IIED – Is urbanization contributing to higher food prices?

September 14, 2009 · 0 comments

Stage et al (2009). Is urbanization contributing to higher food prices? (pdf, 102KB)

Urbanization and emerging population issues working paper series No. 1, IIED, London.

The recent spike in food prices has led to a renewal of interest in agricultural issues and in the long-term drivers of food prices. Urbanization has been mentioned as one possible cause of higher food prices. In this paper we examine some of the links through which urbanization is considered to be contributing to higher food prices and conclude that in most cases urbanization is being conflated with other long-term processes, such as economic growth, population growth and environmental degradation, which can more fruitfully be seen as related but separate processes. We discuss long- and-short term factors affecting food prices, and conclude that the one important way in which urbanization in poor countries may affect food prices, at least potentially, is that it increases the number of households who depend on commercial food supplies, rather than own production, as their main source and hence are likely to hoard food if they fear future price increases. The best policy option for managing this is larger food reserves. Attempts to curb urbanization, on the other hand, would be ill advised.

Kenya – Urban poverty and vulnerabilty

September 11, 2009 · 0 comments

Urban Poverty and Vulnerability In Kenya: Background analysis for the preparation of an Oxfam GB Urban Programme focused on Nairobi. Sept. 2009. OXFAM. (pdf, full-text)

This urban poverty analysis by Oxfam GB was informed by the fact that urban poverty emerged as a key challenge in the OGB Kenya 2007 National Change Strategy review. A range of international actors as well as the government of Kenya now acknowledge the urbanisation of poverty in the country and the scale of the challenges presented by rapid urbanisation. From an Oxfam perspective, this means recognising the need to invest further resources in urban work in a country where, until recently, the programme has focused principally on emergency response and the arid lands in the North in recent years.

Urban poverty and inequality in Kenya
This report brings together the growing evidence about the scale and nature of poverty in Kenya’s urban areas. Between a third and half of the country’s urban population live in poverty, and given the pace of urbanisation, urban poverty will represent almost half of the total poverty in Kenya by 2020. Moreover, while urban poverty has been decreasing according to some measures, statistics indicate that the proportion of the urban population that are poorest of all (the ‘food poor’ and ‘hardcore poor’) has been on the rise.

In Nairobi, the capital city, 60% of the population live in slums and levels of inequality are dangerously high, with negative implications for both human security and economic development. Feelings of insecurity in many of the city’s informal settlements have heightened considerably since the violence following the contested election results of December 2007. Poverty in the city is worst amongst those with low levels of education, another cause for concern given that considerably fewer children attend the later stages of school in Nairobi than in Kenya’s rural areas, and many slum areas have few or no public schools. Meanwhile gender inequalities remain severe, with female slum-dwellers being 5 times more likely to be unemployed than males.

Nairobi slum children least healthy

September 10, 2009 · 0 comments

nairobiNAIROBI, Kenya, Sep 10 – Children living in Nairobi slums are some of the least healthy in the country according to a new report released by Oxfam, a UK based charity.

The report released on Thursday said these children were getting sicker and dying at a higher rate than those in rural areas.

“They get more diarrhea; they are less immunised, they are more likely to suffer from acute respiratory failure and they have breathing problems because of the environment they live in and almost all the children under five have stunted growth,” said Oxfam Country Director Philippa Crosland-Taylor.

She said this was because of the poor living conditions in the slums which had been worsened by the current drought.

The report also stated that in some parts of the capital city, infant mortality rates were double those of poor rural areas, and half of young children suffered from acute respiratory infections and stunted growth.

Acute child malnutrition was also a growing concern.

Ms Crosland-Taylor said the declining income for those in informal employment had led to about 90 percent of poor families skipping or reducing the amount of food they ate.

“These figures were put together in April this year and it is worrying. When you live in the conditions that you have seen in the informal settlements, diseases spread very fast. Sometimes you can argue that this is a pandemic waiting to happen,” she said.

“If you look at the whole sewage situation, a single pit latrine in one of the areas in Kibera can serve up to 150 people in one day, can you imagine what that’s like?” she posed.

The Oxfam Kenya Chapter boss said the urban crisis had intensified over the past year, with people now earning less but having to pay more to survive.

The report warned of a social crisis in Nairobi owing to increasing urban settlements coupled with rising poverty levels.

It said the growing inequality between the rich minority and the poor majority was leaving millions of urban residents living in deplorable conditions with limited or non-existent access to water, sanitation, housing, education and health care services.

“Kenya is facing a new urban time bomb, with millions of Nairobi residents suffering a daily struggle for food and water as the divide between rich and poor widens,” Ms Crosland-Taylor said.
Oxfam warned that the resulting poverty combined with poor governance and ethnicity could have catastrophic consequences.

The organisation accused the Kenyan government of repeatedly ignoring the growing magnitude of the urban crisis, and urged it to invest more funds and resources in improving life for the most vulnerable residents of Nairobi’s slums.

Ms Crosland-Taylor said Projects that improved access to clean water and sanitation, and boost people’s income, were most urgently needed and International donors, who have tended to focus exclusively on rural poverty, also needed to recognise the scale of the urban problem.

It is estimated that Nairobi’s population would double to six million in the next 15 years.

Analysts have also warned that half of all Kenya’s poor would be living in urban areas by 2020 posing a challenge to the already strained basic facilities.

“An increasingly disenfranchised and poverty-stricken urban underclass is set to be the country’s defining crisis over the next decade, unless the Kenyan government and international donors act urgently to address it,” she said.

Source – http://www.capitalfm.co.ke/news/Kenyanews/Nairobi-slum-children-least-healthy-5745.html

A bibliography on urban reproductive health, June-August 2009

September 10, 2009 · 2 comments

Below are citations and abstracts to 10 urban reproductive health studies published from June – August 2009. Entries are listed alphabetically by journal title.

1 –  Cult Health Sex. 2009 Jul 10:1. 

Guiding change: provider voices in youth pre-abortion counselling in urban Vietnam.

Nguyen HK, Martin P, Chinh NQ, Cong DD. Nossal Institute for Global Health, University of Melbourne, Australia.

Pre-abortion counselling has a role in promoting safe sex practices and in preventing repeated unplanned pregnancies and repeated abortions among abortion-seeking women. Such counselling is essential in Vietnam, especially given the common use of abortion. Arguably, in Ho Chi Minh City, Vietnam, the delivery of pre-abortion counselling is more urgent for young women, who have historically been ignored by State reproductive health initiatives and are increasingly exposed to transmission of sexually transmitted infections (STIs), unplanned pregnancies and abortion. This paper charts urban Vietnamese service providers’ discourses in pre-abortion counselling specific for reducing risks of additional unwanted pregnancies, repeat abortion and STI/HIV transmission among young Vietnamese women. Thirteen providers working in counselling delivery, management and programme-planning at the Reproductive Health Care Centre of Ho Chi Minh City participated in this study. Through qualitative interviews, this paper elicits a range of provider attitudes, considerations and approaches in pre-abortion counselling and presents these discourses using participant anecdotes. Demonstrated among participant responses were five key pre-abortion counselling phases for promoting effective family planning among young women. Topics covered in these counselling phases included abortion complications, post-abortion fertility return, contraception, behaviour change and STI/HIV prevention and sexual and reproductive health basics (SRH). The service provider discourses gleaned from this study are foundational for further research and development of best practice guidelines in pre-abortion counselling.

2:  Health Care Women Int. 2009 Jun;30(6):475-83.

Experience with side effects among users of injectables, the IUD, and oral contraceptive pills in four urban areas of Honduras.

Barden-O’Fallon J, Speizer I, Rodriguez F, Calix J. MEASURE Evaluation Project, Chapel Hill, NC 27516, USA. bardenof@email.unc.edu

Contraceptive side effects are often the most commonly reported reason for method discontinuation, particularly of modern methods. We use data from eight focus groups and 800 exit interviews to examine women’s experiences with contraceptive side effects in four urban areas of Honduras. Ease of treatment and differences in motivation to avoid pregnancy are suggested explanations for why side effects cause some women to continue and others to discontinue. Although side effects are a common reason for discontinuation in this population, less than half of the surveyed women were informed about potential side effects by a health worker on the day of the interview.

3:  Hum Reprod. 2009 Jul 29. 

Psychological distress among men suffering from couple infertility in South Africa: a quantitative assessment.

Dyer S, Lombard C, Van der Spuy Z. Division of Obstetrics and Gynaecology, Faculty of Health Sciences, Groote Schuur 7937, Cape Town, South Africa.

BACKGROUND Recent years have seen a growing interest in the impact of infertility on reproductive health in developing countries. Most of the research which has addressed the psychosocial consequences of infertility in African countries has been qualitative in nature and focused on women. It was the aim of this study to assess psychological distress quantitatively in men suffering from couple infertility living in an urban community in South Africa.

METHODS The Symptom Checklist-90-R, a standardized instrument for the measurement of current psychological symptom status, was administered to 120 men upon first presentation to a public health sector infertility clinic (study group) in a tertiary referral centre. The control group comprised 120 men who attended an antenatal clinic with their partner. All men may have previously fathered a child. Raw test scores were converted into standard area T scores and analyzed further. RESULTS Participants in the study group differed in their psychological symptom status when compared with controls. Male partners of infertile couples had significantly elevated mean T scores for all nine primary symptom dimensions as well as the three global markers of distress (P < 0.0001 versus control), but these did not exceed the upper range of normal.

CONCLUSIONS When compared with controls, male partners of infertile couples experienced elevated levels of psychological distress, but without, on average, suffering from psychopathology. A comparison with qualitative studies from African countries and with quantitative studies from the Western industrialized world revealed both similarities and differences. Understanding and addressing the male perspective of infertility is an important component of infertility management.

4:  Int J Cancer. 2009 Aug 1;125(3):662-5.

Breastfeeding and breast cancer risk in India: a multicenter case-control study.

Gajalakshmi V, Mathew A, Brennan P, Rajan B, Kanimozhi VC, Mathews A, Mathew BS, Boffetta P.  Epidemiological Research Center, Chennai, Tamil Nadu, India.

Breast cancer incidence is low in India compared with high-income countries, but it has increased in recent decades, particularly among urban women. The reasons for this pattern are not known although they are likely related to reproductive and lifestyle factors. Here, we report the results of a large case-control study on the association between breastfeeding and breast cancer risk. The study was conducted in 2 areas in South India during 2002-2005 and included 1,866 cases and 1,873 controls. Detailed information regarding menstruation, reproduction, breastfeeding and physical activity was collected through in-person interview. Odds ratios (OR) and 95% confidence intervals (CI) were estimated by unconditional logistic regression models. Breastfeeding for long duration was common in the study population. Lifetime duration of breastfeeding was inversely associated with breast cancer risk among premenopausal women (p-value of linear trend, 0.02). No such protective effect was observed in postmenopausal women, among whom a protective effect of parity was suggested. A reduction of breast cancer risk with prolonged breastfeeding was shown among premenopausal women. Health campaign focusing on breastfeeding behavior by appropriately educating women would contribute to reduce breast cancer burden. Publication Types: Multicenter Study Research Support, Non-U.S. Gov’t PMID: 19452516 [

5:  J Sex Med. 2009 Jul 21. 

Prevalence and Potential Risk Factors of Female Sexual Difficulties: An Urban Iranian Population-Based Study.

Goshtasebi A, Vahdaninia M, Rahimi Foroshani A. Iranian Institute for Health Sciences Research (IHSR), ACECR, Tehran, Iran.

Introduction. Female sexual dysfunction is common, a multifactorial phenomenon with a potential to cause marital strain, impaired fertility, and poor quality of life. Epidemiologic data are scarce and little is known about the prevalence of sexual difficulties and the exact role of putative risk factors in Iran. Aim. To determine the prevalence of female sexual difficulties and the potential risk factors in an urban Iranian population.

Methods. A cross-sectional study was performed in the province of Kohgilooyeh-Boyerahmad (KB) in the southwest of Iran and involved sexually active urban women aged 15 years and over, selected via a quota-based cluster sampling method. The study used an ad hoc questionnaire covering the demographic and reproductive variables as well as the data related to sexual difficulties. Data were analyzed using multiple logistic regression models. The main outcome measures were the prevalence rates and the predictors of sexual difficulties.

Main Outcome Measures. The prevalence of female sexual difficulties and the associated risk factors. Results. One thousand four hundred fifty-six sexually active women living in the urban areas of KB province in 2005 were selected. The mean age of the sample was 34.04 +/- 9.2 (16-71) years and the mean number of completed grades was 7.18 (+/-4.8). More than 52% of the participants had experienced at least one type of sexual difficulty. The greatest and smallest frequencies were observed for orgasm difficulty (21.3%, confidence interval[CI](0.95) = 19.2-23.4%) and lubrication difficulty (11.9%, CI(0.95) = 10.2-13.6%). Age, education, contraceptive modality, and obstetric/gynecologic procedures were all associated with at least one type of sexual dysfunction.

Conclusion. Similar to previous studies, we found a relatively high prevalence of sexual difficulties in this urban population of low socioeconomic status. However, our results concerning the role of some demographic and reproductive variables in producing sexual difficulties were different from those reported by other researchers. Goshtasebi A, Vahdaninia M, and Rahimi Foroshani A. Prevalence and potential risk factors of female sexual difficulties: An urban Iranian population-based study.

6:  Midwifery. 2009 Jun;25(3):317-26. 

Perceived prenatal learning needs of multigravid Ghanaian women.

Bansah M, O’Brien B, Oware-Gyekye F. Nursing & Midwifery Training College, P.O. Box 333, Secondi, Ghana.

OBJECTIVE: to explore the learning needs of multigravid Ghanaian women in an effort to develop more effective prenatal education programmes. DESIGN: a descriptive-exploratory design consisting of in-depth individual semi-structured interviews and a single focus group.

SETTING: prenatal clinic of a large hospital in a city in Ghana, Africa.

PARTICIPANTS: 18 multigravid Ghanaian women between 38 and 40 weeks of gestation who were not experiencing complications with the index pregnancy. FINDINGS: the women reported particular learning needs that were not being addressed during their prenatal care. They identified areas where they wanted more information about specific topics such as birth control, sexual activity during pregnancy and promoting ideal fetal positions. They also wanted information about how to care for themselves and their babies after birth. They received information from staff at the prenatal clinic that sometimes conflicted with what they learned from those in their informal support system (e.g. mothers and friends).

KEY CONCLUSIONS: inconsistency with respect to information received from health professionals and that received from other sources of support created tension that led to increased doubt and anxiety on the part of the women. They reported that they wanted more in-depth information that was relevant to their specific needs and solution centred. They wanted a more interactive educational process including some separate teaching sessions specifically for multigravid women. They also wanted access to information during both private and group encounters with health-care professionals.

IMPLICATIONS FOR PRACTICE: information and strategies deemed to be of interest and importance to these multigravid women, such as private counselling sessions to address individual concerns about safe sexual health and birth control, and interactive groups for multigravid women, could be implemented to increase interest and promote the well-being of these women.

7:  Public Health Nutr. 2009 Jun;12(6):789-98. 

Determinants of low birth weight in urban Pakistan.

Janjua NZ, Delzell E, Larson RR, Meleth S, Kristensen S, Kabagambe E, Sathiakumar N. Department of Epidemiology, University of Alabama at Birmingham, 1665 University Blvd, RPHB 430, Birmingham, AL 35294, USA.  

OBJECTIVE: To identify determinants of low birth weight (LBW) in Karachi, Pakistan, including environmental exposures and nutritional status of the mother during pregnancy.

DESIGN: Cross-sectional study.ParticipantsFive hundred and forty mother-infant pairs. We interviewed mothers about obstetric history, diet and exposure to Pb. We measured birth weight and blood lead level (BLL). We performed multiple log binomial regression analysis to identify factors related to LBW.

RESULTS: Of 540 infants, 100 (18.5 %) weighed <or=2.5 kg. Umbilical cord BLL was not significantly associated with LBW. Maternal poor self-rated health (adjusted prevalence ratio (adjPR) = 1.83; 95 % CI 1.09, 3.07) and none or one prenatal visit (adjPR = 2.18; 95 % CI 1.39, 3.43) were associated with LBW. A statistically significant interaction between mothers’ mid upper-arm circumference (MUAC) and dietary vitamin C intake was noted. Compared with mothers with MUAC above the median and dietary vitamin C intake above the 3rd quartile (>208.7 mg/d), infants of mothers with MUAC less than or equal to the median and dietary vitamin C intake >208.7 mg/d (adjPR = 10.80; 95 % CI 1.46, 79.76), mothers with MUAC above the median and vitamin C intake <or=208.7 mg/d (adjPR = 10.67; 95 % CI 1.50, 76.02) and mothers with MUAC less than or equal to the median and vitamin C intake <or=208.7 mg/d (adjPR = 13.19; 95 % CI 1.85, 93.79) more likely to give birth to an LBW infant.

CONCLUSIONS: In Pakistan, poor nutritional status and inadequate prenatal care were major determinants of LBW in this setting. Environmental factors including umbilical cord BLL were not significantly associated with LBW.

8:  Reprod Health. 2009 Jun 16;6:9.

Maternal health in resource-poor urban settings: how does women’s autonomy influence the utilization of obstetric care services?

Fotso JC, Ezeh AC, Essendi H. African Population and Health Research Center (APHRC), Nairobi, Kenya. jcfotso@aphrc.org

BACKGROUND: Despite various international efforts initiated to improve maternal health, more than half a million women worldwide die each year as a result of complications arising from pregnancy and childbirth. This research was guided by the following questions: 1) How does women’s autonomy influence the choice of place of delivery in resource-poor urban settings? 2) Does its effect vary by household wealth? and 3) To what extent does women’s autonomy mediate the relationship between women’s education and use of health facility for delivery?

METHODS: The data used is from a maternal health study carried out in the slums of Nairobi, Kenya. A total of 1,927 women (out of 2,482) who had a pregnancy outcome in 2004-2005 were selected and interviewed. Seventeen variable items on autonomy were used to construct women’s decision-making, freedom of movement, and overall autonomy. Further, all health facilities serving the study population were assessed with regard to the number, training and competency of obstetric staff; services offered; physical infrastructure; and availability, adequacy and functional status of supplies and other essential equipment for safe delivery, among others. A total of 25 facilities were surveyed. RESULTS: While household wealth, education and demographic and health covariates had strong relationships with place of delivery, the effects of women’s overall autonomy, decision-making and freedom of movement were rather weak. Among middle to least poor households, all three measures of women’s autonomy were associated with place of delivery, and in the expected direction; whereas among the poorest women, they were strong and counter-intuitive. Finally, the study showed that autonomy may not be a major mediator of the link between education and use of health services for delivery.

CONCLUSION: The paper argues in favor of broad actions to increase women’s autonomy both as an end and as a means to facilitate improved reproductive health outcomes. It also supports the call for more appropriate data that could further support this line of action. It highlights the need for efforts to improve households’ livelihoods and increase girls’ schooling to alter perceptions of the value of skilled maternal health care.

9:  Stud Fam Plann. 2009 Jun;40(2):101-12.

Are female orphans at risk for early marriage, early sexual debut, and teen pregnancy? Evidence from sub-Saharan Africa.

Palermo T, Peterman A. Ipas, 300 Market Street, Suite 200, Chapel Hill, NC 27516, USA. palermot@ipas.org

Female orphans are widely cited as being at risk for early marriage, early childbearing, and risky sexual behavior; however, to date no studies have examined these linkages using population-level data across multiple countries. This study draws from recent Demographic and Health Surveys from ten sub-Saharan African countries to examine the relationship between orphanhood status and measures of early marriage, early sexual debut, and teen pregnancy among adolescent girls aged 15 to 17. Results indicate that, overall, little association is found between orphanhood and early marriage or teen pregnancy, whereas evidence from seven countries supports associations between orphanhood and early sexual debut. Findings are sensitive to the use of multivariate models, type of orphan, and country setting. Orphanhood status alone may not be a sufficient targeting mechanism for addressing these outcomes in many countries; a broader, multidimensional targeting scheme including orphan type, schooling, and poverty measures would be more robust in identifying and aiding young women at risk.

10: Vaccine. 2009 Jul 9;27(32):4284-8. 

Scaling up interventions to eliminate neonatal tetanus: factors associated with the coverage of tetanus toxoid and clean deliveries among women in Vientiane, Lao PDR.

Masuno K, Xaysomphoo D, Phengsavanh A, Douangmala S, Kuroiwa C. Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan. ring8ring8@hotmail.com

The Lao People’s Democratic Republic (PDR) is one of seven countries that have not eliminated maternal and neonatal tetanus in more than 50% of districts. We conducted a community-based household survey to assess the achievements of strategies towards maternal and neonatal tetanus elimination in the capital province. The coverage of tetanus toxoid (TT) was 79.7% by the protection-at-birth (PAB) method. The percentages of deliveries attended by skilled personnel and of deliveries at a health facility were 68.4% and 63.7%, respectively. The progress towards eliminating neonatal tetanus in Lao PDR is not sufficient despite the study sites being placed in the capital province. The lack of continuum of care for mothers and newborns is the major obstacle to scale up the tetanus toxoid coverage and PAB as well as clean deliveries.

Migration flows to African towns are slowing

September 10, 2009 · 0 comments

Cities and migration can make an important contribution to development in poor countries. But in many sub-Saharan African countries, migration to large towns is falling and urbanisation is slowing. This is often the result of declining economic opportunities in urban areas.

Research from Kings College London, in the UK, examines urbanisation in sub-Saharan Africa. Using census and survey data, the research looks at recent growth trends in large and medium-sized towns in 14 African countries: Benin, Burkina Faso, Côte d’Ivoire, Ghana, Kenya, Mali, Mauritania, Mozambique, Niger, Nigeria, Senegal, Tanzania, Uganda and Zambia.

In many poor countries, employment opportunities make urban areas very attractive for migrants from rural areas. But experiences differ widely across developing regions. In many sub-Saharan African towns and cities, structural changes have led to falls in formal employment and a rise in dependence on informal, low-paid work.

As urban migrants lack access to economic safety nets, they often have little option but to return home when a crisis hits (for example, if they lose their job). This has led to an increase in circular migration (the continuing movement of people between rural and urban areas), which has always been important in sub-Saharan Africa.

Where urban economies are attractive to migrants, it is often clear that their population growth is mainly derived from in-migration from rural areas. However, the research shows that many towns in Africa – particularly in West Africa – are not growing much faster, and occasionally are growing more slowly, than rural populations.

Other key findings of the research include:

  • Across Africa, net migration to towns has slowed significantly.
  • Counter-urbanisation has occurred in Zambia, Côte d’Ivoire and Mali.
  • Net in-migration has become weak or negligible in most urban centres in Benin, Mauritania, Mozambique, Niger and Senegal.
  • In Niger, Kenya and Tanzania, the capital cities are still experiencing strong net in-migration but the situation in other main towns is mixed.
  • In Uganda, violent conflict has encouraged migration to Gulu and Lira, but migration to other towns is low or negative.
  • In Ghana, net migration to towns is low except for Kumasi.
  • The research shows that some African countries are now not necessarily becoming more urban, or are only urbanising very slowly. It is important that the economic problems and urban livelihood issues that are driving these trends are fully recognised.

The implications of the research include:

  • The appearance of new, unplanned residential areas does not necessarily indicate that a city is attracting and keeping large flows of in-migrants.
  • Circular migration has increased as a result of structural change in many sub-Saharan African countries.
  • In Côte d’Ivoire and Burkina Faso, many young people are among those leaving the large towns and cities for rural areas.

The trends identified are important indicators of the crisis in urban poverty and livelihood insecurity in many of sub-Saharan Africa’s urban areas.  Policymakers need to recognise the urgency of addressing these issues.

Source – http://www.id21.org/zinter/id21zinter.exe?a=i&w=u7dp1g2

2009 studies on sanitation, hygiene and water quality

September 3, 2009 · 0 comments

Below are citations to 12 recently published or forthoming reports and articles. Links are included to the full-text when available.

These Environmental Health Updates can also be found on the Environmental Health at USAID website at: http://www.ehproject.org/eh/eh_topics.html

New Reports

1 – USAID Hygiene Improvement Project, 2009 – Assessment of Hygiene Promotion in Madagascar 2007-2008: Comparisons for Households, Schools, and Health Facilities. This report presents comparative findings of the USAID Hygiene Improvement Project’s annual behavioral outcome monitoring of hygiene practices measured in 2007 and again in 2008 in the four regions in central, south central, and eastern Madagascar where HIP is operational.

2 – USAID Hygiene Improvement Project – Lessons Learned to Improve Basic Sanitation (World Water Week 2009). Author: Merri Weinger.

3 – WHO, 2009 – Scaling Up Household Water Treatment Among Low-Income Populations. Authors: Thomas Clasen (London School of Hygiene & Tropical Medicine). This report examines the evidence to date regarding the scalability of HWTS. It seeks to consolidate existing knowledge and experience and distill the lessons learnt. Its primary aims are to 1) review the development and evolution of leading household water treatment technologies in their efforts to achieve scale, 2) identify the main constraints that they have encountered and 3) recommend ways forward.

4 – Water and Sanitation Program (WSP), 2009 – Study for Financial and Economic Analysis of Ecological Sanitation in Sub-Saharan Africa. This study on financial and economic analysis of ecological sanitation (ecosan) in Sub-Saharan Africa was financed by the Water and Sanitation Program (WSP). It focused on a comparison of sanitation technologies suitable for urban settlements. The aim of the study was to compare ecosan with conventional sanitation systems in terms of financial and economic costs and benefits, in order to assist decision-makers and sponsors of development programs to make informed decisions about relative merits of different types of sanitation.

Recently Published or Forthcoming Articles

5 – Tropical Medicine & International Health, forthcoming article

The effect of a soap promotion and hygiene education campaign on handwashing behaviour in rural India: a cluster randomised trial

Adam Biran, Wolf-Peter Schmidt, Richard Wright, Therese Jones, M Seshadri, Pradeep Isaac, N. A. Nathan, Peter Hall, Joeleen McKenna, Stewart Granger, Pat Bidinger and Val Curtis.

Objective – To investigate the effectiveness of a hygiene promotion intervention based on germ awareness in increasing handwashing with soap on key occasions (after faecal contact and before eating) in rural Indian households.

Methods – Cluster randomised trial of a hygiene promotion intervention in five intervention and five control villages. Handwashing was assessed through structured observation in a random sample of 30 households per village. Additionally, soap use was monitored in a sub-sample of 10 households per village using electronic motion detectors embedded in soap bars.

Results – The intervention reached 40% of the target population. Germ awareness increased as well as reported handwashing (a possible indicator of perceived social norms). Observed handwashing with soap on key occasions was rare (6%), especially after faecal contact (2%). Observed handwashing with soap on key occasions did not change 4 weeks after the intervention in either the intervention arm (−1%, 95% CI −2%/+0.3%), or the control arm (+0.4%, 95% CI −1%/+2%). Data from motion detectors indicated a significant but small increase in overall soap use in the intervention arm. We cannot confidently identify the nature of this increase except to say that there was no change in a key measure of handwashing after defecation.

Conclusion – The intervention proved scalable and effective in raising hygiene awareness. There was some evidence of an impact on soap use but not on the primary outcome of handwashing at key times. However, the results do not exclude that changes in knowledge and social norms may lay the foundations for behaviour change in the longer term.

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6 – Epidemiology and Infection, forthcoming article

Dirty hands: bacteria of faecal origin on commuters’ hands

JUDAH,G., DONACHIE,P., COBB,E., SCHMIDT,W., HOLLAND,M., CURTIS,V.

Although many studies have investigated bacteria on the hands of health-care workers and caregivers, few have looked at microbiological contamination on the hands of the general adult public. This study investigated faecal bacteria on the hands of commuters in five UK cities. Of the 404 people sampled 28% were found to have bacteria of faecal origin on their hands. A breakdown by city showed that the proportion of people with contaminated hands increased the further north the city of investigation (P<0·001), an effect which was due in large part to a significant trend in men but not in women. Bus users were more contaminated than train users. The results of this exploratory study indicate that hand hygiene practices in the UK may be inadequate and that faecal indicator bacteria on hands may be used to monitor the effect of hand-washing promotion campaigns.

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7 – Epidemiology and Infection, forthcoming article

Recall errors in a weekly survey of diarrhoea in Guatemala: determining the optimal length of recall

ZAFAR,S. N., LUBY,S. P., MENDOZA,C.

We measured the recall error, optimal recall length and factors associated with diarrhoea in a weekly survey. Data was taken from a year-long randomized controlled trial in which characteristics of diarrhoeal episodes were recorded weekly. We labelled the recall period as days 1–6; day 1 being the day before the visit. Recall error was the percentage difference between the number of episodes reported to begin on a particular day and the mean for days 1 and 2. Generalized estimating equations were used to determine associations. Recall error was 37% on day 3 and 51% on day 5. The error was less in younger children (by 10%), severe episodes (by 29%) and when blood was present in the stool (by 18%). Diarrhoea was underreported when the recall period extended beyond 2 days. Surveys that use longer recall periods risk underestimating diarrhoea incidence and selectively capturing more severe episodes.

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8 – Journal of Water and Health Vol 07 No 3 pp 380–391

Environmental risk factors for diarrhoea among male schoolchildren in Jeddah City, Saudi Arabia.

Mansour A. Al-Ghamdi, Graham Bentham and Paul R. Hunter

Diarrhoeal disease is still one of the major causes of mortality and morbidity of children in developing countries. Our objective was to assess the prevalence of diarrhoeal disease among male schoolchildren in Jeddah and to identify the associated risk factors, especially those related to drinking water and sanitation disposal. This cross-sectional study was conducted randomly where self-administered questionnaires were issued to parents through the schools. The data were collected from 1,064 respondents indicating that 14.9% of the children had diarrhoea during the previous month. The main risk factors were: the number of children under five years living in the same house (OR per child 1.34, 95% confidence intervals 1.15–1.56), being of Saudi nationality (OR 1.75, 1.08–2.84), reporting sewage spillage near the home (OR 1.69, 1.14–2.53), eating out after school hours (OR 1.74, 1.16–2.60), not drying hands after washing them (OR 1.66, 1.10–2.51), using reusable cloths or sponges to dry dishes (OR 1.70, 1.14–2.52).

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9 – Journal of Water and Health Vol 07 No 2 pp 259–266

Child dysentery in the Limpopo Valley: a cohort study of water, sanitation and hygiene risk factors

Stephen W. Gundry, James A. Wright, Ronán M. Conroy, Martella Du Preez, Bettina Genthe, Sibonginkosi Moyo, Charles Mutisi and Natasha Potgieter

The objective of this cohort study was to assess risk factors for child dysentery and watery diarrhoea. The study participants consisted of 254 children aged 12–24 months in rural South Africa and Zimbabwe in households where drinking water was collected from communal sources. The main outcome measure was the most severe diarrhoea episode: dysentery, watery diarrhoea or none. For dysentery, drinking water from sources other than standpipes had a relative risk ratio of 3.8 (95% CI 1.5–9.8). Poor source water quality, as indicated by Escherichia coli counts of 10 or more cfu 100 ml-1, increased risk by 2.9 (1.5–5.7). There were no other significant risk factors for dysentery and none for watery diarrhoea. In this study, endemic dysentery is associated only with faecal contamination of source water. Sources other than standpipes, including improved groundwater, are of greater risk. Remediation of water quality by treatment at source or in the household will be required to achieve access to safe drinking water in accordance with the 7th Millennium Development Goal.

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10 – Journal of Water and Health Vol 07 No 3 pp 527–534

Increasing equity of access to point-of-use water treatment products through social marketing and entrepreneurship: a case study in western Kenya.

Matthew C. Freeman, Robert E. Quick, Daniel P. Abbott, Paul Ogutu and Richard Rheingans

Point-of-use water chlorination reduces diarrhoea risk by 25–85%. Social marketing has expanded access to inexpensive sodium hypochlorite for water treatment, at a cost of less than US$0.01 per day, in Kenya. To increase product access, women’s groups in western Kenya were trained to educate neighbours and sell health products to generate income. We evaluated this programme’s impact on equity of access to water treatment products in a cross-sectional survey. We surveyed 487 randomly selected households in eight communities served by the women’s groups. Overall, 20% (range 5–39%) of households in eight communities purchased and used chlorine, as confirmed by residual chlorine observed in stored water. Multivariate models using illiteracy and the poorest socioeconomic status as a referent showed that persons with at least some primary education (OR 2.5, 95% CI 1.8, 3.5) or secondary education (OR 5.4, 95% CI 1.6, 17.5) and persons in the four wealthiest quintiles (OR 2.5, 95% CI 1.0, 6.0) were more likely to chlorinate stored water. While this implementation model was associated with good product penetration and use, barriers to access to inexpensive water treatment remained among the very poor and less educated.

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11 – Jnl Health, Population & Nutrition, August 2009

Capability Development among the Ultra-poor in Bangladesh: A Case Study (pdf, full-text)

Syed Masud Ahmed

Microcredit is advocated as a development tool that has the potential to reduce poverty, empower participants, and improve health. Results of several studies have shown that the extreme poor, or the ultra-poor, often are unable to benefit from traditional microcredit programmes and can, as a result of taking a loan they cannot repay, sink deeper into economic and social poverty. This case study describes an intervention directed at enabling the ultra-poor rural populations to pull themselves out of poverty. The intervention integrates multiple components, including asset grants for income generation, skills training, a time-bound monthly stipend for subsistence, social development and mobilization of local elite, and health support. Results of an evaluation showed that, after 18 months, the programme positively impacted livelihood, economic, social and health status to the extent that 63% of households (n=5,000) maintained asset growth and joined (or intended to join) a regular microcredit programme. Impacts included improved income, improved food security, and improved health knowledge and behaviour. Applying a social exclusion framework to the intervention helps identify the different dynamic forces that can exclude or include the ultra-poor in Bangladesh in development interventions such as microcredit.

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12 – Environmental Health Perspectives, Sept. 2009

Low-Dose Arsenic Compromises the Immune Response to Influenza A Infection in Vivo. (pdf, full-text)

Courtney D. Kozul, Kenneth H. Ely, Richard I. Enelow, and Joshua W. Hamilton

Background: Arsenic exposure is a significant worldwide environmental health concern. We recently reported that 5-week exposure to environmentally relevant levels (10 and 100 ppb) of As in drinking water significantly altered components of the innate immune response in mouse lung, which we hypothesize is an important contributor to the increased risk of lung disease in exposed human populations.

Objectives: We investigated the effects of As exposure on respiratory influenza A (H1N1) virus infection, a common and potentially fatal disease.

Methods: In this study, we exposed C57BL/6J mice to 100 ppb As in drinking water for 5 weeks, followed by intranasal inoculation with a sublethal dose of influenza A/PuertoRico/8/34 (H1N1) virus. Multiple end points were assessed postinfection.

Results: Arsenic was associated with a number of significant changes in response to influenza, including an increase in morbidity and higher pulmonary influenza virus titers on day 7 postinfection. We also found many alterations in the immune response relative to As-unexposed controls, including a decrease in the number of dendritic cells in the mediastinal lymph nodes early in the course of infection.

Conclusions: Our data indicate that chronic As exposure significantly compromises the immune response to infection. Alterations in response to repeated lung infection may also contribute to other chronic illnesses, such as bronchiectasis, which is elevated by As exposure in epidemiology studies.

South Africa – Paraffin related injuries in Cape Town

September 2, 2009 · 0 comments

WHO Bulletin, Sept. 2009

Paraffin-related injury in low-income South African communities: knowledge, practice and perceived risk.

Full-text: http://www.who.int/bulletin/volumes/87/9/08-057505.pdf (pdf, 576KB)

David C Schwebel,a Dehran Swart,b Siu-kuen Azor Hui,a Jennifer Simpsona & Phumla Hobeb

Objective – To explore what individuals at risk of injury from using paraffin (also known as kerosene) know about paraffin safety, what they do to protect themselves and their families from paraffin-related injury, and how they perceive their risk for such injury. Also, to explore interrelations between these factors and age, sex, education and income.

Methods – A sample of 238 individuals was randomly recruited from low-income housing districts near Cape Town, South Africa in 2007. Trained research assistants interviewed participants to explore their knowledge about paraffin-related safety and their perceived risk of injury from using paraffin. Researchers inspected participants’ homes to evaluate paraffin safety practices. Descriptive and correlational analyses were conducted.

Findings – Participants had relatively low levels of knowledge about paraffin-related safety. They had high levels of unsafe practice and their perceived risk of injury was moderate. Knowledge of paraffin safety and safe practices were positively correlated with each other. Greater knowledge showed a negative correlation with the perception of being at risk for injury, but safe practices showed no correlation with perceived risk of injury. Formal education, the number of children in the home and frequency of paraffin use were positively correlated with knowledge but not with safe practices. The only significant correlate to safe practices was greater income, perhaps a reflection of the impact of financial resources on paraffin safety practices.

Conclusion – To develop successful paraffin safety interventions, it is necessary to understand baseline levels of knowledge, practice and perceived risk of injury among at-risk populations. Our findings could be of value for designing interventions that will increase knowledge, improve safe practices and lead to the accurate perception of the risk of injury from using paraffin.

Urban sprawl, bad sanitation spread dengue fever

September 1, 2009 · 0 comments

MANILA, Sept 1 (Reuters) – The rapid growth of crowded cities has helped spread and increase the transmission of dengue around the world, health experts said on Tuesday, warning up to 3 billion people were already at risk.

They also disputed reports that climate change could become a factor in the spread of the disease from tropical areas because the mosquito that carries dengue has reached temperate regions due to rising temperatures.

“Climate change has very little effect on the disease,” Duane Gubler, director of Asia Pacific Institute of Tropical Medicine and Infectious Diseases at the University of Hawaii, told Reuters on the sidelines of a three-day dengue symposium in Manila.

Scientists and health experts are meeting to exchange practices and strategies to combat the disease that infects 50 million people every year, causing tens of thousands of deaths, mainly among children.

“As early the 1980s, dengue fever had reached epidemic proportions in some countries in Asia long before climate change became an issue. Rapid urbanisation, increase in air travel and lack of mosquito control are the main drivers of the disease.”

Gubler said dengue spreads quickly in crowded cities with inadequate basic services, such as potable water, sanitation and waste-management and weak public health infrastructures.

In the 1950s, when the first dengue outbreak was reported in Manila, only 10 countries in Southeast and South Asia had dengue problems but the disease has now spread to about 100 states in the Pacific islands, Latin America and Africa due to rise in air travel.

About 57 percent of people across the globe are now living in cities, Gubler said, adding most urban areas in the region now have a population of over 5 million.

Gubler said only about 50 million people travelled every year in the 1950s, but the figure has risen to about 2 billion in the last six decades, helping spread the disease.

He said the disease could only be controlled if governments worked closely with the science and health sectors to improve public health services, make more people aware of the disease and eliminate mosquito breeding grounds.

Gubler said the world is rushing to develop an anti-dengue drug by 2012 and a vaccine in five to seven years, citing seven pharmaceutical and biotech companies that were at various stages of clinical tests to produce the drugs and vaccines.

Source – http://www.reuters.com/article/latestCrisis/idUSMAN483973

Health Experts Look for Ways to Fight Spread of Dengue Fever

September 1, 2009 · 0 comments

New York Times, September 1, 2009

KUALA LUMPUR — When Muhammad Fariz Irfan Noordin’s father took him to the University Malaya Medical Center, his blood platelet count was so low that doctors admitted him immediately. The 15-year-old boy had been ill for several days with a fever, headache and vomiting, and he had a rash on his hands and face.

Muhammad was hooked up to an intravenous drip, and nurses constantly monitored his vital signs to ensure that he would not suffer internal bleeding and become another victim of the disease that has already claimed 67 lives in Malaysia this year.

With 28,710 cases reported through Aug. 15, compared with 27,900 for the same period last year, Malaysia is losing ground in its campaign to contain the spread of dengue fever. The government recently announced its “Dengue Strategic Plan, 2009-2013,” an effort aimed at reducing cases 10 percent each year.

But Malaysia, which has continued to record new dengue cases after the end of its peak season, is not alone in its struggle. Sri Lanka has experienced one of its worst outbreaks in recent years, and health officials are waiting to see what will happen once India enters its peak transmission season in September.

“We anticipate this is the beginning of the transmission season for many countries in the region,” said Chusak Prasittisuk, the World Health Organization’s communicable diseases control coordinator for Southeast Asia.

While emerging diseases like influenza A(H1N1), also known as swine flu, continue to dominate the headlines, experts say dengue is not only thriving in many endemic areas, it is also spreading to countries previously unaffected by the disease. Data compiled by the W.H.O. show the number of cases in Southeast Asia surged from 152,448 in 2004 to 242,241 last year. In the Western Pacific region, 213,248 cases were reported in 2008, up from 160,823 in 2004.

The spread of dengue has been facilitated by greater population mobility, combined with urbanization. Both factors have helped the Aedes mosquito carry the virus further afield and infect greater numbers of people. Some also point the finger at global warming, arguing that higher temperatures have increased the number of potential breeding areas for mosquitoes.

“This has been going on now for the better part of 30 years, this global spread of dengue,” said Duane Gubler, director of the Emerging Infectious Diseases program at the Duke-National University of Singapore Graduate Medical School. “You can see it’s a dramatic increase every decade. It can be correlated perfectly with urbanization and modern air travel.”

But health officials are cautiously optimistic that, from a regional perspective, 2009 may not be as severe as previous years.

“From the information we see now,” Dr. Prasittisuk said, “it’s subject to India,” which the W.H.O. includes in Southeast Asia.

He said the decline in cases since 2007 was “a good sign, but we won’t stop. It may not be sustained because of the nature of dengue.” Outbreaks usually fluctuate in two- to three-year cycles, he added.

Historically, dengue has been found in tropical areas, which provide ideal breeding conditions for mosquitoes. But the disease has spread in recent years to countries like Nepal, which reported its first case in 2006. Bhutan recorded its first cases in 2004, and the disease can now be found in seven districts, Dr. Prasittisuk said.

Australia recorded its second death from dengue in a century this year, prompting the authorities in the northeastern state of Queensland to distribute mosquito repellant to schools. Sri Lanka recorded 190 deaths and 18,500 cases since January, more than double the number of cases from last year, according to figures from the Ministry of Healthcare and Nutrition.

There is still no vaccine for the illness, which has earned the nickname “breakbone fever” for the severe headaches and joint and abdominal pain that can accompany it. Although skillful management of the illness — ensuring the patient is well hydrated and monitored for internal hemorrhaging — has markedly brought down the death rate to less than 1 percent of cases in the region, the relentless spread of the disease has raised concerns.

Exposure to one strain of dengue does not confer immunity to the three other main strains, and, in fact, can leave the patient more susceptible to later, more severe, infection.

The urban sprawl found in Asian cities like Bangkok, Jakarta and Manila, where many residents live in substandard housing with poor sewage and water management, provides ample breeding sites for mosquitoes. The increase in air travel in the region has also made it more likely that a person bitten by an infected mosquito can carry the virus to another country.

Source – http://www.nytimes.com/2009/09/02/world/asia/02iht-fever.html

Selected presentations from the 2008 International Society of Urban Health Conference

September 1, 2009 · 2 comments

Below are links to selected presentations from the 2008 ISUH Conference. Information on the 2009 ISUH Conference in Nairobi, Kenya is at: http://www.icuh2009.org/

- Urban health from a global perspective: Dr Jacob KumaresanWHO Centre for Health Development

- Cities in Crisis – Voices from the Asian Periphery: Anthony Zwi, University of New South Wales

- Urban health in developing countries: what do we know and where do we go?? Professor Trudy Harpham, London South Bank University, UK London School of Hygiene and Tropical Medicine, UK

- Meeting Urban Health Needs through Innovative Research, Policies and Interventions: Alex C. Ezeh, Executive Director, African Population and Health Research Center

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