Water is one the most indispensable human needs. Although pumped wells, bottled water, or public faucets are used in many parts of the world as means to obtain this crucial good, piped water services are considered the gold standard to ensure wide, regular, and secure access. At first glance, piped water services have all the characteristics of a natural monopoly in which the government is better positioned for provision than the private sector: high sunk costs and economies of scale are present, and the quality of the service is costly to supervise. However, in that first intuition, there is one missing block: government behavior. In countries with low state capacity and accountability, weak checks and balances, and institutional dysfunction, public companies are frequently used to fulfill political goals instead of their stated objectives. In those cases, privatization coupled with the creation of an independent regulatory agency can limit the predatory capacity of the government, displace the service to the sphere of private incentives, and provide the opportunity to extend coverage and improve quality.
There is, nonetheless, a fragile side to this solution. If the same institutional vulnerabilities that create poor public companies’ management persist, incentives for predatory government behavior remain latent and can emerge when circumstances facilitate it. This whole parable was observed with the privatization of Obras Sanitarias de la Nación in Argentina. First, a paralyzed and overstaffed public company was replaced by a dynamic private company. During this period, more than 2 million people gained access to the water service and 1.2 million people gained access to the sewage networks, which substantially improved health outcomes for the newly incorporated groups. Then a big economic crisis hit the contractual relationship between the government and the company, and renationalization took place. This change was paired with a return of previously observed predatory practices such as unsustainable pricing policy and non-meritocratic appointments.
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Article
Public Sector Participation in the Water Sector: Opportunities and Pitfalls
Sebastian Galiani
Article
Racism and Indigenous Health
Yin Paradies
There are an estimated 300 million indigenous peoples worldwide. Although there is ample evidence of worse health and social outcomes for the majority of indigenous peoples, compared to their non-indigenous counterparts, there has yet to be a review of racism as a determinant of indigenous health using global literature. Racism constitutes unfair and avoidable disparities in power, resources, capacities, or opportunities centered on ethnic, racial, religious, or cultural differences that can occur at three levels: internalized, interpersonal, or systemic. For indigenous peoples this is closely related to ongoing processes of colonization. Available research suggests that at least a third of indigenous adults experience racism at least once during their lives and that about a fifth of indigenous children experience racism. For indigenous peoples, racism has been associated with a considerable range of health outcomes, including psychological distress, anxiety, depression, suicide, posttraumatic stress disorder, asthma, physical illness, obesity, cardiovascular disease, increased blood pressure, excess body fat, poor sleep, reduced general physical and mental health, and poor oral health, as well as increased alcohol, tobacco, and marijuana use and underutilization of medical and mental healthcare services. Disparities in medical care experienced by indigenous patients compared to non-indigenous patients have also been found. Existing studies indicate that avoidant and passive coping tends to exacerbate the detrimental health impacts of racism for indigenous peoples, whereas active coping ameliorates the ill-health effects of racism. Reducing individual and interpersonal racism can be achieved by (a) providing accurate information and improving awareness of the nature of racism and racial bias; (b) activating values of fairness, reconciling incompatible beliefs, and developing antiracist motivation; (c) fostering empathy and perspective-taking and confidence in regulating emotional responses; (d) improving comfort with other groups and reducing anxiety; and (e) reinforcing antiracist social norms and highlighting personal accountability. There are five key areas for combating systemic racism in organizations and institutions: (a) institutional accountability; (b) diversity in human resources; (c) community partnership; (d) antiracism and cultural competence training; and (e) research and evaluation.
Article
Rebooting Education: A Keystone to Ending Racial and Ethnic Minority Health Disparities
William A. Vega and Esther J. Calzada
Undermining educational attainment at any stage is a threat to life course health. A strong educational platform is required for adequate human development in the 21st century because it provides a foundation for lifelong knowledge, skills, and competencies that protect health. The importance of educational attainment for health has been acknowledged but remains understudied as an interdisciplinary issue. In US American society, unequal educational opportunity is a historical reality and is reflected in health disparities among African American and Latinx populations over the life span. Reform efforts have been initiated for decades, yet gains in educational attainment show limited progress and wide disparities in lifetime health persist. Educational attainment is a fundamental social determinant of health because it leverages higher income, improves the management of other social determinants of health, improves social skills, improves occupational life chances, and extends life expectancy. The reverse is also true. Low educational attainment that is intergenerational imperils human development by failing to prepare youth with the capabilities to overcome structural disadvantages and poverty, which themselves imperil development. African American and Latinx populations in the United States, who together represent nearly 100 million people and who will be the largest component of the majority-minority American population by the year 2046, confront a web of aversive social determinants, including poverty in de facto segregated communities, violence and trauma, toxic exposures, poorly compensated and often temporary employment, a lack of universal health insurance, racism, and sexism in their daily lives. Clearly, there are social, biologic, and psychological issues associated with the educational attainment and health gradient, and early childhood learning experiences represent a critically important opportunity for human potential by advancing cognitive performance, problem-solving ability, motivation to learn, and overall structural and functional brain development. Families from low educational attainment backgrounds experience the negative impacts of social determinants in their daily lives, and their children’s life chances are diminished by poorly funded schools with ineffective educational programs. Putative causes and potential responses to overcoming the historical problem of neglect have been identified, and there are promising efforts at educational system reform aiming to promote health with effective programs and comprehensive strategies that will close the gaps in educational attainment.
Article
Regional Studies of Indigenous Health: Europe and Russia
Peter Bjerregaard
The indigenous peoples of Europe and Russia comprise the Inuit in Greenland, the Sami in northern Norway, Sweden, Finland and Russia and forty officially recognized ethnic minority groups in northern Russia plus a few larger-population indigenous peoples in Russia. While the health of the Inuit and Sami has been well studied, information about the health of the indigenous peoples of Russia is considerably scarcer. The overall health of the Sami is in many aspects not very different from that of their non-indigenous neighbors in northern Scandinavia; the health of the Inuit is similar across Greenland and North America and far less favorable than that of Denmark, southern Canada and the lower 48 American states, respectively; the health of the indigenous peoples of the Russian north is poor, partly due to poverty and alcohol.
Article
Regulating Quality in the Water Sector: A Theoretical Perspective
Emmanuelle Auriol
Regulating quality is challenging because in public utilities such as water and sanitation, quality is multidimensional, is not always objectively measurable, and can be hard to verify, both ex ante and ex post. It is therefore useful to review the main insights from the New Economics of Regulation theoretical literature on quality provision to guide public policy. Focusing on formal utilities, this normative approach emphasizes the asymmetry of information between a regulator and the regulated companies. The analysis shows that when quality is verifiable, it can be included in a contract exactly like a quantity variable. Its provision, however, will be distorted as a result of regulated quantities also being distorted due to asymmetric information. When quality and quantity are complements, service quality ends up being lower because in the optimal regulatory contract, quantities are distorted downward for rent extraction. If quality is not verifiable but is observable by the users, the operator freely chooses its quality investment. It tends to underprovide quality when an improvement in quality raises the gross consumer surplus more than it increases the gross profit of sales because it does not take into account the nonmonetary benefit generated by its investment. It tends to overprovide quality otherwise. In order to correct these distortions, the regulator has to use a production allocation rule to simultaneously lower the informational rent and boost quality. The regulator has a single instrument to achieve the conflicting goals of rent extraction and quality provision. Quantities can be higher or lower than the first-best optimal levels depending on the correction needed to control quality. Finally, when quality is neither verifiable nor observable by consumers, as is typically the case with credence attributes such as those concerning process of production impacting security or pollution, the optimal level of quality investment from the firm’s perspective is zero. In this case, the easiest solution is often to impose a minimum standard and either rely on certification agencies to ensure that this minimum target is met or directly audit the quality investments made by the regulator. Finally, when improving the quality of water and sanitation services requires the creation of new infrastructure or institution, the high opportunity cost of public funds in developing countries raises the question of whether it is optimal to commit public funds for such investments. The analysis illuminates the trade-off between financing those investments with private funds and protecting consumer surplus.
Article
Religion, Aging, and Public Health
Jeff Levin and Ellen Idler
Religion, in both its personal and institutional forms, is a significant force influencing the health of populations across the life course. Decades of research have documented that expressions of faith and the practice of spiritual pursuits exhibit significantly protective effects for physical and mental health, psychological well-being, and population rates of morbidity, mortality, and disability. This finding has been observed across sociodemographic categories, across nations and cultures, across specific disease outcomes, and regardless of one’s religious affiliation. A salutary religious effect on health and well-being is especially apparent among older adults, but is also observed across generations and age cohorts. Moreover, this association has been persistently found for various religious indicators, including attendance at worship services, prayer and other private practices, subjective feelings of religiosity, and numerous measures of religious behaviors, attitudes, beliefs, and experiences. Finally, a protective or primary preventive effect of religion has been observed in clinical, epidemiologic, social, and behavioral studies, regardless of research design or methodology.
Faith-based organizations also have contributed to the health of populations, in partnerships or alliances with medical institutions and public health agencies, many of these dating back many decades. Examples include congregational health promotion and disease prevention programs and community-wide interventions, especially targeting the health and well-being of older congregants and those in less well-resourced communities, as well as faith–health partnerships in healthcare delivery, public health policymaking, and legislative advocacy for healthcare reform. Religious denominations and institutions also play a substantial role in global health development throughout the world, individually and in partnership with national health ministries, transnational medical mission organizations, and established nongovernmental agencies. These efforts focus on a wide range of goals and objectives, including building public health infrastructure, addressing ongoing environmental health needs, and responding to acute public health challenges and crises, such as infectious disease outbreaks. Constituencies include at-risk populations and cohorts throughout the life course, and programming ranges from perinatal care to maternal and child healthcare to geriatric medicine.
Article
Risky Sexual Behaviors: Trends Among Young People (10–24 Years) in Four East African Countries
Fredrick E. Makumbi, Sarah Nabukeera, Justine N. Bukenya, and Simon Peter Sebina Kibira
The future of sub-Saharan Africa depends on the health of young people (10–24 years) who form about one-third of the region’s population. This large population of young people is a potential asset for social-economic development if appropriate investments and social empowerment can be provided. Despite the vast opportunities, young people are faced with enormous social, economic, and health challenges. Young people’s health increasingly remains important especially with the use and misuse of narcotics (drugs and alcohol) a key risk factor for risky sexual behaviors (RSBs).
RSBs are defined as behaviors that increase one’s risk of contracting sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) and unintended pregnancies. RSBs include multiple sex partners, sex without a condom, alcohol use with sex, sex initiation before age 15, nonuse of modern contraceptives, and early marriage (before age 18 years).
RSBs are reportedly influenced by a number of factors including lack of access to accurate, customized HIV information and prevention services, socioeconomic reasons, lack of parental control, peer pressure, and lack of youth-friendly recreational facilities. The consequences or impact of RSB, especially among the adolescents and young people, include poor health (STIs including HIV/AIDS, unintended pregnancies, unsafe abortions, maternal deaths, and mental health such as psychological distress), and negative social and economic challenges (nonenrollment and nonretention in school and early child marriage).
Understanding the trends in RSBs can provide insights in how well available interventions and policies have minimized their consequences among adolescents, and lay a basis to further develop more innovative and effective strategies especially in low-income countries.
Article
The Role of Historically Black Colleges and Universities in Advancing Health Equity
Orlando L. Taylor, Nicole L. Retland, Briana Jeffreys, Elaine Meredith, Melissa E. Wynn, and Pamela L. Carter-Nolan
The end of the Civil War marked a period when America’s medical practitioners considered the Black populace to be unworthy of proper health care on par with that of its White populace. Although slavery had officially ended, its vestiges remained prevalent in the lives of formerly enslaved persons. Indeed, lingering health issues permeated the generations that have followed, such that diseases that are highly treatable have often resulted in premature illness and death. Historically, the health-care industry has even blamed the formerly enslaved and subsequent generations for their own health conditions.
In the early post–Civil War years, state and local statutes legalizing segregation in the American South (known as the Jim Crow laws) cemented these views and perpetuated unfair and unequal health-care conditions. In more recent years, COVID-19 exacerbated an already dire situation, and a disproportionate share of illness and death has occurred among African Americans and other underrepresented masses. Historically Black colleges and universities (HBCUs) can lead the way in bringing some semblance of equality to this situation. Primarily increasing the fiscal resources of HBCUs so that they can further advance the education of a more diverse health-care workforce is a critical component for providing culturally sensitive health care for the nation.
HBCUs already play a disproportionate role in these efforts andwill likely continue their role to effect much-needed change in the prevalence of treatable illnesses and deadly diseases among America’s Black population. While continuing their historic mission to educate the Black populace of the United States, resulting from generations of racial exclusionary and discriminatory practices by predominantly White institutions, HBCUs continue to provide compassionate culturally sensitive education in the public health-care field. Moreover, they provide real-time testimony for the nation’s higher education enterprise on how to provide equality in health-care education.
Article
Sex and Conception Probability
Justin C. Konje and Oladipo A. Ladipo
Central to the survival of any species is the ability to procreate. In most cases, procreation is sexual, involving a process that ensures appropriate and timed contact between the male and female gametes. Successful human reproduction is premised on sexual intercourse occurring at a time when there is a receptive endometrium as well as an ovum ready for fertilization by spermatozoa. This time window of the menstrual cycle known as the fertile or fecund window is poorly defined and highly variable from one individual to another. Furthermore, while spermatogenesis is a continuous process, the impact of too frequent intercourse (defined as that occurring more than every 2 to 3 days) on fertilization has often been thought to be associated with a decreased fertilization potential of spermatozoa. Current evidence challenges previously held views on the fertile window and how it is determined, the timing of intercourse and how it is related to conception and miscarriages, the length of the luteal phase, and the precise time period during which the chances of fertilization are highest in any given menstrual cycle. The ability of spermatozoa to survive in the female genital tract for 5 days means fertilization can occur up to 5 days from sexual intercourse. During each menstrual cycle, there is a window of 5 to 6 days for fertilization to occur, and this period is defined not by the length of the cycle but by the timing of ovulation, with the chances of fertilization highest with intercourse occurring 1 to 2 days before ovulation.
Article
Sexual and Reproductive Health in China
Qianling Zhou, Chu-Yao Jin, and Hai-Jun Wang
Databases of PubMed, Scopus, and China National Knowledge Infrastructure (CNKI) were used to search relevant articles on sexual and reproductive health (SRH) in China published from 2005 to the present (2021), based on the World Health Organization’s (WHO) Operational Framework on Sexual Health and Its Linkages to Reproductive Health. The following results were found. (a) SRH education and information among the Chinese were insufficient, in particular regarding contraception, pregnancy, and sexually transmitted diseases (STDs). Adolescents, migrants, and the rural population had insufficient knowledge of SRH. (b) Fertility care services were mainly available in large cities, in urban areas, and for married couples. Services targeted for rural-to-urban migrants, rural residents, and the disabled and elderly are needed. (c) A total of 22.4% of youths aged 15–24 had premarital sexual intercourse, and the age of first sexual intercourse was decreasing. Risky sexual behaviors included multiple partners, casual and commercial sex, and having sex after drinking alcohol. (d) The contraceptive practice rate of women aged 15–49 in China was higher than the world’s corresponding figure. However, contraceptive use among young people was low (only 32.3% among unmarried women). (e) Unmarried pregnancy induced by low contraceptive practice is a critical issue in China. (f) Induced abortion was the major consequence of unmarried pregnancy. The rate of induced abortion among the general population in 2016 was 28.13‰, and the rate among unmarried women was increasing annually. (g) There were 958,000 HIV-infected cases in China as of October 2019. Sexual transmission was the major transmission route of HIV-AIDS. More men than women were infected. Men having sex with men comprised the high-risk group of sexual transmission of HIV-AIDS. (h) Gender-based violence including intimate partner violence (IPV), sexual violence, sexual coercion, and child sexual abuse (CSA) might be underreported in China, since many victims were afraid to seek help as well as due to limited services. Legal and regulatory measures should therefore be taken to prevent and reduce gender-based violence. For future perspectives of SRH in China, it is important to pay attention to SRH education and services. An up-to-date national survey on SRH is needed to reflect the current situation and to capture changes over the past decade. Most of the current research has been conducted among adolescents, and more studies are needed among other groups, such as the disabled, the elderly, and homosexual populations.
Article
Sexual and Reproductive Health in India
Shireen Jejeebhoy, K. G. Santhya, and A. J. Francis Zavier
India has demonstrated its commitment to improving the sexual and reproductive health of its population. Its policy and program environment has shifted from a narrow focus on family planning to a broader orientation that stresses sexual and reproductive health and the exercise of rights. Significant strides have been made. The total fertility rate is 2.2 (2015–2016) and has reached replacement level in 18 of its 29 states. The age structure places the country in the advantageous position of being able to reap the demographic dividend. Maternal, neonatal, and perinatal mortality have declined, child marriage has declined steeply, contraceptive use and skilled attendance at delivery have increased, and HIV prevalence estimates suggest that the situation is not as dire as assumed earlier.
Yet there is a long way to go. Notwithstanding impressive improvements, pregnancy-related outcomes, both in terms of maternal and neonatal mortality and morbidity, remain unacceptably high. Postpartum care eludes many women. Contraceptive practice patterns reflect a continued focus on female sterilization, limited use of male methods, limited use of non-terminal methods, and persisting unmet need. The overwhelming majority of abortions take place outside of legally sanctioned provider and facility structures. Over one-quarter of young women continues to marry in childhood. Comprehensive sexuality education reaches few adolescents, and in general, sexual and reproductive health promoting information needs are poorly met. Access to and quality of services, as well as the exercise of informed choice are far from optimal. Inequities are widespread, and certain geographies, as well as the poor, the rural, the young, and the socially excluded are notably disadvantaged. Moving forward and, in particular, achieving national goals and SDGs 3 and 5 require multi-pronged efforts to accelerate the pace of change in all of these dimensions of health and rights.
Article
Social and Behavior Change Communication in Sexual and Reproductive Health
Suruchi Sood and Jose Rimon II
Social and behavior change communication (SBCC) is a core public health strategy not just for interventions designed to prevent, control, and treat disease but also for addressing the social determinants of health. Quality SBCC interventions are based on some common design, implementation, and evaluation best practices. The evidence base for using SBCC for sexual and reproductive health (SRH) includes, among other programs, family planning, maternal and neonatal health, and HIV/AIDS. Three global SBCC interventions—one on each of these topics—are presented as exemplars of best practices in public health communication programs designed to improve individual health behaviors and enable social change.
These SBCC programs employed cross-cutting approaches covering different levels of the social-ecological model while tackling multiple related health issues. While emphasizing individual roles and responsibilities, recognizing the importance of the cultural, social, and political context within which individuals live and work allowed these interventions to address social and gender norms. All three were theory-based and evidence-driven. They applied constructs from social and behavior change (SBC) theories to model causal pathways and stages or steps of behavior and community-level change. In addition, they relied on comprehensive, mixed-methods research throughout the project cycle. Other best practices included intersectoral collaboration and steps to ensure scale-up and sustainability.
Article
Social and Environmental Determinants of Health Among People With Disabilities
Eric Emerson
There is extensive evidence that people with disabilities experience significantly poorer health than their nondisabled peers. These are, in part, health inequities (differences in health status that are avoidable, unjust, and unfair) resulting from increased rates of exposure of people with disabilities to a range of well-established social (and environmental) determinants of poor health, including poverty, reduced access to effective education, lack of employment or employment under hazardous or precarious conditions, social disconnectedness, violence, discrimination, and poor healthcare. They also include environmental determinants of poor health that are a direct result of human activity (e.g., outdoor air pollution resulting from industrial processes and transportation). In addition, people with disabilities are often less likely than their peers to have access to many of the resources (power, wealth, social support, problem-solving skills) that have been linked to increased resilience in the face of adversity. As such, it would appear reasonable to expect that the health of people with disabilities is as likely, if not more so, to deteriorate, when exposed to social determinants, than the health of their nondisabled peers. Future research needs to focus on two key issues. First, given that most of the current evidence has been generated in high-income countries, it is critical for future research to focus on the situation of people with disabilities living in middle- and low-income countries. Second, more needs to be known about the determinants of the resilience and/or vulnerability of people with disabilities.
Some significant limitations remain in the current evidence base, but it is clear that existing knowledge is sufficient to drive and guide changes in policy and practice that could reduce the health inequities faced by people with disabilities. These include (a) improving the visibility of people with disabilities in local, national, and international health surveillance systems; (b) making “reasonable accommodations” to the operation of healthcare systems to ensure that people with disabilities are not exposed to systemic discrimination in access to and the quality of healthcare; and (c) ensuring that people with disabilities are included in and benefit equally from local and national strategies to reduce population levels of exposure to well-established social determinants of health.
Article
Social and Gender Norms Influencing Sexual and Reproductive Health: Conceptual Approaches, Intervention Strategies, and Evidence
Shaon Lahiri, Elizabeth Costenbader, and Jeffrey B. Bingenheimer
Research in diverse fields has examined how social and gender norms, broadly defined as informal rules of acceptable behavior in a given group or society, may influence sexual and reproductive health outcomes. One set of conceptual and empirical approaches has focused on perceptions of how commonly others perform a behavior and the extent to which others support or approve of the behavior. Another set of approaches has focused on how social norms emerge from structures of gender and power that characterize the social institutions within which individuals are embedded. Interventions intended to improve sexual and reproductive health outcomes by shifting social and gender norms have been applied across a wide range of populations and settings and to a diverse set of behaviors, including female genital mutilation/cutting, the use of modern contraceptive methods, and behavioral risk reduction for HIV. Norms-based intervention strategies have been implemented at multiple socioecological levels and have taken a variety of forms, including leveraging the influence of prominent individuals, using community activities or mass media to shift attitudes, and introducing legislation or policies that facilitate the changing of social norms.
Recent advances in social and gender norms scholarship include the integration of previously disparate conceptual and empirical approaches into a unified multilevel framework. Although challenges remain in measuring social and gender norms and studying their impacts on sexual and reproductive health-related behaviors across cultures, the research will continue to shape policies and programs that impact sexual and reproductive health globally.
Article
Social Medicine and the Social Sciences in Latin America: Conceptual Tensions for the Transformation of Public Health in the 20th Century
Arachu Castro
The development of public health in Latin America during the 20th century combined, early on, the social medicine framework on the social, political, and environmental origins of disease with the contributions of medical anthropological fieldwork. Despite the hegemony of the medical model, the surge of the preventive medicine framework further legitimized the involvement of social scientists in the study of the multicausality of disease. However, the limitations brought by the preventive medicine model’s lack of historical and political contextualization gave way to the Latin American social medicine movement, which was grounded in historical materialism, and the development of both critical epidemiology and critical medical anthropology.
Article
Street Science: Community Knowledge for Global Health Equity
Jason Corburn
Street science is the processes used by community residents to understand, document, and take action to address the environmental health issues they are experiencing. Street science is an increasingly essential process in global urban health, as more and more people live in complex environments where physical and social inequalities create cumulative disease burdens. Street science builds on a long tradition of critical public health that values local knowledge, participatory action research, and community-driven science, sometimes referred to as “citizen science.” Street scientists often partner with professional scientists, but science from the street does not necessarily fit into professional models, variables or other standards of positivist data. Street science is not one method, but rather an approach where residents are equally expert as professional scientists, and together they co-produce evidence for action. In this way, street science challenges conventional notions in global health and urban planning, which tend to divorce technical issues from their social setting and discourage a plurality of participants from engaging in everything from problem setting to decision-making. Street science does not romanticize local or community knowledge as always more accurate or superior to other ways of knowing and doing, but it also recognizes that local knowledge acts as an oppositional discourse that gives voice to the often silent suffering of disadvantaged people. At its best, street science can offer a framework for a new urban health science that incorporates community knowledge and expertise to ensure our cities and communities promote what is already working, confront the inequities experienced by the poor and vulnerable, and use this evidence to transform the physical and social conditions where people live, learn, work, and play.
Article
Substance Use and Use Disorders in Pregnancy in Two Cultural Contexts: The United States and Afghanistan
Elisabeth Johnson, Abdul Subor Momand, and Hendree E. Jones
Women in all countries use substances, and for some women, such use continues during pregnancy. When substance use impairs life functioning and becomes a use disorder, regardless of the type of substance, effective treatments are available (e.g., medication to treat opioid and alcohol use disorders and behavioral approaches to treat tobacco, stimulant, and other substances). In two very different cultural contexts, the United States and Afghanistan, pregnant women face common issues when using substances and seeking and/or receiving help for problem substance use. In both countries, and around the world, many women who have substance use disorders during and after pregnancy face tremendous stigma and discrimination. Yet, similarly, in both the United States and Afghanistan, when women receive integrated medical and behavioral health care for their substance use disorder, they and their children have more optimized opportunities for healthy life outcomes.
Article
Surveys in Low- and Middle-Income Countries
Madeleine Short Fabic, Yoonjoung Choi, and Fredrick Makumbi
Sexual and reproductive health (SRH) surveys around the world, especially in low- and middle-income countries, have been and continue to be the primary sources of data about individual-, community-, and population-level sexual and reproductive health. Beginning with the Knowledge, Attitudes, and Practices surveys of the late 1950s, SRH surveys have been crucial tools for informing public health programming, healthcare delivery, public policy, and more. Additionally, major demographic and health modeling and estimation efforts rely on SRH survey data, as have thousands of research studies. For more than half a century, surveys have met major SRH information needs, especially in low- and middle-income countries. And even as the world has achieved impressive information technology advances, increasing by orders of magnitude the depth and breadth of data collected and analyzed, the necessity and importance of surveys have not waned.
As of 2021, four major internationally comparable SRH survey platforms are operating in low- and middle-income countries—the Demographic and Health Surveys Program (DHS), Multiple-Indicator Cluster Survey (MICS), Population-Based HIV Impact Assessment (PHIA), and Performance Monitoring for Action (PMA). Among these platforms, DHS collects the widest range of data on population, health, and nutrition, followed by MICS. PHIA collects the most HIV-related data. And PMA’s family planning data are collected with the most frequency. These population-based household surveys are rich data sources, collecting data to measure a wide range of SRH indicators—from contraceptive prevalence to HIV prevalence, from cervical cancer screening rates to skilled birth delivery rates, from age at menarche to age at first sex, and more.
As with other surveys, SRH surveys are imperfect; selection bias, recall bias, social desirability bias, interviewer bias, and misclassification bias and error can represent major concerns. Furthermore, thorny issues persist across the decades, including perpetual historic, measurement, and methodological concerns. To provide a few examples with regard to history, because the major survey programs have historically been led by donors and multilateral organizations based in the Global North, survey content and implementation have been closely connected with donor priorities, which may not align with local priorities. Regarding measurement, maternal mortality data are highly valued and best collected through complete vital registration systems, but many low- and middle-income countries do not have complete systems and therefore rely on estimates collected through household surveys and censuses. And regarding methods, because most surveys offer only a snapshot in time, with the primary purpose of monitoring key indicators using a representative sample, most analyses of survey data can only show correlation and association rather than causation. Opportunities abound for ongoing innovation to address potential biases and persistent thorny issues.
Finally, the SHR field has been and continues to be a global leader for survey development and implementation. If past is prelude, SRH surveys will be invaluable sources of knowledge for decades to come.
Article
Ten Lessons From a Career in Global Health: Guidance to Those Considering a Life Working With the Poor Countries of the World
Jon Rohde
Global health, defined by the World Health Organization as “priority on improving health and achieving equity in health for all people worldwide,” is an expanded view of traditional public health. While utilizing many of the tools widely taught in schools of public health, its emphasis is both on reaching the poorest and most isolated populations and transferring knowledge and skills for their benefit. Extensive and continuous field interactions and collaboration with the populations for whom health interventions are intended to benefit are very important. Thus, immersion in local culture and society, language skills, and active listening are key attributes for a global health professional to acquire. These apply to local health workers as well as expatriates. A broad array of disciplinary insights, ranging from clinical medicine to social sciences, communication strategies, and team building, are often more valuable than a single technocentric expertise, enabling a more holistic approach to health problems. The ability to simplify suggested techniques and interventions and especially the ability to create a culturally understood logic behind biomedical explanations go a long way to establishing acceptance of health messages and advice. Introducing new ideas, habits, and procedures incrementally rather than in one large dose of instructions or training has more lasting impact on both trainees and the targeted population. Invariably, delegating both authority and responsibility to “lower-level” workers—that is, those closer to the people through tradition, familiarity, and geographic access—results in greater acceptability and uptake of desired behaviors. Learning in the field is best accomplished from observing and emulating mentor figures—those who best exemplify the attributes of a widely accepted and respected health leader. In time, one’s own role as a mentor for new recruits facilitates the transfer of attitudes and approaches that embody these important principles of global health work. In the end, one’s impact on communities will be measured by the people and institutions that one inspires and leaves to carry on the work into the future.
Article
The Demography of Fertility
Visseho Adjiwanou and Ben Malinga John
From the first billion people in the world in 1800 to the projected 9.7 billion people in 2050, the world’s population has passed through various stages. However, the different stages have not been the same for each global region or for every country within the same region. On one side of the spectrum is the fertility transition in Europe and North America, where the decline has been steady, with the median total fertility rate (TFR) declining from 2.80 children per woman in 1950–1955 to 1.66 in 2015–2020. In this region, childbearing is no longer the final goal of marriage, and this change has been accompanied by the emergence of new forms of union. The fertility rate is below the level of replacement in almost all the countries. On the other side of the spectrum is sub-Saharan Africa, where fertility has declined slowly and has stalled in various countries since the 2000s. The median TFR in the region declined from 6.51 children per woman in 1950–1955 to 4.72 in 2015–2020. In this region, this trend is associated with slower increase of the age at first marriage and in of the modern contraception. The fertility transition and its associated factors in the other regions of the world fluctuate between these two scenarios.
