People with disability are disproportionately impacted by disaster events. They are two to four times more likely to die in a disaster, experience higher risk of injury and loss of property, have greater difficulty evacuating, sheltering, and require more intensive health and social services during and after disaster. While these impacts stem from a range of factors that increase the vulnerability of people with disability to disaster, a significant barrier to the safety and well-being of people with disability is their absence from emergency management practice and policy formulation. In 2014, the United Nations Office for Disaster Risk Reduction recognized this as a universal challenge. Global Disability-Inclusive Disaster Risk Reduction (DIDRR) initiatives and policy advocacy has helped to advance the incorporation of accessibility, inclusion, and universal design principles into the Sendai Framework for Disaster Risk Reduction (SFDRR) 2015–2030. DIDRR requires shared responsibility of multiple stakeholders working together to identify and remove barriers that increase risk for people with disability before, during, and after disaster. Yet, governments and emergency personnel are faced with the intractable problem of how to develop shared responsibility between local government, emergency personnel, people with disability, and the services that support them. Methods, tools, and programmatic guidance are needed to ensure that people with disability and their support needs are at the center of emergency management. The Person-Centered Emergency Preparedness (P-CEP) framework and process tool offers a new approach for enacting DIDRR; shifting emphasis to preparedness by people with disability in partnership with emergency personnel. The P-CEP was developed through a co-design process involving multiple stakeholders, including people with disability and their support networks. Grounded in the Capability Approach, the P-CEP integrates factors that facilitate personal emergency preparedness together with principles of person-centered planning to enable emergency managers to learn about the preparedness, capabilities, and support needs of people with disability and work together with people and the services that support them toward the development of local community-level DIDRR. The P-CEP takes an all-hazards approach by incorporating self-assessment and tailored preparedness planning for disasters triggered by natural hazard events and other emergencies (e.g., house fire, pandemic). The P-CEP has three components: (a) a capability framework consisting of eight elements to support self-assessment of strengths and support needs; (b) principles guiding the joint effort of multiple stakeholders to enable tailored emergency preparedness planning; and (c) four process steps enabling the developmental progression of preparedness actions and facilitating linkages between people with disability, their support services, and emergency personnel. The P-CEP is being used to advance individual and shared responsibilities for DIDRR in Australian communities through the incremental development of awareness about and responsiveness to the support needs that people with disability have in emergencies. Future research will apply P-CEP to the design of programs and services that: (a) increase the emergency preparedness of people with disability; and (b) ensure that information about the extra supports that people with disability need in emergencies is included in the design of disability-inclusive emergency planning.
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Article
Disability-Inclusive Emergency Planning: Person-Centered Emergency Preparedness
Michelle Villeneuve
Article
Disparities in Healthcare Access and Outcomes Among Racial and Ethnic Minoritized People with Intellectual and Developmental Disabilities
Sandy Magaña, Nazanin Heydarian, and Sandra Vanegas
Compared to the general population, people with intellectual and developmental disabilities (IDD) face worse health outcomes, and outcomes are even worse for children and adults with IDD from minoritized populations. Examining the intersection of people with IDD from minoritized groups is critical to understanding appropriate policies and services that promote health among all people with IDD. People with IDD from minoritized racial and ethnic groups have greater exposure to detrimental social determinants of health, which leads to poor access to adequate healthcare and poor health outcomes. Policies that aim to improve health outcomes among people with IDD and that are related to their disability and appropriate accommodations are not enough. Policies need to address poverty in families, racism and discrimination, poor housing, and other social determinants that are more prevalent among minoritized populations.
Most research on racial and ethnic disparities among children and adults with IDD has been conducted in the United States. While there is emerging research globally on racial and ethnic disparities, there a paucity of this research in the field of IDD. Furthermore, there may be detrimental health effects for other minoritized groups, such as religious minorities, but research is lacking in this area. Clearly, more research on these intersections is needed in the global context.
Article
Do Households Respond to the Marginal or Average Price of Piped Water Services?
Joseph Cook and Daniel Brent
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
Drowning: Global Burden, Risk Factors, and Prevention Strategies
Aminur Rahman, Amy E. Peden, Lamisa Ashraf, Daniel Ryan, Al-Amin Bhuiyan, and Stephen Beerman
Drowning has been described as a major global public health problem and has recently been acknowledged by a United Nations Declaration on Global Drowning Prevention. While drowning impacts countries of all income levels, the burden is overwhelmingly borne by low- and middle-income countries (LMICs) who account for 90% of the global death toll. In addition, there is scarce data collection on drowning in LMICs, so the magnitude of drowning may be far greater than is represented. A range of factors including sex, age, education, income, access to water, a lack of swimming skills, certain occupations like commercial fishing, geographically isolated and flood-prone locations, preexisting medical conditions, and unsafe water transport systems, influence the risk of drowning. Some behavioral factors, such as alcohol or drug consumption, not wearing life jackets, and engaging in risky behaviors such as swimming or boating alone, increase drowning risk. Geopolitical factors such as migration and armed conflict can also impact drowning risk. There is a growing body of evidence on drowning prevention strategies. These include pre-event interventions such as pool fencing, enhancing community education and awareness, providing swimming lessons, use of lifejackets, close supervision of children by adults, and boating regulations. Interventions to reduce harm from drowning include appropriate training for recognition of a drowning event, rescue, and resuscitation. An active and/or passive surveillance system for drowning, focusing on individual settings and targeting populations at risk, is required.
Drowning requires coordinated multisectoral action to provide effective prevention, rescue, and treatment. Therefore, all countries should aim to develop a national water safety plan, as recommended in the WHO Global Report on Drowning. Further research is required on the epidemiology and treatment of drowning in LMICs as well as non-fatal and intentional drowning in both high-income countries (HICs) and LMICs. Effective and context-specific implementation of drowning prevention strategies, including pilot testing, scale up and evaluation, are likely to help reduce the burden of both fatal and non-fatal drowning in all countries.
Article
Dynamic Water Pricing
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
Early Life Origins of ASD and ADHD
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
Engaging Men in Sexual and Reproductive Health
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
Ensuring the Public Value of Long-Term Care Services
Joseph E. Ibrahim
Many seniors needing social and clinical care come from vulnerable populations that have difficulty accessing services, a great need for those services, and/or potentially impaired decision-making skills. At the same time, when seniors use services on a routine basis, they become increasingly dependent on the individual service provider. The aged care sector has a duty to provide “public value”—that is, to provide a valuable contribution to society within existing resource constraints. This requires more than simply addressing the basic individual needs of care recipients. Ethical factors must be considered in policies around services to vulnerable seniors and potential issues in addressing suboptimal quality of care, neglect, and abuse of seniors, as demonstrated by continuing public news of poor care provided to seniors in nursing homes, social care, and residential care settings.
Article
Environmental Health Concerns From Unconventional Natural Gas Development
Irena Gorski and Brian S. Schwartz
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
Environmental Health in Latin American Countries
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
Evaluating Condominial Sewerage Programs: Technology and Community Engagement
Patrícia Campos Borja, Earthea Nance, and Luiz Roberto Santos Moraes
Condominial sewerage is a socio-technical system used in many parts of the world. It has the potential to expand service coverage due to its low cost and adaptability. However, the results and effectiveness of projects that have been implemented and their evaluation methods have been little studied. The aim of this article is to discuss experiences of evaluation of this technology, which have focused on use, functioning, social participation, and health impacts. Other aims are to propose an evaluation scope and to present a comprehensive framework to support future evaluations.
Article
The Evidence Base for Cognitive, Nutrition, and Other Benefits From Water, Sanitation, and Hygiene Interventions
Jennifer Orgill-Meyer
Cost-benefit analysis of WASH (water, sanitation, and hygiene) interventions have traditionally focused on two primary benefits: improved health outcomes, usually measured as reduced diarrheal disease incidence, and reduced time burdens from collecting water, treating water, or traveling to open defecation or shared sanitation sites. However, there are also many other important benefits of water, sanitation, and hygiene interventions for policymakers and researchers to consider, such as improved nutrition and decreased stunting, improved cognitive development and educational attainment, and quality-of-life improvements for women.
Reduced fecal exposure from improved WASH may decrease not only diarrheal disease incidence but also the risk of environmental enteropathy, a condition that reduces the nutritional absorptive capacity of the gut. Environmental enteropathy results in a range of outcomes associated with malnutrition, such as wasting, stunting, and anemia. A growing body of literature has explored the direct relationship between improved sanitation environments and stunting. There are mixed findings from these research studies, suggesting that intervention adherence and baseline sanitation conditions may be important to realizing any potential stunting benefits. The economics literature has documented a strong inverse relationship between childhood stunting and lifetime earnings.
Reduced absorptive capacity from environmental enteropathy may also hinder cognitive development in children. Recent research documents a strong relationship between improved sanitation environments and cognitive development in children, though some studies find no relationship. Beyond cognition, improved health from reduced fecal exposure may also affect a child’s ability to attend school, and research shows a relationship between WASH environments and school attendance and enrollment. Monetizing the benefits of improved schooling in a low-income country context is challenging due to high variation in school quality as well as high rates of self-employment.
Quality-of-life benefits for women are a third category of benefits that are often omitted from WASH cost–benefit analyses. Mostly qualitative research highlights that poor sanitation and water insecurity is associated with safety, security, privacy, and dignity concerns for women. While these concerns and experiences are difficult to quantify in many cases, they should not be ignored when considering WASH benefits.
Article
The Evidence Base for Time Savings Benefits in Water and Sanitation Interventions
Maya Chandrasekaran, Joseph Cook, and Marc Jeuland
Improved access to safe and reliable water, sanitation, and hygiene (WASH) services in the developing world has many positive health and economic impacts. Two of the key channels through which such impacts manifest are (a) the reduced time burden for the household members, usually women, who are responsible for water collection and transportation, and (b) time saved from not having to defecate in the open, far away from living areas. WASH interventions can produce time savings for low-income households via several specific pathways—for example, through access to closer, more convenient, better quality water and sanitation sources; reduced cost of water delivery to the home; direct conveyance of water via reliable piped supply; or improvements that reduce the time costs of coping with unreliable supply.
In existing studies, time savings arising from WASH interventions have primarily been elicited using one of three methods. The first is the time diary approach, which aims to reconstruct an individual’s time use on a recent or typical day. A second approach is direct questioning, where the time spent on a specific activity in a recent (or typical) time period—in this case water collection and WASH management—is recorded. Finally, researchers have begun to use the Global Positioning System and smartphones to track information related to individuals’ movements throughout the day and to determine how those locations map to community water and sanitation facilities. The time savings estimated in published works vary greatly, which may be due to differences in intervention evaluation methods, time elicitation strategies, geographical context, households’ baseline water situation, and the type of improved technology considered.
Then, the value of time saved by individuals from use of improved WASH services depends on the opportunity cost of time—that is, the value of the next best use of that time. From a development perspective, alternative time uses for education or income generation may be of particular interest, but other time use (e.g., for leisure, other domestic work, or rest) may also contribute to enhanced household and individual welfare. Unfortunately, in contrast to a fairly robust time valuation literature, especially regarding transportation choices, there is relatively sparse literature on the reallocation of time savings, and its value, from WASH interventions. Many economic analyses therefore fall back on “rule-of-thumb” methods that assume that time savings are worth some fraction, typically approximately 50%, of the prevailing market wage rate. Two methods for time valuation could be used more extensively for valuing WASH-related time savings and burdens in middle- and low-income countries: (a) revealed preference methods based on choices made by individuals between time and other burdens and (b) structured stated preference trade-offs that yield time values based on respondents choices in hypothetical games.
Given the shortcomings of the literature, researchers working in this domain should devote greater attention to reporting the nature of the pre-intervention WASH situation in their study setting, describing and validating time use elicitation methods, including, when possible, with objective measures, and more thoroughly considering how time savings are reallocated or contribute to household well-being and reduced poverty.
Finally, when conducting cost–benefit analysis of WASH interventions, analysts should use their judgment and knowledge about the specifics of a particular water project when specifying time savings; however, 60% of baseline time spent appears to be a reasonable base case estimate for water supply improvements. For sanitation improvements, the evidence base is thin, but per person time savings of 5–10 minutes per day appears reasonable as a starting point. In each case, sensitivity analysis is recommended around these base case values. Specifically, the value of that time is unlikely to be worth 100% of the household after-tax wage in the policy site, so the analyst should test whether the outcome of a project appraisal would change if time is valued between 25% and 75% of the average after-tax wage rate or, absent that data, the local unskilled wage rate. If the project recommendation changes within this range, the analyst should consider investing in primary research in the policy site, most likely using a stated preference approach. Primary research may also be warranted if distributional consequences of the project (e.g., on women or on the poor) are a central focus of the intervention.
Article
Experimental and Intervention Studies of Couples and Family Planning in Low- and Middle-Income Countries: A Systematic Review
Stan Becker and Dana Sarnak
The vast majority of births in the world occur within marriages or stable partnerships. Yet family planning programs have largely ignored the male partner. One justification for this nearly exclusive focus on women has been that almost all of the modern contraceptive methods are female-oriented. In contrast, studies of fertility preferences within couples that included a later follow-up have shown that men’s fertility preferences are important for predicting subsequent births. Interspousal communication can be key to resolving differences in desired family size and for promoting open contraceptive use.
Experimental studies with couples on family planning education and/or counseling show higher contraceptive prevalence or continuation in the couples groups than in the women-only groups, though the differences are not always significant statistically. Other intervention studies have varying designs and mixed results. The purpose of this systematic review is to summarize the research findings on interventions with couples on reproductive health from experimental and pre–post observational studies. An important conclusion is that couples education and counseling are critical components for involving male partners. There is a need for systematic research on couples using a standardized intervention and fixed follow-up times and including analyses of cost-effectiveness.
Article
Fall Prevention and Interventions for Older People
Claudia Meyer and Lindy Clemson
Across the globe, falls among older people can have grave consequences for individuals and for the healthcare and aged-care systems more broadly. The synergy between intrinsic and situational risk factors adds complexity to the identification and management of falls, as does the public health response at primary, secondary, and tertiary levels of prevention. Falls among people age 65 years and over are recognized as a geriatric syndrome and as a marker of frailty, with increasing rates among those experiencing other chronic conditions, such as Parkinson’s disease, stroke, and dementia.
Prevention or management of falls requires a combination of strategies as single or multicomponent interventions. Multimodal exercise, combining balance and functional exercise, environmental adaptation, medication reduction and withdrawal, cataract surgery, single-lens glasses, vitamin D supplementation, management of foot problems and footwear, and cardiac pacing have a degree of evidence to support their implementation. Multicomponent programs, such as i-FOCIS and PDSAFE, have important benefits for specific population groups.
Importantly, over the past few decades, falls prevention has shifted from a biomedical approach to a holistic biopsychosocial model. This model aids promotion of a whole-of-community approach through building healthy public policy, creating supportive environments, and strengthening personal skills and community action. The biopsychosocial approach also focuses attention on understanding local contexts, ensuring that falls prevention interventional research can be adapted and fit-for-purpose for low-, middle- and high-income countries.
The uptake of falls prevention evidence into practice and policy still faces challenges and new frontiers. Supporting the adoption, implementation, and sustainability of interventions is complex at the individual level, the service provider level, and the healthcare system level. Practice-change frameworks and models are useful, such as those utilized in the Stopping Elderly Accidents, Deaths and Injuries (USA), iSOLVE (Australia), and STRIDE (USA) trials.
Falls prevention is complex, yet solutions can be relatively simple. Working together with older people, health professionals and community health leaders can champion ways of bringing falls prevention activities to scale. Research collaboration between stakeholders is a crucial mechanism for drawing together unique perspectives to address ongoing gaps and concerns.
Article
Family Planning Programs
Amy Tsui and Jane Bertrand
Since the 1950s, there has been unprecedented change in reproductive behavior around the world, in part due to expanded access to modern contraceptive methods. The widespread use of those methods by individuals to bear children at their desired timing and pace reflects the organized efforts of governments, non-profit, and commercial health providers to make contraception acceptable, available, accessible, high-quality, and affordable. The establishment and growth of family planning (FP) programs around the world, and particularly in low- and middle-income countries, have responded to the policies and population circumstances of different regions, countries, and communities over time. Identified as one of the ten great public health achievements of the 20th century, FP continues to face challenges in meeting the reproductive health needs and choices of early 21st-century and future generations of people living in areas with inadequate resources, political commitment, health systems, and social equalities. This review traces the establishment of organized FP programs, their underlying rationales, components and objectives, regional implementation, and future issues and challenges.
Article
Fetal Deaths in High-Income Countries
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.
Article
Firearm Injuries and Public Health
Linda Dahlberg, Alexander Butchart, James Mercy, and Thomas Simon
An important function of public health is to prevent injuries or to lessen their impact when they occur. An estimated 251,000 people worldwide die each year from a firearm-related death and many more suffer nonfatal injuries with consequences that can last a lifetime. Firearm injuries, which include those that are intentionally self-inflicted, unintentional, or from an act of interpersonal violence, are heavily concentrated in the Americas, driven largely by firearm homicides. Firearm-related deaths and injuries disproportionately impact males and younger populations and are associated with factors such as access, substance use, adverse childhood experiences, involvement in high-risk social networks, drug trafficking, density of alcohol outlets, and neighborhood and social disadvantage. While progress is being made to understand firearm injuries and how to effectively prevent them, much more needs to be done to improve the availability and timeliness of data; apply the knowledge that is generated to effectively reduce firearm-related injuries, deaths, and costs; strengthen the scientific infrastructure; and move countries closer to achieving the violence-related targets in the 2030 Sustainable Development Goals.
Article
First Trimester Medication Abortion: Public Health Challenges and Clinical Guidance
Devanshi Somaiya and Candace Lew
According to 2015–2019 data, there are 121 million unintended pregnancies each year globally. One hundred eleven million of these occur in low- and middle-income countries. Of all unintended pregnancies, 61%, or about 73 million pregnancies, end in abortions annually, at the rate of 39 abortions per 1,000 women of reproductive age. About half the abortions, or 35 million of them, are unsafe, contributing to the 299,000 maternal deaths each year. These, in turn, have implications for the realization of almost every one of the 17 United Nations Sustainable Development Goals, specifically ensuring good health and well-being, achieving gender equity, and ending poverty.
Abortions occur in every country irrespective of income level or the legal status of abortion. From 1990 to 2019, there has been a greater increase in the proportion of pregnancies ending in abortions in countries where abortion is restricted compared with countries where abortion is broadly legal.
A growing proportion of these abortions are medication abortions, incorporating the use of mifepristone or misoprostol or both. The availability of this becomes even more important in areas where policy or infrastructure or both are more restrictive for providing safe, legal abortions. Providing quality, women-centered, comprehensive abortion care that is equitably accessible hence becomes imperative to addressing a woman’s ability to access appropriate medical care for her reproductive needs. Making this amenable to a digital platform overcomes even more barriers, be they socioeconomic or policy-driven. Fortunately, recent research and evidence support this, hence broadening the availability of safe abortion care into areas and demographics that remained precluded from the availability of comprehensive reproductive health care. Targeted progress and strengthened commitments are needed to further this penetration and provide access to compassionate, safe, and quality care for abortion and family planning.
Article
Gender and Reproductive Health Empowerment
Shannon N. Wood, Robel Yirgu, and Celia Karp
Gender and reproductive health empowerment are central concepts for understanding and improving population health and well-being. Beginning in the 1990s, global platforms, including the United Nations, began recognizing gender-based inequities, including violence against women and lack of women’s participation in education and the economy, as social determinants of health. Since the 1990s there has been growing international interest in the concept of empowerment as a means for understanding the mechanisms that drive outcomes related to health and development. Although several definitions of empowerment have evolved over the past 30 years, the pivotal work of Dr. Naila Kabeer has grounded many interpretations of women’s empowerment as a process by which a woman has the individual capacity and freedom to act on her own choices in life. To date, the lack of comparable empowerment definitions remains a major hindrance to conducting comprehensive research that links empowerment to health outcomes. Additionally, while most recognize empowerment as a multidimensional process, the majority of measures used for examining this concept have been unidimensional (focused on agency, self-efficacy, household decision-making, etc.), thereby limiting the understanding of empowerment across populations, geographies, and contexts. Subsequent framing of women’s empowerment has focused specifically on sexual and reproductive empowerment, recognizing that women may be empowered in certain realms (e.g., economic), but not in others (e.g., autonomy in contraceptive decisions). Developments in the conceptualization of reproductive empowerment since 2015 have paved the way for improved measurement and exploration of this concept, yet gaps in research remain.
