactions within and between the emergency youth shelter (EYS) and health systems that affect healthcare coordination for YEH in Toronto, Canada, and how these interactions can be targeted to improve healthcare coordination for YEH. Methods This study is part of a larger qualitative case study informed by the framework for transformative systems change. To understand interactions in healthcare coordination for YEH within and between the EYS and health systems, we developed a causal loop diagram (CLD) using in-depth interview data from 24 key informants at various levels of both systems. Open and focused codes developed during analysis using Charmaz’s constructivist grounded theory methodology were re-analysed to identify key variables, and links between them to create the CLD. The CLD was then validated by six stakeholders through a stakeholder forum. Results The CLD illustrates six balancing and one reinforcing feedback loop in current healthcare coordination efforts within the EYS and health systems, respectively. Increasing EYS funding, building human resource capacity, strengthening inter and intra-systemic communication channels, and establishing strategic partnerships and formal referral pathways were identified among several other variables to be targeted to spiral positive change in healthcare coordination for YEH both within and between the EYS and health systems. Conclusions The CLD provides a conceptual overview of the independent and integrated systems through which decision-makers can prioritize and guide interventions to strengthen healthcare coordination within and between the EYS and health systems. Overall, our research findings suggest that key variables such as streamlining communication and improving staff–youth relationships be prioritized, as each of these acts interdependently and influences YEH’s access, quality and coordination of healthcare.

Abstract Background Emerging infectious diseases of zoonotic origin present a critical threat to global population health. As accelerating globalisation makes epidemics and pandemics more difficult to contain, there is a need for effective preventive interventions that reduce the risk of zoonotic spillover events. Public policies can play a key role in preventing spillover events. The aim of this review is to identify and describe evaluations of public policies that target the determinants of zoonotic spillover. Our approach is informed by a One Health perspective, acknowledging the inter-connectedness of human, animal and environmental health. Methods In this systematic scoping review, we searched Medline, SCOPUS, Web of Science and Global Health in May 2021 using search terms combining animal health and the animal-human interface, public policy, prevention and zoonoses. We screened titles and abstracts, extracted data and reported our process in line with PRISMA-ScR guidelines. We also searched relevant organisations’ websites for evaluations published in the grey literature. All evaluations of public policies aiming to prevent zoonotic spillover events were eligible for inclusion. We summarised key data from each study, mapping policies along the spillover pathway. Results Our review found 95 publications evaluating 111 policies. We identified 27 unique policy options including habitat protection; trade regulations; border control and quarantine procedures; farm and market biosecurity measures; public information campaigns; and vaccination programmes, as well as multi-component programmes. These were implemented by many sectors, highlighting the cross-sectoral nature of zoonotic spillover prevention. Reports emphasised the importance of surveillance data in both guiding prevention efforts and enabling policy evaluation, as well as the importance of industry and private sector actors in implementing many of these policies. Thoughtful engagement with stakeholders ranging from subsistence hunters and farmers to industrial animal agriculture operations is key for policy success in this area. Conclusion This review outlines the state of the evaluative evidence around policies to prevent zoonotic spillover in order to guide policy decision-making and focus research efforts. Since we found that most of the existing policy evaluations target ‘downstream’ determinants, additional research could focus on evaluating policies targeting ‘upstream’ determinants of zoonotic spillover, such as land use change, and policies impacting infection intensity and pathogen shedding in animal populations, such as those targeting animal welfare.

Although Svalbard archipelago is considered as a natural laboratory for the environmental studies in the High Arctic, the knowledge on the transport and diversity of bioaerosols (aeroplankton) in the atmosphere is poorly recognized. To improve our knowledge about the aeroplankton over the Svalbard, we conducted a short-term study in the central part of the archipelago with a special focus on two important, but understudied in this region, airborne components: pollen grains and invertebrates. Aerobiological traps, three impact-type samplers and 12 pitfall-type water traps, were operated for a week of July 2022 at three sites located near Longyearbyen, the largest settlement of Svalbard. These sites, that is, Platåfjellet, Longyearbreen Glacier, and glacier valley, varied in the local sources of biological material and altitude. In total, 11 pollen taxa were isolated from pollen impactors. Most of them (68%) belonged to non-native plants, for example, Alnus sp., Betula sp., Picea abies, or Pinus sylvestris-type pollen. In pitfall-type water traps, we found invertebrates representing Acari (Prostigmata, Endeostigmata and Oribatida), Collembola ( Agrenia bidenticulata), Tardigrada (Eutardigrada) and Rotifera (Bdelloidea). The most taxa-rich site, both for pollen and invertebrates, was Platåfjellet, characterized by open landscape dominated by small cryptogams, mainly lichens and mosses, and sparse patches of vascular plants. Even though our sampling was short-term, we found diverse taxa belonged to native and alien species, indicating that both local and long-range transport shape aeroplankton composition and seeding of Arctic habitats. Long-term aerobiological monitoring in diverse ecosystems of Svalbard is needed to understand spatio-temporal influence of aeroplankton on ecosystems.

BackgroundSeveral youth staying at emergency youth shelters (EYSs) in Toronto experience poorly coordinated care for their health needs, as both the EYS and health systems operate largely in silos when coordinating care for this population. Understanding how each system is structurally and functionally bound in their healthcare coordination roles for youth experiencing homelessness (YEH) is a preliminary step to identify how healthcare coordination can be strengthened using a system thinking lens, particularly through the framework for transformative system change.MethodsForty-six documents, and twenty-four semi-structured interviews were analyzed to explore how the EYS and health systems are bound in their healthcare coordination roles. We continuously compared data collected from documents and interviews using constant comparative analysis to build a comprehensive understanding of each system's layers, and the niches (i.e., programs and activities), organizations and actors within these layers that contribute to the provision and coordination of healthcare for YEH, within and between these two systems.ResultsThe EYS and health systems are governed by different ministries, have separate mandates, and therefore have distinct layers, niches, and organizations respective to coordinating healthcare for YEH. While neither system takes sole responsibility for this task, several government, research, and community-based efforts exist to strengthen healthcare coordination for this population, with some overlap between systems. Several organizations and actors within each system are collaborating to develop relevant frameworks, policies, and programs to strengthen healthcare coordination for YEH. Findings indicate that EYS staff play a more active role in coordinating care for YEH than health system staff.ConclusionA vast network of organizations and actors within each system layer, work both in silos and collaboratively to coordinate health services for YEH. Efforts are being made to bridge the gap between systems to improve healthcare coordination, and thereby youths' health outcomes.

Objective: Strain has become a viable index for evaluating abdominal aortic aneurysm stability after endovascular aneurysm repair (EVAR). In addition, literature has shown that healthy aortic tissue requires a degree of strain to maintain homeostasis. This has led to the hypothesis that too much strain reduction conferred by a high degree of graft oversizing is detrimental to the aneurysm neck in the seal zone of abdominal aortic aneurysms after EVAR. We investigated this in a laboratory experiment by examining the effects that graft oversizing has on the pressure-normalized strain (ερ+¯/pulse pressure [PP]) reduction using four different infrarenal EVAR endografts and our ultrasound elastography technique. Approximate graft oversizing percentages were 20% (30 mm phantom-graft combinations), 30% (28 mm phantom-graft combinations), and 50% (24 mm phantom-graft combinations). Methods: Axisymmetric, 10% by mass polyvinyl alcohol phantoms were connected to a flow simulator. Ultrasound elastography was performed before and after implantation with the four different endografts: (1) 36 mm polyester/stainless steel, (2) 36 mm polyester/electropolished nitinol, (3) 35 mm polytetrafluoroethylene (PTFE)/nitinol, and (4) 36 mm nitinol/polyester/platinum-iridium. Five ultrasound cine loops were taken of each phantom-graft combination. They were analyzed over two different cardiac cycles (end-diastole to end-diastole), yielding a total of 10 maximum mean principal strain (ερ+¯) values. ερ+¯ was divided by pulse pressure to yield pressure-normalized strain (ερ+¯/PP). An analysis of variance was performed for graft comparisons. We calculated the average percent ερ+¯/PP reduction by manufacturer and percent oversizing. These values were used for linear regression analysis. Results: Results from one-way analysis of variance showed a significant difference in ερ+¯/PP between the empty phantom condition and all oversizing conditions for all graft manufacturers (F(3, 56) = 106.7 [graft A], 132.7 [graft B], 106.5 [graft C], 105.7 [graft D], P < .0001 for grafts A-D). There was a significant difference when comparing the 50% condition with the 30% and 20% conditions across all manufacturers by post hoc analysis (P < .0001). No significant difference was found when comparing the 20% and 30% oversizing conditions for any of the manufacturers or when comparing ερ+¯/PP values across the manufacturers according to percent oversize. Linear regression demonstrated a significant positive correlation between the percent graft oversize and the all-graft average percent ερ+¯/PP reduction (R2 = 0.84, P < .0001). Conclusions: This brief report suggests that a 10% increase in graft oversizing leads to an approximate 5.9% reduction in ερ+¯/PP on average. Applied clinically, this increase may result in increased stiffness in axisymmetric vessels after EVAR. Further research is needed to determine if this is clinically significant. : Clinical Relevance: This research suggests that a higher degree of graft oversizing results in a higher average percent pressure-normalized strain reduction and thus increased mechanical stiffness. There is evidence suggesting that arteries become less pulsatile when they become stiffened. Therefore, decreasing aortic pulsatile flow by implanting a highly oversized graft may have deleterious long-term effects after endovascular aneurysm repair. This may have implications for future graft construction and for the choice of endograft by the surgeon, especially when considering the benefits of strain reduction to the diseased tissue that comprises the aneurysmal sac. In addition, our technique allows for the assessment of dynamic changes to stiffness after graft implantation in vivo.

The COVID-19 pandemic has sent ripple effects across health systems and impacted the burden of many other diseases, such as malaria in sub-Saharan Africa. This study takes a mixed method approach to assess the impact of COVID-19 on malaria control programs in three rural communes in Benin. We conducted individual semi-structured interviews with key informants who play important roles in malaria control in Benin at three levels of the health system-national, health zone, and commune. Using a purposive sampling technique, informants were interviewed regarding their roles in malaria control, the impact of the pandemic on their activities, and the mitigation strategies adopted. Relevant themes were identified by content analysis. We then formulated an agent-based model of malaria epidemiology to assess the impacts of treatment disruption on malaria burden. The key informant interviews revealed that essential aspects of malaria control were upheld in Benin due to the close collaboration of public health practitioners and health care providers at all levels of the health system. There were some disruptions to case management services for malaria at the start of the pandemic due to the public avoiding health centers and a brief shortage of malaria treatment that may not be entirely attributable to the pandemic. Results from the agent-based model suggest that duration, severity, and timing of treatment disruption can impact malaria burden in a synergistic manner, though the effects are small given the relatively mild disruptions observed. This study highlights the importance of top-down leadership in health emergencies, as well as the critical role of community health workers in preventing negative health outcomes for their communities. We also showcased the integration of qualitative research and mathematical models-an underappreciated form of mixed methods research that offer immense value in the continued evaluation of rapidly evolving health emergencies.

In line with the global trend, the Middle East and North Africa (MENA) region has been growing vulnerable to the direct and indirect health effects of climate change including death tolls due to climatological disasters and diseases sensitive to climate change since the industrial revolution. Regarding the limited capacity of MENA countries to adapt and respond to these effects, and also after relative failures of the previous negotiation in Glasgow, in the upcoming COP27 in Egypt, the heads of the region’s parties are determined to take advantage of the opportunity to host MENA to mitigate and prevent the worst effects of climate change. This would be achieved through mobilizing international partners to support climate resilience, a major economic transformation, and put health policy and management in a strategic position to contribute to thinking and action on these pressing matters, at least to avoid or minimize the future adverse consequences.

Abstract Globalization has been declared dead or dying for many years, although recently, the number of voices declaring it ‘over’ has swelled [1]. As editors of a journal interrogating how globalization affects health, we confront the question: Have the COVID-19 pandemic, Russia’s war against Ukraine, a breakdown in multilateralism, and the risk of a return to the stagflation of the 1970s finally sounded a death knell for the research and scholarship we have been publishing in the journal’s 20-year history? We think not and argue below why, in our post-pandemic fractured and fractious era, it is vitally important to retain a focus on this messy construct short-handed as ‘globalization.’

Abstract Background Several individual studies from specific countries have reported rising numbers of pediatric COVID-19 cases with inconsistent reports on the clinical symptoms including respiratory and gastrointestinal symptoms as well as diverse reports on the mean age and household exposure in children. The epidemiological characteristics of COVID-19 in children are not fully understood, hence, comprehensive meta-analyses are needed to provide a better understanding of these characteristics. Methods This review was conducted in Medline, Scopus, Cochrane library, Embase, Web of Science, and published reports on COVID-19 in children. Data were extracted by two independent researchers and a third researcher resolved disputes. STATA software and the random-effect model were used in the synthesis of our data. For each model, the heterogeneity between studies was estimated using the Q Cochrane test. Heterogeneity and publication bias were calculated using the I2 statistic and Egger’s/Begg’s tests. Results The qualitative systematic review was performed on 32 articles. Furthermore, the meta-analysis estimated an overall rate of involvement at 12% (95% CI: 9–15%) among children, with an I2 of 98.36%. The proportion of household exposure was calculated to be 50.99% (95% CI: 20.80%–80.80%) and the proportion of admitted cases was calculated to be 45% (95% CI: 24%–67%). Additionally, the prevalence of cough, fatigue, fever and dyspnea was calculated to be 25% (95% CI: 0.16–0.36), 9% (95% CI: 0.03–0.18), 33% (95% CI: 0.21–0.47) and 9% (95% CI: 0.04–0.15), respectively. It is estimated that 4% (95% CI: 1–8%) of cases required intensive care unit admission. Conclusions The pediatric clinical picture of COVID-19 is not simply a classic respiratory infection, but unusual presentations have been reported. Given the high incidence of household transmission and atypical clinical presentation in children, we strongly recommend their inclusion in research and population-based preventive measures like vaccination as well as clinical trials to ensure efficacy, safety, and tolerability in this age group.

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With coronavirus disease 2019 (COVID-19) receding, many countries are pondering what a post-pandemic economy should look like. Some advocate a more inclusive stakeholder model of capitalism. Others caution that this would be insufficient to deal with our pre-pandemic crises of income inequality and climate change. Many countries emphasize a ‘green recovery’ with improved funding for health and social protection. Progressive tax reform and fiscal policy innovations are needed, but there is concern that the world is already tilting towards a new round of austerity. Fundamentally, the capitalist growth economy rests on levels of material consumption that are unsustainable and inequitable. More radical proposals thus urge ‘degrowth’ policies to reduce consumption levels while redistributing wealth and income to allow the poorer half of humanity to achieve an ethical life expectancy. We have the policy tools to do so. We need an activist public health movement to ensure there is sufficient political will to adopt them.

Abstract Forced quarantine and nationwide lockdowns have been a primary response by many jurisdictions in their attempt at COVID-19 elimination or containment, yet the associated mental health burden is not fully understood. Using an eight country cross-sectional design, this study investigates the association between COVID-19 induced quarantine and/or isolation on probable generalized anxiety disorder (GAD) and major depressive episode (MDE) psychological outcomes approximately eight months after the pandemic was declared. Overall, 9027 adults participated, and 2937 (32.5%) were indicated with GAD and/or MDE. Reported quarantine and/or isolation was common, with 1199 (13.8%) confined for travel or health requirements, 566 (6.5%) for being close contact, 720 (8.3%) for having COVID-19 symptoms, and 457 (5.3%) for being COVID-19 positive. Compared to those not quarantining or isolating, the adjusted estimated relative risks of GAD and/or MDE associated with quarantine and/or isolation was significant (p

Due to the global problem of electronic wastes (e-wastes), the concept of a circular economy is deemed a viable framework for achieving minimal resource extraction and waste generation. Despite the advances in the literature on managing the circularity of e-wastes, the consumption aspect needs much attention. Although some barriers to the consumption of recovered e-wastes, such as refurbished mobile phones, were already identified, an overarching evaluation of these barriers remains a gap. Thus, this work evaluates these relevant barriers by considering their internal strengths (or priorities) and the intertwined relationships between them under uncertainty. In achieving this agenda, three phases of the methodology were implemented: (1) performing a systematic literature review of the barriers, (2) finalizing the list of barriers following a focus group discussion, and (3) evaluating the barriers using a soft system model. The intricacies of the evaluation process prompt the development of a proposed integration of grey system theory and the weighted influence non-linear gauge systems (WINGS), coined grey WINGS. Findings from a case study in the Philippines reveal that negative perception, inferior quality, the misconception of the refurbishment concept, technological obsolescence, and lack of awareness are the critical barriers to the consumption of refurbished mobile phones. Discussions behind these barriers in view of consumer decisions were offered. Also, some policy insights were outlined to overcome these barriers. In effect, this work contributes twofold to the literature: (1) evaluating the barriers to the consumption of refurbished mobile phones to help design circularity initiatives, and (2) methodologically, integrating grey system theory within the framework of the WINGS method to address uncertainty in judgment elicitations.

Abstract Background Maternal mortality continues to decrease in the world but remain the most important health problems in low-income countries. Although evidence indicates that social support is an important factor influencing health facility delivery, it has not been extensively studied in Ethiopia. Therefore, this study aimed to assess the effect of maternal social support and related factors on health facility delivery in southwest Ethiopia. Methods A cross-sectional survey data on 3304 women aged 15–47 years in three districts of Ethiopia, were analyzed. Using multivariable logistic regression, we assessed the association between health facility birth, social support, and socio-demography variables. Adjusted odds ratios with 95% confidence intervals were used to identify statistically significant associations at 5% alpha level. Result Overall, 46.9% of women delivered at health facility in their last pregnancy. Average travel time from closest health facility (AOR: 1.51, 95% CI 1.21 to 2.90), mean perception score of health facility use (AOR: 1.83, 95% CI 1.44 to 2.33), involvement in final decision to identify their place of childbirth (AOR: 2.12, 95% CI 1.73 to 2.58) had significantly higher odds of health facility childbirth. From social support variables, women who perceived there were family members and husband to help them during childbirth (AOR: 3.62, 95% CI 2.74 to 4.79), women who received continuous support (AOR: 1.97, 95% CI 1.20 to 3.23), women with companions for facility visits (AOR: 1.63, 95% CI 1.34 to 2.00) and women who received support from friends (AOR: 1.62, 95% CI 1.16 to 3.23) had significantly higher odds of health facility childbirth. Conclusions Social support was critical to enhance health facility delivery, especially if women’s close ties help facility delivery. An intervention to increase facility delivery uptake should target not only the women’s general social supports, but also continuous support during childbirth from close ties including family members and close friends as these are influential in place of childbirth. Also actions that increase women’s healthcare decision could be effective in improving health facility delivery.

Abstract Objective To demonstrate that oro‐pharyngo‐esophageal radionuclide scintigraphy (OPERS) not only detects tracheobronchial aspiration after swallowing, but also quantifies the amount of aspiration and subsequent clearance. Methods Data collected between 2014 and 2019 were reviewed for aspiration pneumonia at 12 and 24‐months after OPERS. The predictive value for aspiration pneumonia on flexible endoscopic evaluation of swallowing (FEES), videofluoroscopic swallowing study (VFSS), and OPERS, and the overall survival of patients with or without aspiration were determined. Results Thirty‐seven patients treated with radiotherapy for nasopharyngeal carcinoma (NPC) were reviewed. The incidence of aspiration detected on FEES, VFSS, and OPERS was 78.4%, 66.7%, and 44.4%, respectively. Using VFSS as a gold standard, the sensitivity and specificity of OPERS for aspiration was 73.7% and 100%. The positive and negative predictive values for aspiration were 100% and 66.7%, respectively, with an overall accuracy of 82.8%. A history of aspiration pneumonia was one factor associated with a higher chance of subsequent aspiration pneumonia within 12 months (odds ratio: 15.5, 95% CI 1.67–145.8, p

Abstract Background Over the past decade, 70% of new and re-emerging infectious disease outbreaks in East Africa have originated from the Congo Basin where Rwanda is located. To respond to these increasing risks of disastrous outbreaks, the government began integrating One Health (OH) into its infectious disease response systems in 2011 to strengthen its preparedness and contain outbreaks. The strong performance of Rwanda in responding to the on-going COVID-19 pandemic makes it an excellent example to understand how the structure and principles of OH were applied during this unprecedented situation. Methods A rapid environmental scan of published and grey literature was conducted between August and December 2020, to assess Rwanda’s OH structure and its response to the COVID-19 pandemic. In total, 132 documents including official government documents, published research, newspaper articles, and policies were analysed using thematic analysis. Results Rwanda’s OH structure consists of multidisciplinary teams from sectors responsible for human, animal, and environmental health. The country has developed OH strategic plans and policies outlining its response to zoonotic infections, integrated OH into university curricula to develop a OH workforce, developed multidisciplinary rapid response teams, and created decentralized laboratories in the animal and human health sectors to strengthen surveillance. To address COVID-19, the country created a preparedness and response plan before its onset, and a multisectoral joint task force was set up to coordinate the response to the pandemic. By leveraging its OH structure, Rwanda was able to rapidly implement a OH-informed response to COVID-19. Conclusion Rwanda’s integration of OH into its response systems to infectious diseases and to COVID-19 demonstrates the importance of applying OH principles into the governance of infectious diseases at all levels. Rwanda exemplifies how preparedness and response to outbreaks and pandemics can be strengthened through multisectoral collaboration mechanisms. We do expect limitations in our findings due to the rapid nature of our environmental scan meant to inform the COVID-19 policy response and would encourage a full situational analysis of OH in Rwanda’s Coronavirus response.

Globally, negative impacts of the COVID-19 pandemic on malaria prevention and control efforts have been caused by delayed distributions of long-lasting insecticidal nets (LLIN), decreased outpatient attendance, and disruptions to malaria testing and treatment. Using a mixed methods approach, we aimed to evaluate the impact of COVID-19 on community-level malaria prevention and health-seeking practices in Benin more than one year after the start of the COVID-19 pandemic. We collected data through community-based cross-sectional surveys with 4200 households and ten focus group discussions (FGDs). Mixed effect logistic regression models accounting for a clustered sampling design were used to identify variables associated with main outcomes (good COVID-19 knowledge, LLIN usage and access, and avoidance of health centres). Consistent with the experiences of FGD participants, receiving information from radios or televisions was significantly associated with good COVID-19 knowledge and avoiding health centres because of the pandemic (p

One Health is a transdisciplinary approach used to address complex concerns related to human, animal, plant, and ecosystem health. One Health frameworks and operational tools are available to support countries and communities, particularly for the prevention and control of zoonotic diseases and antimicrobial resistance and the protection of food safety. However, One Health has yet to be implemented in a manner that fully considers the complexities and interconnectedness of the diverse influences that have impacts at a larger system level. This lack of consideration can undermine the sustainability of any positive outcomes. To ensure the One Health approach can function effectively within the new global context of converging and escalating health, social, economic, and ecological crises, it must evolve and expand in three overlapping dimensions: (1) Scope: the partners, knowledge, and knowledge systems included, (2) Approach: the techniques, methodologies, and scholarship considered, and (3) Worldview inclusivity: the interweaving of other worldviews together with the mainstream scientific worldview that currently predominates. Diverse partners and knowledge from outside the mainstream health and scientific sectors, including Indigenous peoples and representatives of local communities, and traditionally generated knowledge, must be included. These systems of knowledge can then be braided together with mainstream science to comprise a holistic framework for decision-making. Scholarship and methodologies being applied in other fields and contexts to solve complex challenges and manage uncertainty, such as collaborative governance, social-ecologic systems theory, and complexity science, must be recognized and incorporated. The spectrum of considered worldviews must also expand to authentically integrate the expanded scope and approach into action and sustainable impact. By increasing community and social engagement and by recognizing and entwining different worldviews, the plurality of disciplines, and traditional and scientific ways of knowing to address community concerns in the contexts in which they exist, we can ensure that One Health remains effective and true to its paradigm in our rapidly changing and complex world.

Today’s food systems are contributing to multiple intersecting health and ecological crises. Many are now calling for transformative, or even radical, food systems change. Our starting assumption in this Special Issue is the broad claim that the transformative changes being called for in a global food system in crisis cannot – and ultimately will not – be achieved without intense scrutiny of and changes in the underlying political economies that drive today’s food systems. The aim is to draw from diverse disciplinary perspectives to critically evaluate the political economy of food systems, understand key challenges, and inform new thinking and action. We received 19 contributions covering a diversity of country contexts and perspectives, and revealing inter-connected challenges and opportunities for realising the transformation agenda. We find that a number of important changes in food governance and power relations have occurred in recent decades, with a displacement of power in four directions. First, upwards as globalization has given rise to more complex and globally integrated food systems governed increasingly by transnational food corporations (TFCs) and international financial actors. Second, downwards as urbanization and decentralization of authority in many countries gives cities and sub-national actors more prominence in food governance. Third, outwards with a greater role for corporate and civil society actors facilitated by an expansion of food industry power, and increasing preferences for market-orientated and multi-stakeholder forms of governance. Finally, power has also shifted inwards as markets have become increasingly concentrated through corporate strategies to gain market power within and across food supply chain segments. The transformation of food systems will ultimately require greater scrutiny of these challenges. Technical ‘problem-solving’ and overly-circumscribed policy approaches that depoliticise food systems challenges, are insufficient to generate the change we need, within the narrow time-frame we have. While there will be many paths to transformation, rights-based and commoning approaches hold great promise, based on principles of participation, accountability and non-discrimination, alongside coalition building and social mobilization, including social movements grounded in food sovereignty and agroecology.

Abstract Background Global health diplomacy (GHD) focuses on the actions taken by diverse stakeholders from different nations –governments, multilateral agents, and civil society– to phenomena that can affect population health and its determinants beyond national borders. Although the literature on conceptual advancements of GHD exists, empirical studies about how health becomes an issue of relevance for foreign policy are scarce. We present an analysis of the entry processes of health into the foreign policy and diplomatic domains in Mexico from the perspective of key informants of three different sectors. Methods A purposive sample of high-rank representatives of three sectors involved in GHD was designed: Two from Health Sector (HS), four from Foreign Affairs Sector (FAS), and three from Non-governmental organizations (NGOs). Nine semi-structured interviews were conducted exploring the topics of: (1) Health concerns entering diplomatic and foreign policy; (2) Processes that allow actors to influence foreign policy and negotiation and; (3) Impact of multilateral negotiations on decision-making at the national level. Results Our analysis suggests that GHD in Mexico is hierarchically driven by the FAS and health concerns only enter foreign policy when they are relevant to national priorities (such as trade or security). HS possesses a lesser degree of influence in GHD, serving as an instance of consultation for the FAS when deciding on health-related issues at global meetings (i.e., World Health Assembly). NGOs resort to lobbying, advocacy, networking, and coalition-working practices with other sectors (academy, think-tanks) to prevent harmful impacts on local health from multilateral decisions and as a mean to compensate its power asymmetry for influencing GHD processes in relation to the government. Conclusions GHD in Mexico occurs in a context of asymmetric power relationships where government actors have the strongest influence. However, NGOs’ experience in raising awareness of health risks needs to be weighted by government decision-makers. This situation calls for capacity building on intersectoral communication and coordination to create formal mechanisms of GHD practices, including the professionalization and training on GHD among government agencies.

Abstract Background A special session of the World Health Assembly (WHA) will be convened in late 2021 to consider developing a WHO convention, agreement or other international instrument on pandemic preparedness and response – a so-called ‘Pandemic Treaty’. Consideration is given to this treaty as well as to reform of the International Health Regulations (IHR) as our principal governing instrument to prevent and mitigate future pandemics. Main body Reasons exist to continue to work with the IHR as our principal governing instrument to prevent and mitigate future pandemics. All WHO member states are party to it. It gives the WHO the authority to oversee the collection of surveillance data and to issue recommendations on trade and travel advisories to control the spread of infectious diseases, among other things. However, the limitations of the IHR in addressing the deep prevention of future pandemics also must be recognized. These include a lack of a regulatory framework to prevent zoonotic spillovers. More advanced multi-sectoral measures are also needed. At the same time, a pandemic treaty would have potential benefits and drawbacks as well. It would be a means of addressing the gross inequity in global vaccine distribution and other gaps in the IHR, but it would also need more involvement at the negotiation table of countries in the Global South, significant funding, and likely many years to adopt. Conclusions Reform of the IHR should be undertaken while engaging with WHO member states (and notably those from the Global South) in discussions on the possible benefits, drawbacks and scope of a new pandemic treaty. Both options are not mutually exclusive.

BackgroundDespite greater attention to the nexus between trade and investment agreements and their potential impacts on public health, less is known regarding the political and governance conditions that enable or constrain attention to health issues on government trade agendas. Drawing on interviews with key stakeholders in the Australian trade domain, this article provides novel insights from policy actors into the range of factors that can enable or constrain attention to health in trade negotiations.MethodsA qualitative case study was chosen focused on Australia’s participation in the Trans-Pacific Partnership (TPP) negotiations and the domestic agenda-setting processes that shaped the government’s negotiating mandate. Process tracing via document analysis of media reporting, parliamentary records and government inquiries identified key events during Australia’s participation in the TPP negotiations. Semi-structured interviews were undertaken with 25 key government and non-government policy actors including Federal politicians, public servants, representatives from public interest nongovernment organisations and industry associations, and academic experts. ResultsInterviews revealed that domestic concerns for protecting regulatory space for access to generic medicines and tobacco control emerged onto the Australian government’s trade agenda. This contrasted with other health issues like alcohol control and nutrition and food systems that did not appear to receive attention. The analysis suggests sixteen key factors that shaped attention to these different health issues, including the strength of exporter interests; extent of political will of Trade and Health Ministers; framing of health issues; support within the major political parties; exogenous influencing events; public support; the strength of available evidence and the presence of existing domestic legislation and international treaties, among others. ConclusionThese findings aid understanding of the factors that can enable or constrain attention to health issues on government trade agendas, and offer insights for potential pathways to elevate greater attention to health in future. They provide a suite of conditions that appear to shape attention to health outside the biomedical health domain for further research in the commercial determinants of health.

Introduction The increasing incidence of pathogen transmission from animals to humans (zoonotic spillover events) has been attributed to behavioural practices and ecological and socioeconomic change. As these events sometimes involve pathogens with epidemic or pandemic potential, they pose a serious threat to population health. Public policies may play a key role in preventing these events. The aim of this review is to identify evaluations of public policies that target the determinants of zoonotic spillover, examining approaches taken to evaluation, choice of outcomes measures and evidence of effectiveness. Our approach to identifying and analysing this literature will be informed by a One Health lens, acknowledging the interconnectedness of human, animal and environmental health.Methods and analysis A systematic scoping review methodology will be used. To identify articles, we will search Medline, SCOPUS, Web of Science and Global Health in May 2021 using search terms combining animal health and the animal–human interface, public policy, prevention and zoonoses. We will screen titles and abstracts and extract data according to published guidelines for scoping reviews. All evaluations of public policies aiming to prevent zoonotic spillover events will be eligible for inclusion. We will summarise key data from each study, mapping policies along the spillover pathway and outlining the range of policies, approaches to evaluation and outcome measures. Review findings will provide a useful reference for researchers and practitioners, outlining the state of the evaluative evidence around policies to prevent zoonotic spillover.Ethics and dissemination Formal ethical approval is not required, because the study does not involve primary data collection. The findings of this study will be disseminated through a peer-reviewed publication, presentations and summaries for key stakeholders.

Protophthiracarus afthonos sp. nov. is described and illustrated using line drawings, transmitted light and SEM imaging. It is characterized by an extraordinary richness of notogastral setae (ca. 166 pairs) that has been previously unseen among phthiracaroid mites. The species originates from the material collected from the litter of primary forest in the Peruvian Andes. The genus Protophthiracarus is well represented in the Neotropical Region. Many species of ptyctimous mites have been found in Peru, representing both widespread and endemic biogeographic elements. Among a total of 37 species, 20 from Peru have been described for the first time. Currently, the ptyctimous fauna consists of 12 endemite, 11 neotropical, 4 semicosmopolitan and 9 pantropical biogeographic elements.

The genus Neoprotereunetes Fain et Camerik, 1994 is revised and its definition is extended in order to incorporate some species of the invalid genus Protereunetes Berlese, 1923. The former type species Neoprotereunetes—Ereunetes lapidarius Oudemans, 1906 is redescribed and transferred to Filieupodes Jesionowska, 2010 (Cocceupodidae); Proterunetes boerneri is redescribed and designated the new type species. Two species groups are proposed to embrace Arctic and Antarctic species, respectively. Protereunetes paulinae Gless, 1972 is redescribed, whereas Protereunetes maudae Strandtmann, 1967 is redescribed and designated the type species of the new genus Antarcteupodes gen. nov. A key to the species of Neopretereunetes is provided.

Our paper responds to a narrative review on the influence of populist radical right parties (PRRPs) on welfare policy and its implications for population health in Europe. Five aspects of their review are striking: (i) welfare chauvinism is higher in tax-funded healthcare systems; (ii) PRRPs in coalition with liberal or social democratic parties are able to shift welfare reform in a more chauvinistic direction; (iii) coalitions involving PRRPs can buffer somewhat the drift to welfare chauvinism, but not by much; (iv) the European Union (EU) and its healthcare policies has served somewhat as a check on PRRPs’ direct influence on healthcare welfare chauvinism; (v) PRRPs perform a balancing act between supporting their base and protecting elected power. We note that PRRPs are not confined to Europe and examine the example of Trump’s USA, arguing that the Republican Party he dominates now comes close to the authors’ definition of a PRRP. We applaud the authors’ scoping review for adding to the literature on political determinants of health but note the narrow frame on welfare policy could be usefully expanded to other areas of public policy. We examine three of such areas: the extent to which policy protects those who are different from mainstream society in terms of race, ethnicity, gender or sexuality; the debate between free trade and protectionism; and the rejection of climate change science by many PRRPs. Our analysis concludes that PRRPs promote agendas which are antithetical to eco-socially just population health, and conclude for a call for more research on the political determinants of health.

With public health attention on the commercial determinants of health showing little sign of abatement, how to manage conflicts of interest (COI) in regulatory policy discussions with corporate actors responsible for these determinants is gaining critical traction. The contribution by Ralston et al explores how COI management has itself become a terrain of contestation in their analysis of submissions on a draft World Health Organization (WHO) tool to manage COI conflicts in development of nutrition policy. The authors identify two camps in conflict with one another: a corporate side emphasizing their individual good intents and contributions, and an non-governmental organization (NGO) side maintaining inherent structural conflicts that require careful proscribing. The study concludes that the draft tool does a reasonable job in ensuring COI are avoided and policy development sheltered from corporate self-interests, introducing novel improvements in global governance for health. At the same time, the tool appears to adhere to a belief that private economic (corporate) and public good (citizen) conflicts can indeed be managed. I question this assumption and posit that public health needs to be much bolder in its critique of the nature of power, influence, and self-interests that pervade and risk dominating our stakeholder models of global governance.

The emergence of the COVID-19 pandemic reinforced the central role of the One Health (OH) approach, as a multisectoral and multidisciplinary perspective, to tackle health threats at the human-animal-environment interface. This study assessed Brazilian preparedness and response to COVID-19 and zoonoses with a focus on the OH approach and equity dimensions. We conducted an environmental scan using a protocol developed as part of a multi-country study. The article selection process resulted in 45 documents: 79 files and 112 references on OH; 41 files and 81 references on equity. The OH and equity aspects are poorly represented in the official documents regarding the COVID-19 response, either at the federal and state levels. Brazil has a governance infrastructure that allows for the response to infectious diseases, including zoonoses, as well as the fight against antimicrobial resistance through the OH approach. However, the response to the pandemic did not fully utilize the resources of the Brazilian state, due to the lack of central coordination and articulation among the sectors involved. Brazil is considered an area of high risk for emergence of zoonoses mainly due to climate change, large-scale deforestation and urbanization, high wildlife biodiversity, wide dry frontier, and poor control of wild animals' traffic. Therefore, encouraging existing mechanisms for collaboration across sectors and disciplines, with the inclusion of vulnerable populations, is required for making a multisectoral OH approach successful in the country.

Abstract Background The 2005 International Health Regulations (IHR (2005)) require States Parties to establish National Focal Points (NFPs) responsible for notifying the World Health Organization (WHO) of potential events that might constitute public health emergencies of international concern (PHEICs), such as outbreaks of novel infectious diseases. Given the critical role of NFPs in the global surveillance and response system supported by the IHR, we sought to assess their experiences in carrying out their functions. Methods In collaboration with WHO officials, we administered a voluntary online survey to all 196 States Parties to the IHR (2005) in Africa, Asia, Europe, and South and North America, from October to November 2019. The survey was available in six languages via a secure internet-based system. Results In total, 121 NFP representatives answered the 56-question survey; 105 in full, and an additional 16 in part, resulting in a response rate of 62% (121 responses to 196 invitations to participate). The majority of NFPs knew how to notify the WHO of a potential PHEIC, and believed they have the content expertise to carry out their functions. Respondents found training workshops organized by WHO Regional Offices helpful on how to report PHEICs. NFPs experienced challenges in four critical areas: 1) insufficient intersectoral collaboration within their countries, including limited access to, or a lack of cooperation from, key relevant ministries; 2) inadequate communications, such as deficient information technology systems in place to carry out their functions in a timely fashion; 3) lack of authority to report potential PHEICs; and 4) inadequacies in some resources made available by the WHO, including a key tool – the NFP Guide. Finally, many NFP representatives expressed concern about how WHO uses the information they receive from NFPs. Conclusion Our study, conducted just prior to the COVID-19 pandemic, illustrates key challenges experienced by NFPs that can affect States Parties and WHO performance when outbreaks occur. In order for NFPs to be able to rapidly and successfully communicate potential PHEICs such as COVID-19 in the future, continued measures need to be taken by both WHO and States Parties to ensure NFPs have the necessary authority, capacity, training, and resources to effectively carry out their functions as described in the IHR.

There are at least 20 distinct types of systemic amyloidosis, all of which result in the organ-compromising accumulation of extracellular amyloid deposits. Amyloidosis is challenging to diagnose due to the heterogeneity of the clinical presentation, yet early detection is critical for favorable patient outcomes. The ability to non-invasively and quantitatively detect amyloid throughout the body, even in at-risk populations, before clinical manifestation would be invaluable. To this end, a pan-amyloid-reactive peptide, p5+14, has been developed that is capable of binding all types of amyloid. Herein, we demonstrate the ex vivo pan-amyloid reactivity of p5+14 by using peptide histochemistry on animal and human tissue sections containing various types of amyloid. Furthermore, we present clinical evidence of pan-amyloid binding using iodine-124-labeled p5+14 in a cohort of patients with eight (n = 8) different types of systemic amyloidosis. These patients underwent PET/CT imaging as part of the first-in-human Phase 1/2 clinical trial evaluating this radiotracer (NCT03678259). The uptake of 124I-p5+14 was observed in abdominothoracic organs in patients with all types of amyloidosis evaluated and was consistent with the disease distribution described in the medical record and literature reports. On the other hand, the distribution in healthy subjects was consistent with radiotracer catabolism and clearance. The early and accurate diagnosis of amyloidosis remains challenging. These data support the utility of 124I-p5+14 for the diagnosis of varied types of systemic amyloidosis by PET/CT imaging.

ObjectivesHypopharyngeal carcinoma (HPC) is a head and neck carcinoma with poor prognosis. Traditional laryngopharyngectomy offered promising oncological outcomes at the cost of functional outcomes. The recent advent in transoral robotic surgery (TORS), an organ-preserving surgery, has opened up new perspectives in the treatment for HPC. Here, we evaluate minimally invasive organ preservation surgery [TORS and endoscopic laryngopharyngeal surgery (ELPS)] for HPC in terms of feasibility and oncological and functional outcomes.MethodsThis is a systematic review. Six databases [CUHK Full-Text Journals, Embase 1910 to 2021, Ovid Emcare, Ovid MEDLINE (R), CINAHL, PubMed] were searched for articles and primary studies for TORS and ELPS for HPC. Screening was completed using predefined inclusion or exclusion criteria.ResultsA total of 8 studies on TORS and 3 studies on ELPS were eventually chosen after full-text review. For studies on TORS, 61.3% of patients (84 out of 137) still survived at the last follow-up with a mean follow-up time of 23.20 months (range: 12.8–37.21 months). Severe intraoperative and postoperative complications have not been reported. No cases of TORS required a conversion to open surgery. Swallowing function was optimal postoperatively with only 6 patients eventually required a percutaneous endoscopic gastrostomy (PEG) for feeding. Disease-specific survival was taken as the parameter for the measurement of oncological outcomes. A total of 2 studies reported a disease-specific survival of 100% within their follow-up period of 1 and 1.5 years, respectively. Another 2 studies reported a 2-year DSS of 89 and 98%, respectively. A 5-year DSS of 100% in early stage and 74% in late stage were achieved in one study. Another study also reported a 5-year DSS of 91.7%. For studies of ELPS, a 5- and 3-year disease-specific survival of 100% were achieved in 2 studies. Patients who underwent ELPS had good postoperative swallowing function with no PEG placement. There were also no other fatal complications.ConclusionsBoth TORS and ELPS for HPC provide satisfactory long-term oncological and functional outcomes improving postoperative quality of life of patients.

Abstract Background Maternity waiting homes (MWHs), residential spaces for pregnant women close to obstetric care facilities, are being used to tackle physical barriers to access. However, their effectiveness has not been rigorously assessed. The objective of this cluster randomized trial was to evaluate the effectiveness of functional MWHs combined with community mobilization by trained local leaders in improving institutional births in Jimma Zone, Ethiopia. Methods A pragmatic, parallel arm cluster-randomized trial was conducted in three districts. Twenty-four primary health care units (PHCUs) were randomly assigned to either (i) upgraded MWHs combined with local leader training on safe motherhood strategies, (ii) local leader training only, or (iii) usual care. Data were collected using repeat cross-sectional surveys at baseline and 21 months after intervention to assess the effect of intervention on the primary outcome, defined as institutional births, at the individual level. Women who had a pregnancy outcome (livebirth, stillbirth or abortion) 12 months prior to being surveyed were eligible for interview. Random effects logistic regression was used to evaluate the effect of the interventions. Results Data from 24 PHCUs and 7593 women were analysed using intention-to-treat. The proportion of institutional births was comparable at baseline between the three arms. At endline, institutional births were slightly higher in the MWH + training (54% [n = 671/1239]) and training only arms (65% [n = 821/1263]) compared to usual care (51% [n = 646/1271]). MWH use at baseline was 6.7% (n = 256/3784) and 5.8% at endline (n = 219/3809). Both intervention groups exhibited a non-statistically significant higher odds of institutional births compared to usual care (MWH+ & leader training odds ratio [OR] = 1.09, 97.5% confidence interval [CI] 0.67 to 1.75; leader training OR = 1.37, 97.5% CI 0.85 to 2.22). Conclusions Both the combined MWH+ & leader training and the leader training alone intervention led to a small but non-significant increase in institutional births when compared to usual care. Implementation challenges and short intervention duration may have hindered intervention effectiveness. Nevertheless, the observed increases suggest the interventions have potential to improve women’s use of maternal healthcare services. Optimal distances at which MWHs are most beneficial to women need to be investigated. Trial registration The trial was retrospectively registered on the Clinical Trials website ( https://clinicaltrials.gov ) on 3rd October 2017. The trial identifier is NCT03299491 .

Abstract Background Analysis of disaggregated national data suggest uneven access to essential maternal healthcare services within countries. This is of concern as it hinders equitable progress in health outcomes. Mounting an effective response requires identification of subnational areas that may be lagging behind. This paper aims to explore spatial variation in maternal healthcare service use at health centre catchment, village and household levels. Spatial correlations of service use with household wealth and women’s education levels were also assessed. Methods Using survey data from 3758 households enrolled in a cluster randomized trial geographical variation in the use of maternity waiting homes (MWH), antenatal care (ANC), delivery care and postnatal care (PNC) was investigated in three districts in Jimma Zone. Correlations of service use with education and wealth levels were also explored among 24 health centre catchment areas using choropleth maps. Global spatial autocorrelation was assessed using Moran’s I. Cluster analyses were performed at village and household levels using Getis Ord Gi* and Kulldorf spatial scan statistics to identify cluster locations. Results Significant global spatial autocorrelation was present in ANC use (Moran’s I = 0.15, p value = 0.025), delivery care (Moran’s I = 0.17, p value = 0.01) and PNC use (Moran’s I = 0.31, p value

Abstract Background The People’s Health Movement (PHM) was formed in 2000 and drew inspiration from the Alma Ata Declaration on Primary Health Care’s ‘Health for All’ (1978). Since then PHM has been an active part of a global counter-hegemonic social movement. This study aimed to gain insights on social movement building, drawing on the successes and failures reported by activists over their experiences of working in the Health for All social movement to improve health, justice and equity. Methods Qualitative research methods were employed in this study to capture complex and historical narratives of individual activists, through semi-structured interviews and subsequent thematic analysis of transcripts. The research design and analysis were informed by social movement theory and literature on health activism as a pathway for social change. In this study we examine the semi-structured interviews of 15 health activists who are part of the PHM, with the aim of deriving lessons for strengthening movements for Health for All. Results This study locates the activists’ narratives within a socio-political analysis of the global trends of late modern individualism and capitalist neoliberalism. This highlights the challenges faced by civil society groups mobilising collective action and building social movements for Health for All. The study found that within the constraints of the neoliberal socio-political and economic conditions which have caused the rise in social and health inequities, this group of long-term health activists have been nurturing alternative approaches to structuring society and building collective agency to improve health. Conclusion The practical long-term experiences of the PHM activists examined in this study contribute to a better understanding of the processes and motivations that lead to and sustain health activism, and the dilemmas, strategies, impacts and achievements of such activism.

Abstract Background Sacroiliitis is commonly seen in enthesitis-related arthritis (ERA), a subtype of juvenile idiopathic arthritis (JIA). Sacroiliitis is characterized by the inflammation of the sacroiliac (SI) joints (+/− adjacent tissues). The treatment options include systemic therapy with or without corticosteroid SI joint injections. Image guided SI joint injections are frequently requested in pediatric patients with sacroiliitis. The purpose of this study was to evaluate the feasibility and efficacy of SI joint injections in children with sacroiliitis. Methods A retrospective study of patients referred to Interventional Radiology (IR) for SI joint corticosteroid injections (2000–2018). Clinical information was collected from Electronic Patient Charts and procedural details from PACS. Efficacy was determined clinically, by MRI, or both when available. Results 50 patients (13.8 years; M:F = 35:15) underwent image-guided SI joint corticosteroid injections. Most common indications were JIA (84%) and inflammatory bowel disease (14%). 80% had bilateral injections. 80% were performed under general anesthesia and 20% under sedation. The corticosteroid of choice was triamcinolone hexacetonide in 98% of patients. Needle guidance and confirmation was performed using CT and fluoroscopy (54%), Cone Beam CT (CBCT, 46%), with initial ultrasound assistance in 34%. All procedures were technically successful without any complications. 32/50 patients had long-term follow-up (2 years); 21/32 (66%) had clinical improvement within 3-months. Of 15 patients who had both pre- and post-procedure MRIs, 93% showed short-term improvement. At 2 years, 6% of patients were in remission, 44% continued the same treatment and 47% escalated treatment. Conclusion Image-guided SI joint injections are safe and technically feasible in children. Imaging modalities for guidance have evolved, with CBCT being the current first choice. Most patients showed short-term clinical and imaging improvement, requiring long-term maintenance or escalation of medical treatment.

Abstract The COVID-19 pandemic has ushered in a new climate of uncertainty which is fuelling protectionism and playing into nationalist narratives. Globalisation is under significant threat as governments scramble to reduce their vulnerability to the virus by limiting global trade and flows of people. With the imposition of border closures and strict migration measures, there have been major disruptions in Africa’s global supply chains with adverse impacts on employment and poverty. The African economies overly reliant on single export-orientated industries, such as oil and gas, are expected to be severely hit. This situation is further aggravated by tumbling oil prices and a lowered global demand for African non-oil products. The agricultural sector, which should buffer these shocks, is also being affected by the enforcement of lockdowns which threaten people’s livelihoods and food security. Lockdowns may not be the answer in Africa and the issue of public health pandemic response will need to be addressed by enacting context-specific policies which should be implemented in a humane way. In addressing the socioeconomic impact of COVID-19 on African nations, we argue that governments should prioritize social protection programmes to provide people with resources to maintain economic productivity while limiting job losses. International funders are committing assistance to Africa for this purpose, but generally as loans (adding to debt burdens) rather than as grants. G20 agreement so suspend debt payments for a year will help, but is insufficient to fiscal need. Maintaining cross-border trade and cooperation to continue generating public revenues is desirable. New strategies for diversifying African economies and limiting their dependence on external funding by promoting trade with a more regionalised (continental) focus as promoted by the African Continental Free Trade Agreement, while not without limitations, should be explored. While it is premature to judge the final economic and death toll of COVID-19, African leaders’ response to the pandemic, and the support they receive from wealthier nations, will determine its eventual outcomes.

Abstract The USMCA (NAFTA 2.0), although signed over a year ago, went through several months of renegotiation of certain of its new rules that the Democrat-controlled US Congress wanted altered or strengthened. In December a ‘Protocol of Amendment’ was agreed upon and signed by the three Parties (the USA, Mexico, and Canada). A number of tough, new measures governing pharmaceuticals were revised or deleted, making it potentially easier for generic competition and lower drug costs in all three countries. Rules on protection of labour rights were also strengthened, lowering the threshold at which a complaint of unfair labour practices could be initiated. Procedures for investigating such a complaint or resolving a formal dispute were also improved. Similar procedural improvements were made on measures affecting environmental protection. These Protocol agreements are more health-positive than health-negative, and in the case of pharmaceuticals are of significant impact. Overall, however, these amendments are simply a political fine-tuning of the agreement. Concerns raised in our earlier health impact assessment of the USMCA, notably how the agreement’s regulatory reforms reduce public health policy flexibilities, remain. The agreement continues to subordinate known or potential health costs of many of its measures to dubious claims of aggregate economic gains. Moreover, these gains, if materialized, are likely to accrue to those atop the income/wealth hierarchies in all three nations.

Neoliberal logic and institutional lethargy may well explain part of the reason why governments pay little attention to how their economic and development policies negatively affect health outcomes associated with the global diffusion of unhealthy commodities. In calling attention to this the authors encourage health advocates to consider strategies other than just regulation to curb both the supply and demand for these commodities, by better understanding how neoliberal logic suffuses institutional regimes, and how it might be coopted to alternative ends. The argument is compelling as possible mid-level reform, but it omits the history of the development of neoliberalism, from its founding in liberal philosophy and ethics in the transition from feudalism to capitalism, to its hegemonic rise in global economics over the past four decades. This rise was as much due to elites (the 1% and now 0.001%) wanting to reverse the progressive compression in income and wealth distribution during the first three decades that followed World War Two. Through three phases of neoliberal policy (structural adjustment, financialization, austerity) wealth ceased trickling downwards, and spiralled upwards. Citizen discontent with stagnating or declining livelihoods became the fuel for illiberal leaders to take power in many countries, heralding a new, autocratic and nationalistic form of neoliberalism. With climate crises mounting and ecological limits rendering mid-level reform of coopting the neoliberal logic to incentivize production of healthier commodities, health advocates need to consider more profound idea of how to tame or erode (increasingly predatory) capitalism itself.

Abstract In 2015, the United Nations’ (UN) Member States adopted a bold and holistic agenda of the Sustainable Development Goals (SDGs), integrating a vision of peace and prosperity for people and planet. Extensive work within, between, across sectors is required for this bold and holistic agenda to be implemented. It is in this context that this special article collection showcases multisectoral approaches to achieving SDG 3—Good Health and Well-Being—which, though focused explicitly on health, is connected to almost all other goals. A confluence of social and health inequities, within a context of widespread environmental degradation demands systems thinking and intersectoral action. Articles in this issue focus on the SDGs as a stimulus for renewed multisectoral action: processes, policies, and programs primarily outside the health sector, that have health implications through social, commercial, economic, environmental, and political determinants of health. Case studies offer critical lessons on effectively engaging other sectors to enhance their health outputs, identifying co-benefits and ‘win-wins’ that enhance human health.

Abstract To respond to the global noncommunicable disease (NCD) crisis, the Codex Alimentarius Commission (Codex), a multilateral United Nations body responsible for work on food standards, is developing global guidance for front of pack (FoP) nutrition labelling. Guidance from Codex regarding FoP nutrition labelling at the global level will almost certainly influence national policy making. This shift in Codex’s activities towards standards to address NCDs presents new risks for achievement of public health goals, as a result of the high level of industry involvement in this forum; there is a potential commercial conflict of interest held by manufacturers of products whose consumption could be discouraged by such guidance. In this Commentary, we examine the implications of Codex processes for developing robust global guidance on FoP nutrition labelling and identify opportunities to increase consideration of public health objectives. To date, there has been significantly higher representation of food industry compared to public health actors in Codex discussions on FoP nutrition labelling. Without a strong public health voice in Codex, the industry voice could dominate discussions on FoP nutrition labelling, such that subsequent global guidance prioritises future trade and profits over potential risks to public health. There is currently a critical window of opportunity for public health interests to be prioritised in this multisectoral international forum. The key public health priority for global guidance on FoP nutrition labelling is to ensure protection of policy space for national governments to implement strong and effective regulation, and allow scope for innovation. Public health actors can engage directly with Codex processes, at both the national and global level, and also need to raise awareness among domestic policy makers – including with Ministries of Agriculture and Industry, which often represent countries at Codex – regarding the importance and effectiveness of FoP labelling in NCD prevention. Increased engagement with Codex processes represents a tangible new opportunity to strengthen global governance for public health, and move towards improved coherence between trade policy and health protection goals.

Abstract Background Ethiopia is one of the ten countries in the world that together account for almost 60% of all maternal deaths. Recent reductions in maternal mortality have been seen, yet just 26% of women who gave birth in Ethiopia in 2016 reported doing so at a health facility. Maternity waiting homes (MWHs) have been introduced to overcome geographical and financial barriers to institutional births but there is no conclusive evidence as to their effectiveness. We aim to evaluate the effects of upgraded MWHs and local leader training in increasing institutional births in the Jimma zone of Ethiopia. Methods A parallel, three-arm, stratified, cluster-randomized controlled trial design is being employed to evaluate intervention effects on institutional births, which is the primary outcome. Trial arms are: (1) upgraded MWH + religious/community leader training; (2) leader training alone; and (3) standard care. Twenty-four primary health care unit catchment areas (clusters) have been randomized and 3840 women of reproductive age who had a pregnancy outcome (livebirth, stillbirth or abortion) are being randomly recruited for each survey round. Outcome assessments will be made using repeat cross-sectional surveys at baseline and 24 months postintervention. An intention to treat approach will be used and the primary outcome analysed using generalized linear mixed models with a random effect for cluster and time. A cost-effectiveness analysis will also be conducted from a societal perspective. Discussion This is one of the first trials to evaluate the effectiveness of upgraded MWHs and will provide much needed evidence to policy makers about aspects of functionality and the community engagement required as they scale-up this programme in Ethiopia. Trial registration ClinicalTrial.gov, NCT03299491. Retrospectively registered on 3 October 2017.