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
Demographic Transition in India: Insights Into Population Growth, Composition, and Its Major Drivers
Usha Ram and Faujdar Ram
Article
Diabetes in South Asians
Sara Garduño‐Diaz and Santosh Khokhar
As of 2023, it is estimated that Type 2 diabetes (T2D) affects approximately 783 million people worldwide, with South Asians presenting the highest age-adjusted comparative diabetes prevalence among adults (90,204.5 people). Ethnicity has been highlighted as a major risk factor for the development of T2D with central adiposity, insulin resistance, and unfavorable lipid profile identified as predominant signals of alarm. Leading databases, including Web of Science, Medline, PubMed, Google Scholar, and ScienceDirect, were consulted, and manual searches were carried out for cited references in leading diabetes-related journals. Genetic predisposition, central adiposity, and unfavorable lifestyles, including physical inactivity and an unhealthy diet, have been found to be associated with the prevalence of T2D in migrant South Asians. Additionally, “Westernization,” acculturation, socioeconomic factors, and lack of awareness regarding seriousness and consequences of the disease have also been identified as contributors to the development of T2D in this population. However, the higher prevalence of T2D in migrant South Asians may not be entirely attributed to genetic predisposition; hence, ethnicity and associated modifiable risk factors warrant further investigation. Preventive measures and appropriate interventions are limited by the lack of ethnic-specific cut-off points for anthropometric and biological markers, as well as by the absence of reliable methods for dietary and physical activity assessment.
Article
Digital Public Health: Quality, Interoperability and Capability Maturity
Siaw-Teng Liaw
Digitalization was accelerated to address the access, safety and quality needs of health professionals and citizens during care provision in the presence of human, animal and environmental vectors of pandemic infections. Digital transformation will harness cloud computing, artificial intelligence (AI), data networks and personalized digital agents, sensors, and visualization tools to monitor and enhance the care of individuals, populations and communities. A sociotechnical, multidisciplinary, and enterprise-wide approach is essential to improve the quintuple aims of cost-effectiveness, provider and patient well-being, and equity. Digitally competent health professionals and digitally mature health organizations are necessary to produce and use high-quality interoperable digital data and technologies to improve decisions and practice. The maturity of five essential digital health foundations (infrastructure, tools/agents, readiness to share information, enablers of trust and adoption, and quality improvement) is assessed across the micro–meso–macro continuum. The Digital Health Profile and Maturity Assessment Toolkit Maturity Model illustrates a sociotechnical capability maturity approach to assess how organizations manage, govern, improve, and sustain the ethical and safe production, use and sharing of digital health tools and data in the real world. The linkage and convergence of real-word data (RWD) from public health, clinical and managerial practice highlights potential cost-efficiencies in integrated data collection, reporting, aggregation, analysis, and use. Challenges include access, quality, and interoperability of RWD and tools. AI-driven data analytics is increasingly being used, despite misgivings about trustworthiness, biases and fairness of software agents, algorithms, and training data sets. The sociotechnical approach emphasizes leadership, inclusive governance, mutual trust, and reciprocity within a cocreation paradigm; communities of learning and practice operating within regulatory frameworks that promote quality, safety, and equitable access to digital tools and data; quality improvement and professional development programs aimed to improve digital health maturity; and science and digital health diplomacy to harmonize the multiplicity of actors and technology in digital public health ecosystems and global supply chains. Learning organizations that “think small and big simultaneously” within a standards-based cocreation paradigm will create the digital assets and social capital necessary for the national and global digital public health enterprise.
Article
Disability-Inclusive Emergency Planning: Person-Centered Emergency Preparedness
Michelle Villeneuve
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.
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
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
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
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
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
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
Gender-Based Violence
Phyu Phyu Oo
Gender-based violence (GBV) is a significant global public health and human rights problem, predominantly affecting women and girls worldwide across various age groups. While GBV manifests in various forms, intimate partner violence and domestic violence are the two most common forms that are widely studied and discussed in the research and policymaking processes due to the disturbingly high prevalence. The World Health Organization (WHO) estimated that 736 million women and girls globally are affected by IPV and non-partner sexual violence, even though the statistics vary across different regions . While the knowledge in understanding the prevalence and patterns of GBV has been improved over time, gathering reliable data on certain forms of GBV like femicide, rape, early marriage, sexual violence in situations of armed conflict, and trafficking in women and girls remains challenging . This data limitation stems primarily from socio-cultural norms that stigmatize the experiences of GBV survivors and a male-dominated culture that obstructs survivors from reporting and seeking help. The data gap is more notable for male survivors, despite studies showing that men and boys often fall victim to various forms of GBV, particularly in armed conflicts.
GBV in any form against any gender produces immediate, short-term, and lasting physical, mental, and social consequences for survivors, their families, and communities. A swift and comprehensive response to GBV can mitigate specific health risks, such as HIV/AIDS transmission and unintended pregnancies, significantly reducing the public health burden. However, survivors often face immense challenges in accessing appropriate care due to limited availability and accessibility. The barriers to seeking care are compounded by negative societal perceptions of GBV survivors and limited legal protection mechanisms. Unequal gender norms and discriminatory practices against women and girls in most societies are the fundamental cause of GBV while several intersecting factors like age, ethnicity, education, social beliefs, and cultural norms significantly influence the manifestation of GBV. Eliminating GBV is a complex process that requires a multidimensional approach at the individual, community, and societal levels. The most effective strategies involve transforming social norms, reforming laws, and empowering women through awareness-raising and state policies. However, resistance stemming from deeply embedded male-dominated cultures and a lack of political will among state actors often pose obstacles to effective prevention efforts. Research plays a crucial role and dedicating resources to fill knowledge gaps and evaluating ongoing practices will enhance the understanding of effective measures for preventing and responding to GBV.
Article
Global Epidemiology of Induced Abortion
Suzanne O. Bell, Mridula Shankar, and Caroline Moreau
Induced abortion is a common reproductive experience, with more than 73 million abortions occurring each year globally. Worldwide, the annual abortion incidence decreased in the 1990s and the early decades of the 21st century, but this decline has been driven by high-resource settings, whereas abortion rates in low- and middle-resource countries have remained stable. Induced abortion is a very safe procedure when performed according to World Health Organization guidelines; however, legal restrictions, stigma, cost, lack of resources, and poor health system accountability limit the availability, accessibility, and use of quality abortion care services. Even as women’s use of safer self-managed medication abortion options becomes more common in some parts of the world, 45% of all abortions annually are unsafe, nearly all of which occur in low- and middle-resource settings, where unsafe abortion remains a primary cause of maternal death. Beyond country-level legal and health care system factors, significant disparities exist in women’s reliance on unsafe abortion. Even among women who receive a safe abortion, quality of care is often poor. Yet abortion’s precarious status as a health care service and its clandestine practice have precluded a systematic focus on quality monitoring and evaluation of service inputs. Improving abortion and postabortion care quality is essential to meeting this reproductive health need, as are efforts to prevent abortion-related mortality and morbidity more broadly. This requires a three-tier approach: primary prevention to reduce unintended pregnancy, secondary prevention to make abortion procedures safer, and tertiary prevention to reduce the negative sequelae of unsafe abortion procedures. Strategies include two complementary approaches: vulnerability reduction and harm reduction, the first focusing on the root causes of unsafe abortion by addressing the determinants of unwanted pregnancy and clandestine abortion, while the latter addresses the harmful consequences of clandestine abortion. Political commitments to extend service coverage of abortion and postabortion care need to be implemented through actions that build the public health system’s capacity. Beyond the model of receiving care exclusively in clinical settings, models of guided self-managed abortion are expanding the capacity of individuals to take evidence-based actions to terminate their pregnancies safely and without the threat of judgment. Research has strived to keep up with the changes in the abortion care landscape, but there remains a continuing need to improve methodologies to generate robust evidence to identify and address inequities in abortion care and its health consequences in a diversified landscape. Doing so will provide information for stakeholders to take actions toward a new era of health care reforms that repositions abortion as an integral component of sexual and reproductive health care.
Article
Global Goal Setting and the Human Right to Water
Cristy Clark
Since the 1970s, global goal setting to increase access to safe drinking water has taken a number of different approaches to whether water should be primarily understood as a “human right” or a “human need.” In the Mar del Plata declaration of 1977, states both recognized a human right to water and committed themselves to achieving universal access by 1990. By the 1990 New Delhi Statement, with universal access still out of reach, the goal was renewed with a new deadline of 2000, but water was described as a human need rather than a human right. This approach was coupled with an emphasis on water’s economic values and the need for increased cost recovery, which in turn increased the focus on, and uptake of, private-sector participation in the delivery of water and sanitation services across the Global South.
A similar needs-based approach was adopted at the start of the new millennium in Target 7 of the Millennium Development Goals (MDGs), but during this decade a consensus on the recognition of the human right to water also emerged in international law. As the normative status and content of this right came to be better articulated and understood, it began to influence the practice of providing water and sanitation services, and by the end of the MDG process a rights-based approach featured more prominently in the Sustainable Development Goals (SDGs) of 2015.
While the provision of water and sanitation services is multifaceted, the evidence of global achievements from the 1970s onward indicates that a rights-based approach increases the priority given to the social values of such services and focuses attention on the need to go beyond technical solutions to address the structural issues at the heart of water inequality. Going forward, approaches to the provision of water and sanitation services and the human right to water will need to continue to adapt to new challenges and to changing conceptualizations of water, including the growing recognition that all living things have a right to water and that water itself can have rights.
Article
Global Trends in Life Expectancy and Healthy Life Expectancy
Emmanuelle Cambois, Géraldine Duthé, and France Meslé
In the known history of humanity, life expectancy scarcely exceeded 30 years, with half of newborns dying before age five, up to the 18th century. However, from the 18th century onward, major epidemics were combatted more efficiently, famines became less frequent, and life expectancy thus began to increase, first in Northwest Europe, then spreading to North America, Australia, Japan, and to the rest of Europe. The health transition reached Latin America, the rest of Asia, and Africa only in the 20th century.
In 2015–2020, worldwide life expectancy at birth reached 72.5 years. However, differences remained large between regions and countries. The Japanese experienced the highest level at 84.4 years, thanks to their increasingly effective noncommunicable disease (NCD) control and an especially dramatic decrease in cardiovascular mortality. On average, life expectancy was 80.9 years in high income countries, 71.4 in middle income countries and 63.4 in low income countries. It was only 60 years in sub-Saharan Africa, with some countries barely exceeding 50. High mortality countries suffer a heavy burden from both infectious and NCDs.
Due to increasing life expectancy, deaths shifting to older ages, and changing cause-of-death patterns, questions arise concerning the health of populations. The health expectancies made available mainly in high income countries are indicators that combine mortality and health data. Although it seems that severe disability has not increased in the early 21st century, the results for less severe disabilities diverge from one country to the other. Along their longer life expectancy, females live more unhealthy years than males; in some countries they even live fewer healthy years than males.
The future may see life expectancy surpassing 90 years in the most advanced countries, likely before the end of the 21st century. However, achieving this requires that humanity face major challenges, especially in overcoming infectious diseases, impeding NCDs, reducing poverty and socioeconomic inequalities, and combating the deterioration of our environment.
Article
Health Care Access for Migrants in Europe
Catherine A. O'Donnell
Migration is a reality of today’s world, with over one billion migrants worldwide. While many choose to move voluntarily, others are forced to migrate due to economic reasons or to flee war, conflict, or persecution. Such migrants often find themselves in precarious and marginalized situations—particularly asylum seekers, refugees, and undocumented or irregular migrants. While often viewed as a single group, the legal status and entitlements of these three groups are different. This has implications for their ability to access health care; in addition, rights and entitlements vary across the 28 countries of the European Union and across different parts of national health systems. The lack of entitlement to receive care, including primary and secondary care, is a significant barrier for many asylum seekers and refugees and an even greater barrier for undocumented migrants. Other barriers include different health profiles and awareness of chronic disease risk amongst migrants; awareness of the organization of health systems in host countries; and language and communication. The use of professional interpreters can help to overcome communication barriers, but entitlement to free interpreting services is highly variable. Host countries need to consider how to ensure their health systems are “migrant-friendly”: solutions include provision of professional interpreters; ensuring that health care staff are aware of migrants’ rights to access health care; and increasing knowledge of migrants in relation to the organization of the health care system in their host country and how to access care, for example through the use of patient navigators. However, perhaps one of the greatest facilitators for migrants will be a more favorable political situation, which stops demonizing people who are forced to migrate due to situations out of their control.
