BMJ Open
2016, Volume 6, Issue 2
http://bmjopen.bmj.com/content/current

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Research
Postnuclear disaster evacuation and chronic health in adults in Fukushima, Japan: a long-term retrospective analysis
Shuhei Nomura, Marta Blangiardo, Masaharu Tsubokura, Akihiko Ozaki, Tomohiro Morita, Susan Hodgson
BMJ Open 2016;6:e010080 doi:10.1136/bmjopen-2015-010080
Abstract
Objective Japan’s 2011 Fukushima Daiichi Nuclear Power Plant incident required the evacuation of over a million people, creating a large displaced population with potentially increased vulnerability in terms of chronic health conditions. We assessed the long-term impact of evacuation on diabetes, hyperlipidaemia and hypertension.
Participants We considered participants in annual public health check-ups from 2008 to 2014, administrated by Minamisoma City and Soma City, located about 10–50 km from the Fukushima nuclear plant.
Methods Disease risks, measured in terms of pre-incident and post-incident relative risks, were examined and compared between evacuees and non-evacuees/temporary-evacuees. We also constructed logistic regression models to assess the impact of evacuation on the disease risks adjusted for covariates.
Results Data from a total of 6406 individuals aged 40–74 years who participated in the check-ups both at baseline (2008–2010) and in one or more post-incident years were analysed. Regardless of evacuation, significant post-incident increases in risk were observed for diabetes and hyperlipidaemia (relative risk: 1.27–1.60 and 1.12–1.30, respectively, depending on evacuation status and post-incident year). After adjustment for covariates, the increase in hyperlipidaemia was significantly greater among evacuees than among non-evacuees/temporary-evacuees (OR 1.18, 95% CI 1.06 to 1.32, p<0.01).
Conclusions The singularity of this study is that evacuation following the Fukushima disaster was found to be associated with a small increase in long-term hyperlipidaemia risk in adults. Our findings help identify discussion points on disaster planning, including preparedness, response and recovery measures, applicable to future disasters requiring mass evacuation.

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Protocol
Development of a Health Empowerment Programme to improve the health of working poor families: protocol for a prospective cohort study in Hong Kong
Colman Siu Cheung Fung, Esther Yee Tak Yu, Vivian Yawei Guo, Carlos King Ho Wong, Kenny Kung, Sin Yi Ho, Lai Ying Lam, Patrick Ip, Daniel Yee Tak Fong, David Chi Leung Lam, William Chi Wai Wong, Sandra Kit Man Tsang, Agnes Fung Yee Tiwari, Cindy Lo Kuen Lam
BMJ Open 2016;6:e010015 doi:10.1136/bmjopen-2015-010015
Abstract
Introduction
People from working poor families are at high risk of poor health partly due to limited healthcare access. Health empowerment, a process by which people can gain greater control over the decisions affecting their lives and health through education and motivation, can be an effective way to enhance health, health-related quality of life (HRQOL), health awareness and health-seeking behaviours of these people. A new cohort study will be launched to explore the potential for a Health Empowerment Programme to enable these families by enhancing their health status and modifying their attitudes towards health-related issues. If proven effective, similar empowerment programme models could be tested and further disseminated in collaborations with healthcare providers and policymakers.
Method and analysis
A prospective cohort study with 200 intervention families will be launched and followed up for 5 years. The following inclusion criteria will be used at the time of recruitment: (1) Having at least one working family member; (2) Having at least one child studying in grades 1–3; and (3) Having a monthly household income that is less than 75% of the median monthly household income of Hong Kong families. The Health Empowerment Programme that will be offered to intervention families will comprise four components: health assessment, health literacy, self-care enablement and health ambassador. Their health status, HRQOL, lifestyle and health service utilisation will be assessed and compared with 200 control families with matching characteristics but will not receive the health empowerment intervention.
Ethics and dissemination
This project was approved by the University of Hong Kong—the Hospital Authority Hong Kong West Cluster IRB, Reference number: UW 12-517. The study findings will be disseminated through a series of peer-reviewed publications and conference presentations, as well as a yearly report to the philanthropic funding body–Kerry Group Kuok Foundation (Hong Kong) Limited.

Bulletin of the World Health Organization
Volume 94, Number 2, February 2016, 77-156
http://www.who.int/bulletin/volumes/94/2/en/

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EDITORIALS
Building research and development on poverty-related diseases
John C Reeder & Winnie Mpanju-Shumbusho
doi: 10.2471/BLT.15.167072
[No abstract]

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RESEARCH
Community-based surveillance of maternal deaths in rural Ghana
Joseph Adomako, Gloria Q Asare, Anthony Ofosu, Bradley E Iott, Tiffany Anthony, Andrea S Momoh, Elisa V Warner, Judy P Idrovo, Rachel Ward & Frank WJ Anderson
doi: 10.2471/B
Objective
To examine the feasibility and effectiveness of community-based maternal mortality surveillance in rural Ghana, where most information on maternal deaths usually comes from retrospective surveys and hospital records.
Methods
In 2013, community-based surveillance volunteers used a modified reproductive age mortality survey (RAMOS 4+2) to interview family members of women of reproductive age (13–49 years) who died in Bosomtwe district in the previous five years. The survey comprised four yes–no questions and two supplementary questions. Verbal autopsies were done if there was a positive answer to at least one yes–no question. A mortality review committee established the cause of death.
Findings
Survey results were available for 357 women of reproductive age who died in the district. A positive response to at least one yes–no question was recorded for respondents reporting on the deaths of 132 women. These women had either a maternal death or died within one year of termination of pregnancy. Review of 108 available verbal autopsies found that 64 women had a maternal or late maternal death and 36 died of causes unrelated to childbearing. The most common causes of death were haemorrhage (15) and abortion (14). The resulting maternal mortality ratio was 357 per 100 000 live births, compared with 128 per 100 000 live births derived from hospital records.
Conclusion
The community-based mortality survey was effective for ascertaining maternal deaths and identified many deaths not included in hospital records. National surveys could provide the information needed to end preventable maternal mortality by 2030.

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Research
Drinking water and sanitation: progress in 73 countries in relation to socioeconomic indicators
Jeanne Luh & Jamie Bartram
doi: 10.2471/BLT.15.162974
Objective
To assess progress in the provision of drinking water and sanitation in relation to national socioeconomic indicators.
Methods
We used household survey data for 73 countries – collected between 2000 and 2012 – to calculate linear rates of change in population access to improved drinking water (n = 67) and/or sanitation (n = 61). To enable comparison of progress between countries with different initial levels of access, the calculated rates of change were normalized to fall between –1 and 1. In regression analyses, we investigated associations between the normalized rates of change in population access and national socioeconomic indicators: gross national income per capita, government effectiveness, official development assistance, freshwater resources, education, poverty, Gini coefficient, child mortality and the human development index.
Findings
The normalized rates of change indicated that most of the investigated countries were making progress towards achieving universal access to improved drinking water and sanitation. However, only about a third showed a level of progress that was at least half the maximum achievable level. The normalized rates of change did not appear to be correlated with any of the national indicators that we investigated.
Conclusion
In many countries, the progress being made towards universal access to improved drinking water and sanitation is falling well short of the maximum achievable level. Progress does not appear to be correlated with a country’s social and economic characteristics. The between-country variations observed in such progress may be linked to variations in government policies and in the institutional commitment and capacity needed to execute such policies effectively.

PERSPECTIVES
The use of mobile phones in polio eradication
Abdul Momin Kazi & Lubna Ashraf Jafri
doi: 10.2471/BLT.15.163683
[No abstract]

Health Policy and Planning
Volume 31 Issue 1 February 2016
http://heapol.oxfordjournals.org/content/current

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Original Articles
Editor’s Choice: The free health care initiative: how has it affected health workers in Sierra Leone?
Sophie Witter, Haja Wurie, and Maria Paola Bertone
Health Policy Plan. (2016) 31 (1): 1-9 doi:10.1093/heapol/czv006
Abstract
There is an acknowledged gap in the literature on the impact of fee exemption policies on health staff, and, conversely, the implications of staffing for fee exemption. This article draws from five research tools used to analyse changing health worker policies and incentives in post-war Sierra Leone to document the effects of the Free Health Care Initiative (FHCI) of 2010 on health workers.
Data were collected through document review (57 documents fully reviewed, published and grey); key informant interviews (23 with government, donors, NGO staff and consultants); analysis of human resource data held by the MoHS; in-depth interviews with health workers (23 doctors, nurses, mid-wives and community health officers); and a health worker survey (312 participants, including all main cadres). The article traces the HR reforms which were triggered by the FHCI and evidence of their effects, which include substantial increases in number and pay (particularly for higher cadres), as well as a reported reduction in absenteeism and attrition, and an increase (at least for some areas, where data is available) in outputs per health worker. The findings highlight how a flagship policy, combined with high profile support and financial and technical resources, can galvanize systemic changes. In this regard, the story of Sierra Leone differs from many countries introducing fee exemptions, where fee exemption has been a stand-alone programme, unconnected to wider health system reforms. The challenge will be sustaining the momentum and the attention to delivering results as the FHCI ceases to be an initiative and becomes just ‘business as normal’. The health system in Sierra Leone was fragile and conflict-affected prior to the FHCI and still faces significant challenges, both in human resources for health and more widely, as vividly evidenced by the current Ebola crisis

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Developing a holistic policy and intervention framework for global mental health
Akwatu Khenti, Stéfanie Fréel, Ruth Trainor, Sirad Mohamoud, Pablo Diaz, Erica Suh, Sireesha J Bobbili, and Jaime C Sapag
Health Policy Plan. (2016) 31 (1): 37-45 doi:10.1093/heapol/czv016
Abstract
Introduction: There are significant gaps in the accessibility and quality of mental health services around the globe. A wide range of institutions are addressing the challenges, but there is limited reflection and evaluation on the various approaches, how they compare with each other, and conclusions regarding the most effective approach for particular settings. This article presents a framework for global mental health capacity building that could potentially serve as a promising or best practice in the field. The framework is the outcome of a decade of collaborative global health work at the Centre for Addiction and Mental Health (CAMH) (Ontario, Canada). The framework is grounded in scientific evidence, relevant learning and behavioural theories and the underlying principles of health equity and human rights.
Methods: Grounded in CAMH’s research, programme evaluation and practical experience in developing and implementing mental health capacity building interventions, this article presents the iterative learning process and impetus that formed the basis of the framework. A developmental evaluation (Patton M.2010. Developmental Evaluation: Applying Complexity Concepts to Enhance Innovation and Use. New York: Guilford Press.) approach was used to build the framework, as global mental health collaboration occurs in complex or uncertain environments and evolving learning systems.
Results: A multilevel framework consists of five central components: (1) holistic health, (2) cultural and socioeconomic relevance, (3) partnerships, (4) collaborative action-based education and learning and (5) sustainability. The framework’s practical application is illustrated through the presentation of three international case studies and four policy implications. Lessons learned, limitations and future opportunities are also discussed.
Conclusion: The holistic policy and intervention framework for global mental health reflects an iterative learning process that can be applied and scaled up across different settings through appropriate modifications.

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Two decades of maternity care fee exemption policies in Ghana: have they benefited the poor?
Fiifi Amoako Johnson, Faustina Frempong-Ainguah, and Sabu S Padmadas
Health Policy Plan. (2016) 31 (1): 46-55 doi:10.1093/heapol/czv017

Human Service Organizations Management, Leadership & Governance
Volume 40, Issue 1, 2016
http://www.tandfonline.com/toc/wasw21/current

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Guest Editorial
Implementing Challenging Policy and Systems Change: Identifying Leadership Competencies
Marvin Southard
pages 1-5
[No abstract]

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Articles
Change Communication Strategies in Public Child Welfare Organizations: Engaging the Front Line
Yiwen Cao, Alicia C. Bunger, Jill Hoffman & Hillary A. Robertson
pages 37-50
DOI:10.1080/23303131.2015.1093570
Abstract
In public child-welfare agencies, successful organizational change depends on effective internal communication and engagement with frontline workers. This qualitative study examines approaches for communicating planned organizational change among frontline child-welfare workers. Five, 90-minute focus groups were conducted with 50 frontline workers in an urban, public child-welfare agency. Consistent with prior research on change communication in business organizations, two broad categories of communication strategies were described: programmatic (top-down) and participatory approaches. Results suggest that participatory communicative strategies emphasizing employee engagement might be most effective in combination with programmatic approaches that communicate targeted messages about the change.

International Journal of Disaster Risk Reduction
Volume 15, In Progress (March 2016)
http://www.sciencedirect.com/science/journal/22124209/15

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Review Article
Government-sponsored natural disaster insurance pools: A view from down-under
Pages 1-9
John McAneney, Delphine McAneney, Rade Musulin, George Walker, Ryan Crompton
Abstract
In the light of the rising cost of natural disasters we review the provision of catastrophe insurance by the public sector in the US, France, New Zealand, Spain, the United Kingdom, and its absence in the Netherlands, where flood risk is viewed as a national security concern. We do this in the context of the Australian home insurance market where insurers increasingly employ risk-reflective, multi-peril premiums as new technology allows them to better understand their exposure to risk. Motivations behind government pools vary by country, as do hazard profiles. In the US, for example, pools have usually arisen in the face of market failure of private sector insurance following a significant natural disaster; the initial concern has been the provision of affordable insurance rather than disaster risk reduction. Government pools have certain advantages over the private sector including their ability to raise funds post-event, but face financial unsustainability given political intervention to maintain affordability of cover in high-risk areas. In Australia, it is too early to judge whether risk-based premiums are leading to better land-use planning and increased mitigation spending, but in the case of northern Australia, a region that faces flooding and tropical cyclone risks, rising premiums are causing concern in Government. Nonetheless, the corollary seems self-evident, i.e. in the absence of transparency about the cost of risk, there is no incentive on the part of homeowners, local councils or land developers to improve the ‘riskscape’; insurers are the only actors with immediate financial incentives to acknowledge these risks.

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A comparison of the governance landscape of earthquake risk reduction in Nepal and the Indian State of Bihar
Original Research Article
Pages 29-42
Samantha Jones, Katie J. Oven, Ben Wisner
Abstract
On 25 April 2015, a Mw 7.8 earthquake struck central Nepal, killing more than 8700 people. An earthquake of this magnitude has long been anticipated in Nepal and the neighbouring northern Indian state of Bihar, which straddle the active Himalayan frontal fault system. Drawing on field research undertaken before the earthquake, this paper traces the progress made in earthquake risk reduction efforts at the national scale in Nepal and at the sub-national scale in Bihar. With their contrasting ‘governance landscapes’, we examine the political and institutional context and power relations among different stakeholder groups, as well as the interests and political will motivating earthquake risk reduction. Nepal is a post-conflict country, with a weak legislative and institutional setting for earthquake risk reduction, and a multitude of different stakeholders (government, multi and bi-lateral donors, UN organisations, and national and international NGOs) engaged in the disaster risk reduction process. Bihar, by comparison, has a strong, hierarchical, sub-national government system with minimal influence of non-government stakeholders in earthquake risk reduction. While Nepal appears to have progressed further in strengthening earthquake resilience, the institutional structures in Bihar are stronger and could potentially support more sustainable resilience building in the long-term. The role of individual ‘champions’ in both instances (in Nepal among a national NGO, donors and multilateral agencies, and in Bihar within the government) has been instrumental in shaping the earthquake risk reduction agenda and initiatives.

JAMA
February 2, 2016, Vol 315, No. 5
http://jama.jamanetwork.com/issue.aspx

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Editorial
Sharing Clinical Trial Data: A Proposal From the International Committee of Medical Journal Editors
FREE
Darren B. Taichman, MD, PhD; Joyce Backus, MSLS; Christopher Baethge, MD; Howard Bauchner, MD; Peter W. de Leeuw, MD; Jeffrey M. Drazen, MD; John Fletcher, MB, BChir, MPH; Frank A. Frizelle, MBChB, FRACS; Trish Groves, MBBS, MRCPsych; Abraham Haileamlak, MD; Astrid James, MBBS; Christine Laine, MD, MPH; Larry Peiperl, MD; Anja Pinborg, MD; Peush Sahni, MBBS, MS, PhD; Sinan Wu, MD

JAMA Pediatrics
February 2016, Vol 170, No. 2
http://archpedi.jamanetwork.com/issue.aspx

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Children Exposed to Abuse in Youth-Serving Organizations: Results From National Sample Surveys
FREE ONLINE ONLY
Anne Shattuck, PhD; David Finkelhor, PhD; Heather Turner, PhD; Sherry Hamby, PhD
Abstract
Importance
Protecting children in youth-serving organizations is a national concern.
Objective
To provide clinicians, policymakers, and parents with estimates of children’s exposure to abuse in youth-serving organizations.
Design, Setting, and Participants
Telephone survey data from the 3 National Surveys of Children’s Exposure to Violence (2008, 2011, and 2014) were combined to create a sample of 13 052 children and youths aged 0 to 17 years. The survey participants included youths aged 10 to 17 years and caregivers of children aged 0 to 9 years.
Main Outcomes and Measures
Items from the Juvenile Victimization Questionnaire.
Results In the combined sample of 13 052 children and youths aged 0 to 17 years, the rate of abuse by persons in youth-serving organizations was 0.4% (95% CI, 0.2-0.7) for the past year and 0.8% (95% CI, 0.5-1.1) over the lifetime. Most of the maltreatment (63.2%) was verbal abuse and only 6.4% was any form of sexual violence or assault.
Conclusions and Relevance
Abuse in youth-serving organizations was a relatively rare form of abuse, dwarfed by abuse by family members and other adults.

JAMA Pediatrics
February 2016, Vol 170, No. 2
http://archpedi.jamanetwork.com/issue.aspx

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Viewpoint
Sepsis and the Global Burden of Disease in Children
Niranjan Kissoon, MD, FRCPC; Timothy M. Uyeki, MD, MPH, MPP
Initial text
This Viewpoint discusses the impact of sepsis on childhood mortality worldwide.
In 2010, an estimated 25% of disability-adjusted life-years—a metric that incorporates premature death by years of life lost and years lived with disability—and 13% of all deaths worldwide were in children younger than 5 years.1,2 While reductions in mortality in children younger than 5 years have occurred in many countries since 1990, mortality increased in young children in some parts of sub-Saharan Africa, with severe infections leading to sepsis being a major contributor.1 For instance, in the neonatal period, diarrhea, lower respiratory tract infections, and meningitis were important contributors to mortality in 2010, while in the postneonatal period, nearly 1 million estimated deaths (half of all deaths) were due to lower respiratory tract infections (respiratory syncytial virus, Haemophilus influenzae type B, Streptococcus pneumoniae), diarrheal diseases (rotavirus, Cryptosporidium), and malaria.2 Other infectious causes of death in children younger than 5 years were measles, pertussis, and human immunodeficiency virus/AIDS. We suggest that sepsis-related pediatric deaths are substantially underestimated and that efforts are needed to better assess the impact of sepsis on childhood mortality worldwide…

Journal of Medical Ethics
February 2016, Volume 42, Issue 2
http://jme.bmj.com/content/current

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Research ethics
Paper: Obtaining informed consent for genomics research in Africa: analysis of H3Africa consent documents
Nchangwi Syntia Munung, Patricia Marshall, Megan Campbell, Katherine Littler, Francis Masiye,
Odile Ouwe-Missi-Oukem-Boyer, Janet Seeley, D J Stein, Paulina Tindana, Jantina de Vries
J Med Ethics 2016;42:132-137 Published Online First: 7 December 2015 doi:10.1136/medethics-2015-102796
Abstract
Background
The rise in genomic and biobanking research worldwide has led to the development of different informed consent models for use in such research. This study analyses consent documents used by investigators in the H3Africa (Human Heredity and Health in Africa) Consortium.
Methods
A qualitative method for text analysis was used to analyse consent documents used in the collection of samples and data in H3Africa projects. Thematic domains included type of consent model, explanations of genetics/genomics, data sharing and feedback of test results.
Results
Informed consent documents for 13 of the 19 H3Africa projects were analysed. Seven projects used broad consent, five projects used tiered consent and one used specific consent. Genetics was mostly explained in terms of inherited characteristics, heredity and health, genes and disease causation, or disease susceptibility. Only one project made provisions for the feedback of individual genetic results.
Conclusion
H3Africa research makes use of three consent models—specific, tiered and broad consent. We outlined different strategies used by H3Africa investigators to explain concepts in genomics to potential research participants. To further ensure that the decision to participate in genomic research is informed and meaningful, we recommend that innovative approaches to the informed consent process be developed, preferably in consultation with research participants, research ethics committees and researchers in Africa.

The Lancet
Feb 06, 2016 Volume 387 Number 10018 p505-618 e13-e19
http://www.thelancet.com/journals/lancet/issue/current

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Series
Ending preventable stillbirths
Stillbirths: progress and unfinished business
J Frederik Frøen, Ingrid K Friberg, Joy E Lawn, Zulfiqar A Bhutta, Robert C Pattinson, Emma R Allanson, Vicki Flenady, Elizabeth M McClure, Lynne Franco, Robert L Goldenberg, Mary V Kinney, Susannah Hopkins Leisher, Catherine Pitt, Monir Islam, Ajay Khera, Lakhbir Dhaliwal, Neelam Aggarwal, Neena Raina, Marleen Temmerman, The Lancet Ending Preventable Stillbirths Series study group
Summary
This first paper of the Lancet Series on ending preventable stillbirths reviews progress in essential areas, identified in the 2011 call to action for stillbirth prevention, to inform the integrated post-2015 agenda for maternal and newborn health. Worldwide attention to babies who die in stillbirth is rapidly increasing, from integration within the new Global Strategy for Women’s, Children’s and Adolescents’ Health, to country policies inspired by the Every Newborn Action Plan. Supportive new guidance and metrics including stillbirth as a core health indicator and measure of quality of care are emerging. Prenatal health is a crucial biological foundation to life-long health. A key priority is to integrate action for prenatal health within the continuum of care for maternal and newborn health. Still, specific actions for stillbirths are needed for advocacy, policy formulation, monitoring, and research, including improvement in the dearth of data for effective coverage of proven interventions for prenatal survival. Strong leadership is needed worldwide and in countries. Institutions with a mandate to lead global efforts for mothers and their babies must assert their leadership to reduce stillbirths by promoting healthy and safe pregnancies.

Ending preventable stillbirths
Stillbirths: rates, risk factors, and acceleration towards 2030
Joy E Lawn, Hannah Blencowe, Peter Waiswa, Agbessi Amouzou, Colin Mathers, Dan Hogan, Vicki Flenady, J Frederik Frøen, Zeshan U Qureshi, Claire Calderwood, Suhail Shiekh, Fiorella Bianchi Jassir, Danzhen You, Elizabeth M McClure, Matthews Mathai, Simon Cousens, Lancet Ending Preventable Stillbirths Series study group, The Lancet Stillbirth Epidemiology investigator group
Summary
An estimated 2·6 million third trimester stillbirths occurred in 2015 (uncertainty range 2·4–3·0 million). The number of stillbirths has reduced more slowly than has maternal mortality or mortality in children younger than 5 years, which were explicitly targeted in the Millennium Development Goals. The Every Newborn Action Plan has the target of 12 or fewer stillbirths per 1000 births in every country by 2030. 94 mainly high-income countries and upper middle-income countries have already met this target, although with noticeable disparities. At least 56 countries, particularly in Africa and in areas affected by conflict, will have to more than double present progress to reach this target. Most (98%) stillbirths are in low-income and middle-income countries. Improved care at birth is essential to prevent 1·3 million (uncertainty range 1·2–1·6 million) intrapartum stillbirths, end preventable maternal and neonatal deaths, and improve child development. Estimates for stillbirth causation are impeded by various classification systems, but for 18 countries with reliable data, congenital abnormalities account for a median of only 7·4% of stillbirths. Many disorders associated with stillbirths are potentially modifiable and often coexist, such as maternal infections (population attributable fraction: malaria 8·0% and syphilis 7·7%), non-communicable diseases, nutrition and lifestyle factors (each about 10%), and maternal age older than 35 years (6·7%). Prolonged pregnancies contribute to 14·0% of stillbirths. Causal pathways for stillbirth frequently involve impaired placental function, either with fetal growth restriction or preterm labour, or both. Two-thirds of newborns have their births registered. However, less than 5% of neonatal deaths and even fewer stillbirths have death registration. Records and registrations of all births, stillbirths, neonatal, and maternal deaths in a health facility would substantially increase data availability. Improved data alone will not save lives but provide a way to target interventions to reach more than 7000 women every day worldwide who experience the reality of stillbirth.

Ending preventable stillbirths
Stillbirths: economic and psychosocial consequences
Alexander E P Heazell, Dimitrios Siassakos, Hannah Blencowe, Christy Burden, Zulfiqar A Bhutta, Joanne Cacciatore, Nghia Dang, Jai Das, Vicki Flenady, Katherine J Gold, Olivia K Mensah, Joseph Millum, Daniel Nuzum, Keelin O’Donoghue, Maggie Redshaw, Arjumand Rizvi, Tracy Roberts, H E Toyin Saraki, Claire Storey, Aleena M Wojcieszek, Soo Downe, The Lancet Ending Preventable Stillbirths Series study group, The Lancet Ending Preventable Stillbirths investigator group
Summary
Despite the frequency of stillbirths, the subsequent implications are overlooked and underappreciated. We present findings from comprehensive, systematic literature reviews, and new analyses of published and unpublished data, to establish the effect of stillbirth on parents, families, health-care providers, and societies worldwide. Data for direct costs of this event are sparse but suggest that a stillbirth needs more resources than a livebirth, both in the perinatal period and in additional surveillance during subsequent pregnancies. Indirect and intangible costs of stillbirth are extensive and are usually met by families alone. This issue is particularly onerous for those with few resources. Negative effects, particularly on parental mental health, might be moderated by empathic attitudes of care providers and tailored interventions. The value of the baby, as well as the associated costs for parents, families, care providers, communities, and society, should be considered to prevent stillbirths and reduce associated morbidity.

The Lancet Infectious Diseases
Feb 2016 Volume 16 Number 2 p131-264 e10-e21
http://www.thelancet.com/journals/laninf/issue/current

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Editorial
Guinea worm disease nears eradication
The Lancet Infectious Diseases
DOI: http://dx.doi.org/10.1016/S1473-3099(16)00020-7
Summary
Only two infectious diseases have ever been eradicated: smallpox, of which the last naturally transmitted case occurred in 1977, and rinderpest, a disease of cattle and related ungulates, officially declared eradicated in 2011. This year might see a remarkable doubling in the list of eradicated diseases, with both polio (about which we wrote in the August, 2015, issue) and guinea worm no longer being naturally transmitted.

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Comment
Long-term protectiveness of BCG
Giovanni Sotgiu, Giovanni Battista Migliori
Published Online: 18 November 2015
DOI: http://dx.doi.org/10.1016/S1473-3099(15)00414-4
Summary
WHO has launched the End TB Strategy, which contains several elements supporting tuberculosis elimination.1–3 Pillar 1 consists of two tuberculosis prevention interventions: first, diagnosis and treatment of latent tuberculosis infection and, second, vaccination. A new, more effective vaccine is expected by 2025,2 but in the meantime, we still rely on BCG, which is more than a century old.4 Epidemiological studies of the BCG vaccine carried out in the past were not designed to provide high-quality evidence in the way that we define it today (ie, multicentre, randomised, double-blind, placebo-controlled clinical trials).

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Articles
Duration of BCG protection against tuberculosis and change in effectiveness with time since vaccination in Norway: a retrospective population-based cohort study
Patrick Nguipdop-Djomo, Einar Heldal, Laura Cunha Rodrigues, Ibrahim Abubakar, Punam Mangtani
Summary
Background
Little is known about how long the BCG vaccine protects against tuberculosis. We assessed the long-term vaccine effectiveness (VE) in Norwegian-born individuals.
Methods
In this retrospective population-based cohort study, we studied Norwegian-born individuals aged 12–50 years who were tuberculin skin test (TST) negative and eligible for BCG vaccination as part of the last round of Norway’s mandatory mass tuberculosis screening and BCG vaccination programme between 1962 and 1975. We excluded individuals who had tuberculosis before or in the year of screening and those with unknown TST and BCG status. We obtained TST and BCG information and linked it to the National Tuberculosis Register, population and housing censuses, and the population register for emigrations and deaths. We followed individuals up to their first tuberculosis episode, emigration, death, or Dec 31, 2011. We used Cox regressions to estimate VE against all tuberculosis and just pulmonary tuberculosis by time since vaccination, adjusted for age, time, county-level tuberculosis rates, and demographic and socioeconomic indicators.
Findings
Median follow-up was 41 years (IQR 32–49) for 83 421 BCG-unvaccinated and 44 years (41–46) for 297 905 vaccinated individuals, with 260 tuberculosis episodes. Tuberculosis rates were 3·3 per 100 000 person-years in unvaccinated and 1·3 per 100 000 person-years in vaccinated individuals. The adjusted average VE during 40 year follow-up was 49% (95% CI 26–65), although after 20 years, the VE was not significant (up to 9 years VE [excluding tuberculosis episodes in the first 2 years] 61% [95% CI 24–80]; 10–19 years 58% [27–76]; 20–29 years 38% [–32 to 71]; 30–40 years 42% [–24 to 73]). VE against pulmonary tuberculosis up to 9 years (excluding tuberculosis episodes in the first 2 years) was 67% (95% CI 27–85), 10–19 years was 63% (32–80), 20–29 years was 50% (−19 to 79), and 30–40 years was 40% (−46 to 76).
Interpretation
Findings are consistent with long-lasting BCG protection, but waning of VE with time. The vaccine could be more cost effective than has been previously estimated
Funding
Norwegian Institute of Public Health and London School of Hygiene & Tropical Medicine.

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Personal View
Interventions to reduce zoonotic and pandemic risks from avian influenza in Asia
J S Malik Peiris, Benjamin J Cowling, Joseph T Wu, Luzhao Feng, Yi Guan, Hongjie Yu, Gabriel M Leung

Ebola: lessons learned and future challenges for Europe
GianLuca Quaglio, Charles Goerens, Giovanni Putoto, Paul Rübig, Pierre Lafaye, Theodoros Karapiperis, Claudio Dario, Paul Delaunois, Rony Zachariah

Maternal and Child Health Journal
Volume 20, Issue 2, February 2016
http://link.springer.com/journal/10995/20/2/page/1

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Original Paper
Assessing the Continuum of Care Pathway for Maternal Health in South Asia and Sub-Saharan Africa
Kavita Singh, William T. Story, Allisyn C. Moran
Abstract
Objective
We assess how countries in regions of the world where maternal mortality is highest—South Asia and Sub-Saharan Africa—are performing with regards to providing women with vital elements of the continuum of care.
Methods
Using recent Demographic and Health Survey data from nine countries including 18,036 women, descriptive and multilevel regression analyses were conducted on four key elements of the continuum of care—at least one antenatal care visit, four or more antenatal care visits, delivery with a skilled birth attendant and postnatal checks for the mother within the first 24 h since birth. Family planning counseling within a year of birth was also included in the descriptive analyses.
Results
Results indicated that a major drop-out (>50 %) occurs early on in the continuum of care between the first antenatal care visit and four or more antenatal care visits. Few women (<5 %) who do not receive any antenatal care go on to have a skilled delivery or receive postnatal care. Women who receive some or all the elements of the continuum of care have greater autonomy and are richer and more educated than women who receive none of the elements.
Conclusion
Understanding where drop-out occurs and who drops out can enable countries to better target interventions. Four or more ANC visits plays a pivotal role within the continuum of care and warrants more programmatic attention. Strategies to ensure that vital services are available to all women are essential in efforts to improve maternal health.

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Original Paper
Differences in Human Papillomavirus Vaccination Among Adolescent Girls in Metropolitan Versus Non-metropolitan Areas: Considering the Moderating Roles of Maternal Socioeconomic Status and Health Care Access
Shannon M. Monnat, Danielle C. Rhubart…
Abstract
Objectives This study is among the first to examine metropolitan status differences in human papillomavirus (HPV) vaccine initiation and completion among United States adolescent girls and is unique in its focus on how maternal socioeconomic status and health care access moderate metropolitan status differences in HPV vaccination. Methods Using cross-sectional data from 3573 girls aged 12–17 in the U.S. from the 2008–2010 Behavioral Risk Factor Surveillance System, we estimate main and interaction effects from binary logistic regression models to identify subgroups of girls for which there are metropolitan versus non-metropolitan differences in HPV vaccination. Results Overall 34 % of girls initiated vaccination, and 19 % completed all three shots. On average, there were no metropolitan status differences in vaccination odds. However, there were important subgroup differences. Among low-income girls and girls whose mothers did not complete high school, those in non-metropolitan areas had significantly higher probability of vaccine initiation than those in metropolitan areas. Among high-income girls and girls whose mothers completed college, those in metropolitan areas had significantly higher odds of vaccine initiation than those in non-metropolitan areas. Moreover, among girls whose mothers experienced a medical cost barrier, non-metropolitan girls were less likely to initiate vaccination compared to metropolitan girls. Conclusions Mothers remain essential targets for public health efforts to increase HPV vaccination and combat cervical cancer. Public health experts who study barriers to HPV vaccination and physicians who come into contact with mothers should be aware of group-specific barriers to vaccination and employ more tailored efforts to increase vaccination.

Nonprofit and Voluntary Sector Quarterly
February 2016; 45 (1)
http://nvs.sagepub.com/content/current

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Articles
Episodic Volunteering and Retention – An Integrated Theoretical Approach
Melissa K. Hyde1,2; Jeff Dunn1,2,3; Caitlin Bax4; Suzanne K. Chambers1,2,3,5,6
1Griffith Health Institute, Griffith University, Gold Coast, Queensland, Australia
2Cancer Council Queensland, Spring Hill, Australia
3School of Social Science, University of Queensland, St. Lucia, Australia
4School of Applied Psychology, Griffith University, Mt. Gravatt, Queensland, Australia
5Prostate Cancer Foundation of Australia, St. Leonards, New South Wales, Australia
6Health and Wellness Institute Edith Cowan University, Perth, Western Australia, Australia
Melissa K. Hyde, Griffith Health Institute, Griffith University, Gold Coast Campus, Queensland 4222, Australia. Email: melissa.hyde@griffith.edu.au
Abstract
Episodic volunteers (EVs) are vital for non-profit organization activities. However, theory-based research on episodic volunteering is scant and the determinants of episodic volunteering are not well understood. This study integrates the volunteer process model and three-stage model of volunteers’ duration of service to explore determinants of EV retention. A cross-sectional survey of 340 EVs assessed volunteering antecedents, experiences, and retention. Social/enjoyment (β = .17) and benefit (β = −.15) motives, social norm (β = .20), and satisfaction (β = .56) predicted Novice EV (first experience) retention; satisfaction (β = .47) and commitment (β = .38) predicted Transition EV (2-4 years intermittently) retention; and supporting the organization financially (β = .31), social norm (β = .18), satisfaction (β = .41), and commitment (β = .19) predicted Sustained EV (5-6 years consecutively) retention. Integrated theoretical approaches appear efficacious for understanding EV retention. An Episodic Volunteer Engagement and Retention model is proposed for further testing in prospective work.

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Systematic Review
Nonprofit Organizations Becoming Business-Like
Florentine Maier1; Michael Meyer1; Martin Steinbereithner1
1WU Vienna University of Economics and Business, Austria
Florentine Maier, WU Vienna University of Economics and Business, Welthandelsplatz 1, Vienna 1020, Austria. Email: florentine.maier@wu.ac.at
Abstract
By now, the becoming business-like of nonprofit organizations (NPOs) is a well-established global phenomenon that has received ever-growing attention from management and organization studies. However, the field remains hard to grasp in its entirety, as researchers use a multitude of similar, yet distinct, key concepts. The considerable range and complexity of these overlapping notions create major challenges: Scholars struggle to position their work in a larger context; it is not easy to build on previous findings and methodological developments; and research gaps are difficult to identify. The present article presents the first systematic literature review to confront those challenges by reviewing 599 relevant sources. In a first step, various key concepts are clarified. Second, the field is mapped according to three research foci: causes of NPOs becoming business-like, organizational structures and processes of becoming business-like, and effects of becoming business-like. From this, we draw conclusions and make suggestions for further research.

PLoS Currents: Outbreaks
http://currents.plos.org/outbreaks/
(Accessed 6 February 2016)

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Residency Training at the Front of the West African Ebola Outbreak: Adapting for a Rare Opportunity
February 2, 2016 · Discussion
Medical trainees face multiple barriers to participation in major outbreak responses such as that required for Ebola Virus Disease through 2014-2015 in West Africa. Hurdles include fear of contracting and importing the disease, residency requirements, scheduling conflicts, family obligations and lack of experience and maturity. We describe the successful four-week deployment to Liberia of a first year infectious diseases trainee through the mechanism of the Global Outbreak Alert and Response Network of the World Health Organization. The posting received prospective approval from the residency supervisory committees and employing hospital management and was designed with components fulfilling the Accreditation Council for Graduate Medical Education (ACGME) core competencies. It mirrored conventional training with regards to learning objectives, supervisory framework and assessment methods. Together with Centers for Disease Control and Prevention and many other partners, the team joined the infection prevention and control efforts in Monrovia. Contributions were made to a ‘ring fencing’ infection control approach that was being introduced, including enhancement of triage, training and providing supplies in high priority health-care facilities in the capital and border zones. In addition the fellow produced an electronic database that enabled monitoring infection control standards in health facilities. This successful elective posting illustrates that quality training can be achieved, even in the most challenging environments, with support from the pedagogic and sponsoring institutions. Such experiential learning opportunities benefit both the outbreak response and the trainee, and if scaled up would contribute towards building a global health emergency workforce. More should be done from residency accreditation bodies in facilitating postings in outbreak settings.

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Epidemiology of Chikungunya Virus in Bahia, Brazil, 2014-2015
February 1, 2016 · Discussion
Chikungunya is an emerging arbovirus that is characterized into four lineages. One of these, the Asian genotype, has spread rapidly in the Americas after its introduction in the Saint Martin island in October 2013. Unexpectedly, a new lineage, the East-Central-South African genotype, was introduced from Angola in the end of May 2014 in Feira de Santana (FSA), the second largest city in Bahia state, Brazil, where over 5,500 cases have now been reported. Number weekly cases of clinically confirmed CHIKV in FSA were analysed alongside with urban district of residence of CHIKV cases reported between June 2014 and October collected from the municipality’s surveillance network. The number of cases per week from June 2014 until September 2015 reveals two distinct transmission waves. The first wave ignited in June and transmission ceased by December 2014. However, a second transmission wave started in January and peaked in May 2015, 8 months after the first wave peak, and this time in phase with Dengue virus and Zika virus transmission, which ceased when minimum temperature dropped to approximately 15°C. We find that shorter travelling times from the district where the outbreak first emerged to other urban districts of FSA were strongly associated with incidence in each district in 2014 (R2).

PNAS – Proceedings of the National Academy of Sciences of the United States of America
http://www.pnas.org/content/early/
(Accessed 6 February 2016)

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Social Sciences – Sustainability Science – Biological Sciences – Sustainability Science:
Policy impacts of ecosystem services knowledge
Stephen M. Posnera,b,1, Emily McKenziec,d,e, and Taylor H. Rickettsa,b
Author Affiliations
Significance
Our study introduces a conceptual framework and empirical approach to explore how knowledge impacts decision-making. We illustrate this approach with knowledge about ecosystem services (ES), but the approach itself can be applied broadly. Our results indicate that the legitimacy of knowledge (i.e., perceived as unbiased and representative of multiple points of view) is of paramount importance for impact. More surprisingly, we found that credibility of knowledge is not a significant predictor of impact. To enhance legitimacy, ES researchers must engage meaningfully with decision-makers and stakeholders in processes of knowledge coproduction that incorporate diverse perspectives transparently. Our results indicate how research can be designed and carried out to maximize the potential impact on real-world decisions.
Abstract
Research about ecosystem services (ES) often aims to generate knowledge that influences policies and institutions for conservation and human development. However, we have limited understanding of how decision-makers use ES knowledge or what factors facilitate use. Here we address this gap and report on, to our knowledge, the first quantitative analysis of the factors and conditions that explain the policy impact of ES knowledge. We analyze a global sample of cases where similar ES knowledge was generated and applied to decision-making. We first test whether attributes of ES knowledge themselves predict different measures of impact on decisions. We find that legitimacy of knowledge is more often associated with impact than either the credibility or salience of the knowledge. We also examine whether predictor variables related to the science-to-policy process and the contextual conditions of a case are significant in predicting impact. Our findings indicate that, although many factors are important, attributes of the knowledge and aspects of the science-to-policy process that enhance legitimacy best explain the impact of ES science on decision-making. Our results are consistent with both theory and previous qualitative assessments in suggesting that the attributes and perceptions of scientific knowledge and process within which knowledge is coproduced are important determinants of whether that knowledge leads to action.

Prehospital & Disaster Medicine
Volume 31 – Issue 01 – February 2016
https://journals.cambridge.org/action/displayIssue?jid=PDM&tab=currentissue

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Original Research
Developing a Performance Assessment Framework and Indicators for Communicable Disease Management in Natural Disasters
Javad Babaie, Ali Ardalan, Hasan Vatandoost, Mohammad Mehdi Goya and Ali Akbarisari
Prehospital and Disaster Medicine / Volume 31 / Issue 01 / February 2016, pp 27 – 35
Abstract
Introduction
Communicable disease management (CDM) is an important component of disaster public health response operations. However, there is a lack of any performance assessment (PA) framework and related indicators for the PA. This study aimed to develop a PA framework and indicators in CDM in disasters.
Methods
In this study, a series of methods were used. First, a systematic literature review (SLR) was performed in order to extract the existing PA frameworks and indicators. Then, using a qualitative approach, some interviews with purposively selected experts were conducted and used in developing the PA framework and indicators. Finally, the analytical hierarchy process (AHP) was used for weighting of the developed indicators.
Results
The input, process, products, and outcomes (IPPO) framework was found to be an appropriate framework for CDM PA. Seven main functions were revealed to CDM during disasters. Forty PA indicators were developed for the four categories.
Conclusion
There is a lack of any existing PA framework in CDM in disasters. Thus, in this study, a PA framework (IPPO framework) was developed for the PA of CDM in disasters through a series of methods. It can be an appropriate framework and its indicators could measure the performance of CDM in disasters.

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Special Reports
Protecting the Health and Well-being of Populations from Disasters: Health and Health Care in The Sendai Framework for Disaster Risk Reduction 2015-2030
Amina Aitsi-Selmi and Virginia Murray
Prehospital and Disaster Medicine / Volume 31 / Issue 01 / February 2016, pp 74 – 78
DOI: http://dx.doi.org/10.1017/S1049023X15005531 Published online: 17 December 2015
Abstract
The Sendai Framework for Disaster Risk Reduction (DRR) 2015-2030 is the first of three United Nations (UN) landmark agreements this year (the other two being the Sustainable Development Goals due in September 2015 and the climate change agreements due in December 2015). It represents a step in the direction of global policy coherence with explicit reference to health, economic development, and climate change. The multiple efforts of the health community in the policy development process, including campaigning for safe schools and hospitals, helped to put people’s mental and physical health, resilience, and well-being higher up the DRR agenda compared with its predecessor, the 2005 Hyogo Framework for Action. This report reflects on these policy developments and their implications and reviews the range of health impacts from disasters; summarizes the widened remit of DRR in the post-2015 world; and finally, presents the science and health calls of the Sendai Framework to be implemented over the next 15 years to reduce disaster losses in lives and livelihoods.

Science
05 February 2016 Vol 351, Issue 6273
http://www.sciencemag.org/current.dtl

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In Depth
Infectious Disease
The race for a Zika vaccine is on
Jon Cohen
Science 05 Feb 2016:
Vol. 351, Issue 6273, pp. 543-544
DOI: 10.1126/science.351.6273.543
Summary
Scientists first isolated Zika virus in 1947, but the disease it caused in humans was considered mild: It did nothing to 80% of the people it infected, and the ones who had symptoms only had temporary fevers and rashes. But last year, a high number of cases of brain-damaging microcephaly in newborns began to surface in Brazil in lockstep with the arrival of the Zika virus, which is spread by mosquitoes. The World Health Organization on 1 February declared these clusters of disease a “public health emergency of international concern,” and a rush of vaccinemakers has jumped into the race to develop a preventive. Vaccines exist against several other flaviviruses, the family Zika belongs to, and experts predict that this won’t be a major scientific challenge. They also say it may be possible to piggyback on the other flavivirus vaccines, like ones made for dengue and yellow fever. Then again, vaccine R&D takes time, and because this effort is starting from scratch, researchers say it will take at least a few years before a vaccine can prove itself safe and effective in large human efficacy studies.

Social Science & Medicine
Volume 150, Pages 1-290 (February 2016)
http://www.sciencedirect.com/science/journal/02779536/150

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Review article
Understanding the role of Indigenous community participation in Indigenous prenatal and infant-toddler health promotion programs in Canada: A realist review
Pages 128-143
Janet Smylie, Maritt Kirst, Kelly McShane, Michelle Firestone, Sara Wolfe, Patricia O’Campo
Abstract
Purpose
Striking disparities in Indigenous maternal-child health outcomes persist in relatively affluent nations such as Canada, despite significant health promotion investments. The aims of this review were two-fold: 1. To identify Indigenous prenatal and infant-toddler health promotion programs in Canada that demonstrate positive impacts on prenatal or child health outcomes. 2. To understand how, why, for which outcomes, and in what contexts Indigenous prenatal and infant-toddler health promotion programs in Canada positively impact Indigenous health and wellbeing.
Methods
We systematically searched computerized databases and identified non-indexed reports using key informants. Included literature evaluated a prenatal or child health promoting program intervention in an Indigenous population in Canada. We used realist methods to investigate how, for whom, and in what circumstances programs worked. We developed and appraised the evidence for a middle range theory of Indigenous community investment-ownership-activation as an explanation for program success.
Findings
Seventeen articles and six reports describing twenty programs met final inclusion criteria. Program evidence of local Indigenous community investment, community perception of the program as intrinsic (mechanism of community ownership) and high levels of sustained community participation and leadership (community activation) was linked to positive program change across a diverse range of outcomes including: birth outcomes; access to pre- and postnatal care; prenatal street drug use; breast-feeding; dental health; infant nutrition; child development; and child exposure to Indigenous languages and culture.
Conclusions
These findings demonstrate Indigenous community investment-ownership-activation as an important pathway for success in Indigenous prenatal and infant-toddler health programs.

Tropical Medicine & International Health
February 2016 Volume 21, Issue 2 Pages 157–291
http://onlinelibrary.wiley.com/doi/10.1111/tmi.2016.21.issue-2/issuetoc

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Original Research Papers
Health status and disease burden of unaccompanied asylum-seeking adolescents in Bielefeld, Germany: cross-sectional pilot study (pages 210–218)
L. Marquardt, A. Krämer, F. Fischer and L. Prüfer-Krämer
Article first published online: 22 DEC 2015 | DOI: 10.1111/tmi.12649
Abstract
Objective
This exploratory pilot study aimed to investigate the physical and mental disease burden of unaccompanied asylum-seeking adolescents arriving in Bielefeld, a medium-size city in Germany.
Methods
A cross-sectional survey with purposive sampling of 102 unaccompanied asylum-seeking adolescents aged 12–18 years was performed. Information on general health status, selected infectious and non-communicable diseases, iron deficiency anaemia and mental illness was collected during routine check-up medical examinations upon arrival in Bielefeld, Germany. The data were analysed using descriptive statistics.
Results
The analysis revealed a complex disease burden with a high prevalence of infections (58.8%), mental illness (13.7%) and iron deficiency anaemia (17.6%) and a very low prevalence of non-communicable diseases (<2.0%). One in five of the refugees were infected with parasites. Whilst sub-Saharan Africans showed the highest prevalence of infections (86.7%), including highest prevalences of parasites (46.7%), West Asians had the highest prevalence of mental disorders (20.0%). Overall, the disease burden in females was higher.
Conclusion
A thorough medical and psychological screening after arrival is highly recommended to reduce the individual disease burden and the risk of infection for others. This promotes good physical and mental health, which is needed for successful integration into the receiving society. Barriers to health service access for unaccompanied asylum-seeking adolescents need to be lowered to allow need-specific health care and prevention.

Tropical Medicine & International Health
February 2016 Volume 21, Issue 2 Pages 157–291
http://onlinelibrary.wiley.com/doi/10.1111/tmi.2016.21.issue-2/issuetoc

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Reviews
Prevalence and causes of hearing impairment in Africa (pages 158–165)
W. Mulwafu, H. Kuper and R. J. H. Ensink
Article first published online: 14 DEC 2015 | DOI: 10.1111/tmi.12640
Abstract
Objective
To systematically assess the data on the prevalence and causes of hearing impairment in Africa.
Methods
Systematic review on the prevalence and causes of hearing loss in Africa. We undertook a literature search of seven electronic databases (EMBASE, PubMed, Medline, Global Health, Web of Knowledge, Academic Search Complete and Africa Wide Information) and manually searched bibliographies of included articles. The search was restricted to population-based studies on hearing impairment in Africa. Data were extracted using a standard protocol.
Results
We identified 232 articles and included 28 articles in the final analysis. The most common cut-offs used for hearing impairment were 25 and 30 dB HL, but this ranged between 15 and 40 dB HL. For a cut-off of 25 dB, the median was 7.7% for the children- or school-based studies and 17% for population-based studies. For a cut-off of 30 dB HL, the median was 6.6% for the children or school-based studies and 31% for population-based studies. In schools for the deaf, the most common cause of hearing impairment was cryptogenic deafness (50%) followed by infectious causes (43%). In mainstream schools and general population, the most common cause of hearing impairment was middle ear disease (36%), followed by undetermined causes (35%) and cerumen impaction (24%).
Conclusion
There are very few population-based studies available to estimate the prevalence of hearing impairment in Africa. Those studies that are available use different cut-offs, making comparison difficult. However, the evidence suggests that the prevalence of hearing impairment is high and that much of it is avoidable or treatable.