1-20 of 78 Results

Article

Ndola Prata and Karen Weidert

Adolescence, spanning 10 to 19 years of age, begins with biological changes while transitioning from a social status of a child to an adult. For millions of adolescents in low- and middle-income countries (LMICs), this is a period of exposure to vulnerabilities and risks related to sexual and reproductive health (SRH), compounded by challenges in having their SHR needs met. Globally, adolescent sexual and reproductive ill-health disease burden is concentrated in LMICs, with sexually transmitted infections and complications from pregnancy and childbirth accounting for the majority of the burden. Adolescents around the world are using their voices to champion access to high-quality, comprehensive SRH information and services. Thus, it is imperative that adolescents’ SRH and rights be reinforced and that investments in services be prioritized.

Article

The design of municipal water tariffs requires balancing multiple criteria such as financial self-sufficiency for the service provider, equity among customers, and economic efficiency for society. Globally, various forms of water tariffs are in use (e.g., tariffs based on fixed or volumetric charges, single and two-part tariffs, and increasing or decreasing block tariffs) but increasing block tariffs (IBTs) have become popular worldwide over the last few decades for two main reasons. Apart from the fact that IBTs incentivize households to save water by charging large volumes at a higher price, there is a widespread belief that IBTs are pro-poor. The latter would be the consequence of providing all households with a minimum amount of water at a low (subsidized) price while large water users pay higher prices. However cross-subsidization between wealthy and poor households will occur only if poor households’ consumption falls in the low (subsidized) block and if rich households consume in the higher block and pay a price that is above the average cost of supply. These two conditions are rarely met in reality and IBTs often fail to allocate subsidies to the poor effectively. There are a few examples of water utilities making adjustments to the tariff to take into account that poor households with large families are likely to be adversely affected by IBTs. However, the provision of a minimum amount of water for free (as in South Africa), the design of household-specific low-cost water allowances (as in California), or tariffs being adjusted based on household size do not usually improve the targeting of subsidies to the poorest households. The widespread use of IBTs is difficult to rationalize, in particular while knowing that the use of a (simple) uniform volumetric tariff where water provision is charged at its full cost could improve social welfare by removing price distortions and would be easier for households to understand than IBTs. This simple tariff could be combined with some consumer assistance programs to help the poorest households pay their bills.

Article

Water planners and policy analysts need to pay closer attention to the behavioral aspects of water use, including the use of nonprice measures such as norms, public communications, and intrinsic motivations. Empirical research has shown that people are motivated by normative as well as economic incentives when it comes to water. In fact, this research finds that after exposure to feedback about water use, adding an economic incentive (rebate) for reducing water use holds no additional power. In other cases, nonprice measures can be a way to increase the salience, and subsequently, effectiveness of any adopted pricing mechanisms. We review these empirical findings and locate them within more general literature on normative incentives for behavioral change. Given increasing water scarcity and decreasing water security in cities, policy planners need to make more room for normative incentives when designing rules for proenvironmental behavior.

Article

Lillian Abracinskas and Santiago Puyol

As time goes by, the world experiences advances and setbacks in the field of sexual and reproductive health and rights. But new challenges appear in terms of professional performance and implementation of services created by newer laws and policies. The development of new ethical frames in dialogue with disputed value systems is one of the main obstacles to ensuring universal access and comprehensive services to guarantee the exercise of these rights. Since 2002, Uruguay has been one of the few countries in Latin America and the Caribbean that has achieved significant advances regarding sexual and reproductive rights by recognizing them as human rights. The passage of several laws has resulted in the implementation of programs in SRHS and legal abortion as being considered mandatory for the National Health System. The follow-up and monitoring of this process by the Observatory of Mujer y Salud en Uruguay (MYSU) has demonstrated how changes in the legal framework led to a new stage for health-care providers, politicians, and decision makers and also for the social movement that has historically advocated for this agenda, all now facing new problems and challenges—some of which are completely unexpected. The high prevalence of conscientious objection exercised by physicians and OB/GYNs in refusing the provision of care in SRHS is one of the ethical dilemmas that needs to be discussed to innovate solutions to the problems and promote best practices from a gender equity and human rights paradigm.

Article

Marie Thoma, Jasmine Fledderjohann, Carie Cox, and Rudolph Kantum Adageba

Infertility remains a neglected area in sexual and reproductive health, yet its consequences are staggering. Infertility is estimated to impact about 10–25% (estimates range from 48 to 180 million) of couples of reproductive age worldwide. It is associated with adverse physical and mental health outcomes, financial distress, severe social stigma, increased risk of domestic abuse, and marital instability. Although men and women are equally likely to be infertile, women often bear the societal burden of infertility, particularly in societies where a woman’s identity and social value are closely tied to her ability to bear children. Despite these consequences, disparities in access to infertility treatment between low- and high-income populations persist given the high cost and limited geographic availability of diagnostic services and assisted reproductive technologies. In addition, a considerable proportion of infertility is a result of preventable factors, such as smoking, sexually transmitted infections, pregnancy-related infection or unsafe abortion, and environmental contaminants. Accordingly, programs that address the equitable prevention and treatment of infertility are not only in keeping with a reproductive rights perspective but can also improve public health. However, progress on infertility as a global concern in the field of sexual and reproductive health and rights is stymied by challenges in understanding the global epidemiology of infertility, including its causes and determinants, barriers to accessing quality fertility care, and a lack of political will and attention to this issue. The tracking and measurement of infertility are highly complex, resulting in considerable ambiguity about its prevalence and stratification in reproduction globally. A renewed global focus on infertility epidemiology, risk factors, and access to and receipt of quality of care will support individuals in trying to reach their desired number and spacing of children and improve overall health and well-being.

Article

Célia Landmann Szwarcwald, Maria do Carmo Leal, Wanessa da Silva de Almeida, Mauricio Lima Barreto, Paulo Germano de Frias, Mariza Miranda Theme Filha, Rosa Maria Soares Madeira Domingues, Elisabeth Barboza Franca, Silvana Granado Nogueira da Gama, Cristiano Sigueira Boccolini, and Cesar Victora

Child health has been placed at the forefront of international initiatives for development. The adoption of the Millennium Development Goals has propelled worldwide actions to improve maternal and child health. In the course of the year 2000, the Latin American (LA) countries made marked progress in implementing effective newborn and infant life-saving interventions. Under-five mortality in LA fell by a third between 1990 and 2015, with a sharp decline in diarrheal diseases and respiratory infections. Due to the successful immunization programs in the region, some vaccine-preventable diseases have been eliminated. Many of the LA countries have reached nearly universal coverage of childbirths attended by skilled personnel and >80% coverage for antenatal care. In 2015, 18 countries in the region reported the elimination of mother-to-child transmission for both HIV and syphilis. Although the advances in the public agenda aimed at promoting child health and development in Latin American countries are undeniable, unresolved issues remain. While many stillbirths and neonatal deaths could be averted by improving access to antenatal, intra-partum, and postnatal interventions, Latin America has the highest cesarean rate among all regions of the world with an excessive number of such operations without medical indications. The simultaneous lack and excess of cesarean deliveries in LA countries reflects a model of care that excludes a considerable portion of the population and reveals the persistent gaps and inequalities in the region. One of the main challenges to be faced is the lack of sustainable financing mechanisms to provide integrated and high-quality health care to all children, equal education opportunities, and social services to support disadvantaged families. When planning interventions, equity should be restored as the guiding principle of actions to ensure inclusion and social justice. Children represent the future of society in Latin America and elsewhere. For this reason, social commitment to provide universal child health is the genesis of sustainable development and must be an absolute priority.

Article

Empowerment features prominently in public health and health promotion policy and practice aimed at improving the social determinants of health that impact communities and groups that are experiencing disadvantage and discrimination. This raises two important questions. How should empowerment be understood from the perspective of health and health equity and how can public health practitioners support empowerment for greater health equity? Many contemporary definitions link empowerment to improvements in individual self-care and/or the adoption of “healthier” lifestyles. In contrast, from a health equity perspective community empowerment is understood as sociopolitical processes that engage with power dynamics and result in people bearing the brunt of social injustice exercising greater collective control over decisions and actions that impact their lives and health. There is growing evidence that increased collective control at the population level is associated with improved social determinants of health and population health outcomes. But alongside this, there is also evidence that many contemporary community interventions are not “empowering” for the people targeted and may actually be having negative impacts. To achieve more positive outcomes, existing frameworks need to be used to recenter power in the design, implementation, and evaluation of local community initiatives in the health field. In addition, health professionals and agencies must act to remove barriers to the empowerment of disadvantaged communities and groups. They can do this by taking experiential knowledge more seriously, by challenging processes that stigmatize disadvantaged groups, and by developing sustainable spaces for the authentic participation of lay communities of interest and place in decisions that have an impact on their lives.

Article

Amira M. Khan, Zohra S. Lassi, and Zulfiqar A. Bhutta

Nearly 80% of the world’s population lives in low- and middle-income countries (LMICs) and these regions bear the greatest burden of maternal, neonatal, and child mortality, with most of the deaths occurring at home. Much of global maternal and child mortality is attributable to easily preventable and treatable conditions. However, the challenge lies in reaching the most vulnerable communities, especially the rural populations, making it imperative that maternal, newborn, and child health (MNCH) interventions focus on communities in tandem with facility-based strategies. There is widespread consensus that delivering effective primary health care (PHC) interventions through the continuum of care, starting from pregnancy to delivery and then to the newborn, infant, and the young child, is an integral component of health strategies in high-, middle- and low-income settings. Despite gaps in research, several effective community-based PHC approaches have been proven to impact MNCH positively. Implementation of these strategies is needed at scale in LMICs and in partnership with all stakeholders including the public and private sector. Community-based PHC, operating on the principles of community engagement and community mobilization, is now more critical than ever. Further robust studies are needed to evaluate certain strategies of community-based PHC and their impact on maternal and child health outcomes, such as the use of mobile technology and social franchises. Recognition of community health workers (CHWs) as a formal cadre and the integration of community-based health services within PHC are vital in strengthening efforts to impact maternal, neonatal, and child health outcomes positively. However, despite the importance of community-based PHC for MNCH in LMICs, the existence of a strong health system and skilled workforce is central to achieving positive health outcomes in these regions.

Article

Ine Vanwesenbeeck

Comprehensive sexuality education (CSE) is increasingly accepted as the most preferred way of structurally enhancing young peoples’ sexual and reproductive well-being. A historical development can be seen from “conventional,” health-based programs to empowerment-directed, rights-based approaches. Notably the latter have an enormous potential to enable young people to develop accurate and age-appropriate sexual knowledge, attitudes, skills, intentions, and behaviors that contribute to safe, healthy, positive, and gender-equitable relationships. There is ample evidence of program effectiveness, provided basic principles are adhered to in terms of content (e.g., adoption of a broad curriculum, including gender and rights as core elements) and delivery (e.g., learner centeredness). Additional and crucial levers of success are appropriate teacher training, the availability of sexual health services and supplies, and an altogether enabling (school, cultural, and political) context. CSE’s potential extends far beyond individual sexual health outcomes toward, for instance, school social climates and countries’ socioeconomic development. CSE is gaining worldwide political commitment, but a huge gap remains between political frameworks and actual implementation. For CSE to reach scale and its full potential, multicomponent approaches are called for that also address social, ideological, and infrastructural barriers on international, national, and local levels. CSE is a work never done. Current unfinished business comprises, among others, fighting persevering opposition, advancing equitable international cooperation, and realizing ongoing innovation in specific content, delivery, and research-methodological areas.

Article

Organizations regulating the water sector have major impacts on public health and the sustainability of supply to households, industry, power generation, agriculture, and the environment. Access to affordable water is a human right, but it is costly to produce, as is wastewater treatment. Capital investments required for water supply and sanitation are substantial, and operating costs are significant as well. That means that there are trade-offs among access, affordability, and cost recovery. Political leaders prioritize goals and implement policy through a number of organizations: government ministries, municipalities, sector regulators, health agencies, and environmental regulators. The economic regulators of the water sector set targets and quality standards for water operators and determine prices that promote the financial sustainability of those operators. Their decisions affect drinking water safety and sanitation. In developing countries with large rural populations, centralized water networks may not be feasible. Sector regulators often oversee how local organizations ensure water supply to citizens and address wastewater transport, treatment, and disposal, including non-networked sanitation systems. Both rural and urban situations present challenges for sector regulators. The theoretical rationale for water-sector regulation address operator monopoly power (restricting output) and transparency, so customers have information regarding service quality and operator efficiency. Externalities (like pollution) are especially problematic in the water sector. In addition, water and sanitation enhance community health and personal dignity: they promote cohesion within a community. Regulatory systems attempt to address those issues. Of course, government intervention can actually be problematic if short-term political objectives dominate public policy or rules are established to benefit politically powerful groups. In such situations, the fair and efficient provision of water and sanitation services is not given priority. Note that the governance of economic regulators (their organizational design, values or principles, functions, and processes) creates incentives (and disincentives) for operators to improve performance. Related ministries that provide oversight of the environment, health and safety, urban and housing issues, and water resource management also influence the long-term sustainability of the water sector and associated health impacts. Ministries formulate public policy for those areas under their jurisdiction and monitor its implementation by designated authorities. Ideally, water-sector regulators are somewhat insulated from day-to-day political pressures and have the expertise (and authority) to implement public policy and address emerging sector issues. Many health issues related to water are caused or aggravated by lack of clean water supply or lack of effective sanitation. These problems can be attributed to lack of access or to lack of quality supplied if there is access. The economic regulation of utilities has an effect on public health through the setting of quality standards for water supply and sanitation, the incentives provided for productive efficiency (encouraging least-cost provision of quality services), setting tariffs to provide cash flows to fund supply and network expansion, and providing incentives and monitoring so that investments translate into system expansion and better quality service. Thus, although water-sector regulators tend not to focus directly on health outcomes, their regulatory decisions determine access to safe water and sanitation.

Article

For decades, researchers have been puzzled by the finding that despite low socioeconomic status, fewer social mobility opportunities, and access barriers to health care, some migrant groups appear to experience lower mortality than the majority population of the respective host country (and possibly also of the country of origin). This phenomenon has been acknowledged as a paradox, and in turn, researchers attempted to explain this paradox through theoretical interpretations, innovative research designs, and methodological speculations. Specific focus on the salmon effect/bias and the convergence theory may help characterize the past and current tendencies in migrant health research to explain the paradox of healthy migrants: the first examines whether the paradox reveals a real effect or is a reflection of methodological error, and the second suggests that even if migrants indeed have a mortality advantage, it may soon disappear due to acculturation. These discussions should encompass mental health in addition to physical health. It is impossible to forecast the future trajectories of migration patterns and equally impossible to always accurately predict the physical and mental health outcomes migrants/refugees who cannot return to the country of origin in times of war, political conflict, and severe climate change. However, following individuals on their path to becoming acculturated to new societies will not only enrich our understanding of the relationship between migration and health but also contribute to the acculturation process by generating advocacy for inclusive health care.

Article

Concerns about water affordability have centered on access to networked services in low-income countries, but have grown in high-income countries as water, sewer, and stormwater tariffs, which fund replacement of aging infrastructure and management of demand, have risen. The political context includes a UN-recognized human right to water and a set of Sustainable Development Goals that explicitly reference affordable services in water, sanitation, and other sectors. Affordability has traditionally been measured as the ratio of combined water and sewer bills divided by total income or expenditures. Subjective decisions are then made about what constitutes an “affordable” ratio, and the fraction paying more than this is calculated. This measurement approach typically omits the coping costs associated with poor supply, notably the time costs of carrying water home. Three less commonly used approaches include calculating (a) the expenditure related to procuring a “lifeline” quantity of water as a percent of income or expenditures, (b) the amount of income left for other needs after water and sewer expenditures are subtracted, and (c) the number of hours of minimum wage work needed to purchase an essential quantity of water. Lowering water rates for all customers does not necessarily help those in need in low- and middle-income countries. This includes tariff structures that subsidize the price of water in the lowest block or tier (i.e., lifeline blocks) for all customers, not just the poor. Affordability programs that do not operate through tariffs can be characterized by (a) how they are administered and funded, (b) how they target the poor, and (c) how they deliver subsidies to the poor. Common types of delivery mechanisms include subsidizing public taps for unconnected households, subsidizing or financing the fees associated with obtaining a connection to the piped network, and subsidizing monthly bills for poor households. Means-tested consumption subsidies are most common in industrialized countries, whereas subsidizing public taps and connection fees are more common in low- and middle-income countries. A final challenge is directing subsidies to renters who are more likely to be poor and who do not have a direct relationship with a water utility because they pay for water through their landlord, either included as part of their rent or as a separate water payment. Based on data from the 2013 American Housing Survey, approximately 21% of all housing units in the United States are occupied by this type of “hard to reach” customer, although not all of them would be considered poor or eligible for an assistance program. This ratio is as high as 74% of all housing units in metropolitan areas like New York City. Because of data limitations, there are no similar estimates in low-income countries. Instead of sector-by-sector affordability policies, governments might do better to think about the entire package of services a poor person has a perceived right to consume. Direct income support, calculated to cover a package of basic services, could then be delivered to the poor, preserving their autonomy to make spending decisions and preserving the appropriate signals about resource scarcity.

Article

Globally, countries have followed demographic transition theory and transitioned from high levels of fertility and mortality to lower levels. These changes have resulted in the improved health and well-being of people in the form of extended longevity and considerable improvements in survival at all ages, specifically among children and through lower fertility, which empowers women. India, the second most populous country after China, covers 2.4% of the global surface area and holds 18% of the world’s population. The United Nations 2019 medium variant population estimates revealed that India would surpass China in the year 2030 and would maintain the first rank after 2030. The population of India would peak at 1.65 billion in 2061 and would begin to decline thereafter and reach 1.44 billion in the year 2100. Thus, India’s experience will pose significant challenges for the global community, which has expressed its concern about India’s rising population size and persistent higher fertility and mortality levels. India is a country of wide socioeconomic and demographic diversity across its states. The four large states of Uttar Pradesh, Bihar, Madhya Pradesh, and Rajasthan accounted for 37% of the country’s total population in 2011 and continue to exhibit above replacement fertility (that is, the total fertility rate, TFR, of greater than 2.1 children per woman) and higher mortality levels and thus have great potential for future population growth. For example, nationally, the life expectancy at birth in India is below 70 years (lagging by more than 3 years when compared to the world average), but the states of Uttar Pradesh and Rajasthan have an average life expectancy of around 65–66 years. The spatial distribution of India’s population would have a more significant influence on its future political and economic scenario. The population growth rate in Kerala may turn negative around 2036, in Andhra Pradesh (including the newly created state of Telangana) around 2041, and in Karnataka and Tamil Nadu around 2046. Conversely, Uttar Pradesh, Bihar, Madhya Pradesh, and Rajasthan would have 764 million people in 2061 (45% of the national total) by the time India’s population reaches around 1.65 billion. Nationally, the total fertility rate declined from about 6.5 in early 1960 to 2.3 children per woman in 2016, a result of the massive efforts to improve comprehensive maternal and child health programs and nationwide implementation of the national health mission with a greater focus on social determinants of health. However, childhood mortality rates continue to be unacceptably high in Uttar Pradesh, Bihar, Rajasthan, and Madhya Pradesh (for every 1,000 live births, 43 to 55 children die in these states before celebrating their 5th birthday). Intertwined programmatic interventions that focus on female education and child survival are essential to yield desired fertility and mortality in several states that have experienced higher levels. These changes would be crucial for India to stabilize its population before reaching 1.65 billion. India’s demographic journey through the path of the classical demographic transition suggests that India is very close to achieving replacement fertility.

Article

Water utilities commonly use complex, nonlinear tariff structures to balance multiple tariff objectives. When these tariffs change, how will customers respond? Do customers respond to the marginal volumetric prices embedded in each block, or do they respond to an average price? Because empirical demand estimation relies heavily on the answer to this question, it has been discussed in the water, electricity, and tax literatures for over 50 years. To optimize water consumption in an economically rational way, consumers must have knowledge of the tariff structure and their consumption. The former is challenging because of nonlinear tariffs and inadequate tariff information provided on bills; the latter is challenging because consumption is observed only once and with a lag (at the end of the period of consumption). A large number of empirical studies show that, when asked, consumers have poor knowledge about tariff structures, marginal prices, and (often) their water consumption. Several studies since 2010 have used methods with cleaner causal identification, namely regression discontinuity approaches that exploit natural experiments across changes in kinks in the tariff structure, changes in utility service area borders, changes in billing periods, or a combination. Three studies found clear evidence that consumers respond to average volumetric price. Two studies found evidence that consumers react to marginal prices, although in both studies the change in price may have been especially salient. One study did not explicitly rule out an average price response. Only one study examined responsiveness to average total price, which includes the fixed, nonvolumetric component of the bill. There are five messages for water professionals. First, inattention to complex tariff schedules and marginal prices should not be confused with inattention to all prices: customers do react to changes in prices, and prices should remain an important tool for managing scarcity and increasing economic efficiency. Second, there is substantial evidence that most customers do not understand complex tariffs and likely do not respond to changes in marginal price. Third, most studies have failed to clearly distinguish between average total price and average volumetric price, highlighting the importance of fixed charges in consumer perception. Fourth, evidence as of late 2020 pointed toward consumers’ responding to average volumetric price, but it may be that this simply better approximates average total price than marginal or expected marginal prices; no studies have explicitly tested this. Finally, although information treatments can likely increase customers’ understanding of complex tariffs (and hence marginal price), it is likely a better use of resources to simplify tariffs and pair increased volumetric charges with enhanced customer assistance programs to help poor customers, rather than relying on increasing block tariffs.

Article

R. Quentin Grafton, Long Chu, and Paul Wyrwoll

Water insecurity poses threats to both human welfare and ecological systems. Global water abstractions (extractions) have increased threefold over the period 1960–2010, and an increasing trend in abstractions is expected to continue. Rising water use is placing significant pressure on water resources, leading to depletion of surface and underground water systems, and exposing up to 4 billion people to high levels of seasonal or persistent water insecurity. Climate change is deepening the risks of water scarcity by increasing rainfall variability. By the 2050s, the water–climate change challenge could cause an additional 620 million people to live with chronic water shortage and increase by 75% the proportion of cropland exposed to drought. While there is no single solution to water scarcity or water justice, increasing the benefits of water use through better planning and incentives can help. Pricing is an effective tool to regulate water consumption for irrigation, for residential uses, and especially in response to droughts. For a water allocation to be efficient, the water price paid by users should be equal to the marginal economic cost of water supply. Accounting for all costs of supply is important even though, in practice, water prices are typically set to meet a range of social and political objectives. Dynamic water pricing provides a tool for increasing allocative efficiency in short-term water allocation and the long-term planning of water resources. A dynamic relationship exists between water consumption at a point in time and water scarcity in the future. Thus, dynamic water pricing schemes may take into account the benefit of consuming water at that time and also the water availability that could be used should a drought occur in the future. Dynamic water pricing can be applied with the risk-adjusted user cost (RAUC), which measures the risk impact of current water consumption on the welfare of future water users.

Article

Yuelong Ji, Ramkripa Raghavan, and Xiaobin Wang

Autism spectrum disorder (ASD) is a complex neurodevelopmental condition characterized by impairments in social interaction and communication and by the presence of restrictive, repetitive behavior. Attention deficit hyperactivity disorder (ADHD) is another common lifelong neurodevelopmental disorder characterized by three major presentations: predominantly hyperactive/impulsive, predominantly inattentive, and combined. Although ASD and ADHD are different clinical diagnoses, they share various common characteristics, including male dominance, early childhood onset, links to prenatal and perinatal factors, common comorbidity for each other, and, often, persistence into adulthood. They also have both unique and shared risk factors, which originate in early life and have lifelong implications on the affected individuals and families and society. While genetic factors contribute to ASD and ADHD risk, the environmental contribution to ASD and ADHD has been recognized as having potentially equal importance, which raises the hope for early prevention and intervention. Maternal folate levels, maternal metabolic syndrome, and metabolic biomarkers have been associated with the risk of childhood ASD; while maternal high-density lipoprotein, maternal psychosocial stress, and in utero exposure to opioids have been associated with the risk of childhood ADHD. As for shared factors, male sex, preterm birth, placental pathology, and early life exposure to acetaminophen have been associated with both ASD and ADHD. The high rate of comorbidity of ASD and ADHD and their many shared early life risk factors suggest that early identification and intervention of common early life risk factors may be cost-effective to lower the risk of both conditions. Efforts to improve maternal preconception, prenatal, and perinatal health will not only help reduce adverse reproductive and birth outcomes but will also help mitigate the risk of ASD and ADHD associated with those adverse early life events.

Article

Tim Shand and Arik V. Marcell

Engaging men in sexual and reproductive health (SRH) across the life span is necessary for meeting men’s own SRH needs, including: prevention of STIs, HIV, unintended pregnancy, and reproductive system cancers; prevention and management of infertility and male sexual dysfunction; and promotion of men’s sexual health and broader well-being. Engaging men is also important given their relationship to others, particularly their partners and families, enabling men to: equitably support contraceptive use and family planning and to share responsibilities for healthy sexuality and reproduction; improve maternal, newborn, and child health; prevent mother-to-child transmission of HIV; and advocate for sexual and reproductive rights for all. Engaging men is also critical to achieving gender equality and challenging inequitable power dynamics and harmful gender norms that can undermine women’s SRH outcomes, rights, and autonomy and that can discourage help- and health-seeking behaviors among men. Evidence shows that engaging men in SRH can effectively improve health and equality outcomes, particularly for women and children. Approaches to involving men are most effective when they take a gender transformative approach, work at the personal, social, structural, and cultural levels, address specific life stages, and reflect a broad approach to sexuality, masculinities, and gender. While there has been growth in the field of men’s engagement since 2010, it has primarily focused on men’s role as supportive to their partners’ SRH. There remains a gap in evidence and practice around better engaging men as SRH clients and service users in their own right, including providing high-quality and accessible male-friendly services. A greater focus is required within global and national policy, research, programs, and services to scale up, institutionalize, and standardize approaches to engaging men in SRH.

Article

Unconventional natural gas development (UNGD), which includes the processes of horizontal drilling and hydraulic fracturing to extract natural gas from unconventional reservoirs such as shale, has dramatically expanded since 2000. In parallel, concern over environmental and community impacts has increased along with the threats they pose for health. Shale gas reservoirs are present on all continents, but only a small proportion of global reserves has been extracted through 2016. Natural gas production from UNGD is highest in the United States in Pennsylvania, Texas, Louisiana, Oklahoma, and Arkansas. But unconventional production is also in practice elsewhere, including in eighteen other U.S. states, Canada, and China. Given the rapid development of the industry coupled with its likelihood of further growth and public concern about potential cumulative and long-term environmental and health impacts, it is important to review what is currently known about these topics. The environmental impacts from UNGD include chemical, physical, and psychosocial hazards as well as more general community impacts. Chemical hazards commonly include detection of chemical odors; volatile organic compounds (including BTEX chemicals [benzene, toluene, ethylbenzene, and xylene], and several that have been implicated in endocrine disruption) in air, soil, and surface and groundwater; particulate matter, ozone, and oxides of nitrogen (NOx) in air; and inorganic compounds, including heavy metals, in soil and water, particularly near wastewater disposal sites. Physical hazards include noise, light, vibration, and ionizing radiation (including technologically enhanced naturally occurring radioactive materials [TENORMs] in air and water), which can affect health directly or through stress pathways. Psychosocial hazards can also operate through stress pathways and include exposure to increases in traffic accidents, heavy truck traffic, transient workforces, rapid industrialization of previously rural areas, increased crime rates, and changes in employment opportunities as well as land and home values. In addition, the deep-well injection of wastewater from UNGD has been associated with increased seismic activity. These environmental and community impacts have generated considerable concern about potential health effects and corresponding political debate over whether UNGD should be promoted, regulated, or banned. For several years after the expansion of the industry, there were no well-designed, population-based studies that objectively measured UNGD activity or associated exposures in relation to health outcomes. This delay is inherent after the introduction of new industries, but hundreds of thousands of wells were drilled before any health studies were completed. By 2017, there were a number of important, peer-reviewed studies published in the scientific literature that raised concern about potential ongoing health impacts. These studies have reported associations between proximity to UNGD and pregnancy and birth outcomes; migraine headache, chronic rhinosinusitis, severe fatigue, and other symptoms; asthma exacerbations; and psychological and stress-related concerns. Beyond its direct health impacts, UNGD may be substantially contributing to climate change (due to fugitive emissions of methane, a powerful greenhouse gas), which has further health impacts. Certain health outcomes, such as cancer and neurodegenerative diseases, cannot yet be studied because insufficient time has passed in most regions since the expansion of UNGD to allow for latency considerations. With the potential for tens of thousands of additional wells across large geographic areas, these early health studies should give pause about whether and how UNGD should proceed. Citing health concerns, several U.S. states and nations in Europe have already decided to not allow UNGD.

Article

Luiz Augusto Cassanha Galvao, Volney Câmara, and Daniel Buss

The relationship between environment and health is part of the history of medicine and has always been important to any study of human health and to public-health interventions. In Latin America many health improvements are related to environmental interventions, such as the provision of better water and sanitation services. Latin America’s development, industrialization, and sweeping urbanization have brought many improvements to the well-being of its populations; they have also inaugurated new societies, with new patterns of consumption. The region’s basic environmental-health interventions have needed to be updated and upgraded to include disciplines such as toxicology, environmental epidemiology, environmental engineering, and many others. Multidisciplinary and inter-sector approaches are paramount to understanding new profiles of health and well-being, and to promoting effective public-health interventions. The new social, economic, labor, and consumption aspects of modern Latin American society have become more and more relevant to understanding the complex interactions in the region’s social, biological, and physical environment, which are essential to explaining some of the emerging and re-emerging public-health problems. Environmental health, as concept and as intervention, is simple and easily understood, but no longer sufficient to achieve the levels of health and well-being expected and required by these new realities. Many global changes such as climate change, biodiversity loss, and mass migrations has been identified as main cause of ill health and are at the center of the sustainable development challenges in general, and many are critical and specific public health. To face this development, other frameworks have emerged, such as planetary health and environmental and social determinants of health. Public health remains central to some, such as the improved environmental-health agenda, while others assign public health a relative position in a variety of overarching frameworks.

Article

Sarka Lisonkova and K. S. Joseph

Fetal death refers to the death of a post-embryonic product of conception while in utero or during childbirth, and it is one of the most distressing events faced by women and families. Birth following spontaneous fetal death is termed “miscarriage” if it occurs early in gestation, and “stillbirth,” if it occurs beyond the point of viability. There are substantial between-country differences in the criteria used for reporting stillbirths and these differences compromise international comparisons of stillbirth rates. In high-income countries, a majority of fetal deaths occur due to genetic causes, fetal infection, or other pregnancy complications. Congenital anomalies, placental insufficiency, and/or intrauterine growth restriction are frequent antecedents of fetal death. Maternal risk factors include advanced maternal age, high body mass index, smoking and substance use during pregnancy, prior stillbirth, chronic morbidity, and multifetal pregnancy. Disparities in education and socioeconomic status and other factors influencing maternal health also contribute to elevated rates of stillbirth among vulnerable women.