Knowledge and attitudes of physiotherapy students at the University of the Western Cape towards obesity

Magister Scientiae (Physiotherapy) - MSc(Physio)The increasing prevalence of obesity in both developed and developing countries and its associated health risks have brought the issue of obesity prevention and management a public health debate. Health care professionals have been identified to have a role to play in directing the future of obesity management. However, among the numerous barriers for effective management of obesity is lack of knowledge of causes of obesity and negative attitudes towards obese patients by health care professionals. With limited or no studies available for the physiotherapy setting, the aim of the study was to determine the knowledge and attitudes of students of Physiotherapy at the University of the Western Cape, South Africa towards obese individual. A descriptive quantitative research design using a cross-sectional survey was used. One hundred and seventy five (175) students of Physiotherapy took part in the study using a convenience sampling technique. Data was collected by means of a structured, self-administered questionnaire adopted from the Obesity Risk Knowledge-10 scale, Beliefs About Obese Person scale and the Fat Phobia Scale. A response rate of 77.3% was obtained. Descriptive and inferential statistics were employed to describe the relationship and association between variables. Alpha level was set at 0.05. The mean age of the sample was 21.54 (SD = 4.903). Females constituted 73.5% and males 26.5% of the sample. The results showed that majority of the students of Physiotherapy (85%) reported having received no formal education regarding obesity.South Afric

The effect of a sports-based HIVv prevention programme on HIV risk related behaviours among high school learners

Philosophiae Doctor - PhDBackground: The Human Immunodeficiency virus (HIV) has become a global public health challenge amid the growing concern of adolescent risky sexual behaviour, influenced by biological and psycho-social factors. There is an increasing demand for adolescent sexual risk reduction interventions, especially in sub-Saharan Africa which remains the hub of HIV epidemic worldwide. Sport-based HIV prevention programme has been identified as one of the interventions, in addition to other approaches to provide young people with appropriate HIV knowledge and skills to either delay or reduce risk-taking behaviour. Despite the potential of sport-based programme for sexual risk reduction, there is limited information on how to adapt it to meet adolescent needs in terms of design, contents, and delivery. This information is necessary to provide sufficiently strong evidence to support widespread implementation of sport-based programme, especially in rural African schools. Therefore, the study aimed to measure the impact of a sport-based HIV prevention intervention in the reduction of HIV related sexual risk behaviour among rural high school learners aged 13-18. Method: The overall study design was a concurrent mixed method, utilizing both the quantitative and qualitative approach. The population for the quantitative and the qualitative studies was made up of two high schools in a predominantly “Coloured” community in Ceres. Two classes each were randomly selected from grades 8-10 in both intervention and control school. The intervention was developed through a process of focus group discussions with the Grassroot Soccer (GRS) staff and it was guided by the Social Cognitive Theory. The intervention was delivered to grade 8-10 learners by GRS peer facilitators using the GRS generation skillz curriculum that consists of 12-week sessions in the intervention school. Quantitative data were analysed with multivariate statistical techniques and qualitative data with thematic analysis approach. Results: The data that assessed the behavioural and protective factors to understand why learners in rural schools engage in risky sexual behaviour showed that about 27.2% of the learners reported being sexually active. Of the sexually active learners, 48.7% reported engaging in sex by 14 years or younger and nearly 42.2% reported multiple sexual partners with significant higher proportion of boys than girls. Nearly 55.2% of the sexually active learners reported irregular condom use and 46.3% did not use a condom at the last sexual encounter. The majority of the learners (87%) did not know their HIV status. Being male (OR = 6.60;95% C I = 1.62 – 26.84) and peer influence (OR = 3.01; 95% CI = 1.97-4.60) were the strongest predictors of reporting sexual intercourse and early sexual activities before the age 15 respectively. Though the knowledge of HIV was low, those with greater knowledge of HIV were more likely to use a condom at last the sexual encounter (OR = 1.22; 95% C I =1.03-1.44). The learners who participated in sport-based intervention were 1.43times likely to report higher self-efficacy to refuse sex compared to the control group (OR = 1.43; 95% C.I =1.07-1.92).The process evaluation indicated that the sport-based intervention was well received among the learners as it gave them free space to freely express themselves. Conclusion: The findings have shown that sport-based intervention can be successfully implemented in school and is a promising approach to reduce risks associated with risky sexual behaviour in learners. However, the quality of the programme delivery was hampered by irregular session‟s schedule and language of instruction. The process suggests for a longer exposure period and because of social-cultural diversity, learners must be provided with the ownership of the programme in schools

Cost-effectiveness of Self-managed Program Versus Usual Physiotherapy Care of Patients With Knee Osteoarthritis in Nigeria

Objectives: This study aims to compare, from a patient’s perspective, the cost-effectiveness between a self-managed program and usual physiotherapy care in treating knee osteoarthritis. Methods: The study participants were assigned into two groups: group I received a weekly physiotherapy treatment plus instructions on self-management skills in goal setting, pain management, exercise, healthy eating, and dealing with fatigue (self-managed group); group II had a physiotherapy session three times a week (usual care group). The osteoarthritis cost and consequence and European quality of life-5 dimension (EQ-5D) were used to generate utility scores. The health effects measure of quality-adjusted life year (QALY) was obtained, and an incremental cost-effective ratio was calculated. Cost-effectiveness was determined by plotting a cost-effectiveness plane of incremental cost against QALY obtained. Results: After 8 weeks of intervention, the self-managed group recorded more significant improvements in pain level, function, and health-related quality of life than the usual care group. Clinical consultation costs (Mean±SD NGN [Nigerian naira]=1800±979), physiotherapy treatment costs (Mean±SD NGN=4000±00), and transportation costs (Mean±SD NGN=1,940±1,150) were less for the self-managed group than the usual care group. Imaging (x-ray) and drug costs did not differ significantly between groups. The QALYs gained over the 8-week intervention period was 0.13 for the self-management group compared to 0.11 for the usual care group.  Discussion: From the patient’s perspective, a self-managed program was cost-effective and cheaper for healthcare resource use. Physiotherapists may adopt the program to reduce out-of-pocket expenses for patients with knee osteoarthritis

Prevalence, associated factors and predictors of post stroke pneumonia in a Nigerian population : a retrospective study

Abstract: Objectives: Stroke can trigger an immune response that can raise the risk of infection, alter tracheal epithelium, reduce pulmonary clearance and impair secretions drainage capacity. Infection, altered tracheal epithelium, reduced pulmonary clearance, impaired secretions drainage capacity and aspiration can cause pneumonia after stroke. The aim of this study is to find out the prevalence of post stroke pneumonia in a Nigerian population and factors that are associated with it.Materials and Method: Study data was extracted from the case files of patients with stroke who were managed between 1(st) January, 2011 and 1(st) February, 2021 in the study setting.Results: The result showed that, there was a record of only 591 patients with stroke (mean age, 62.78 +/- 14.86 years) who were managed in the two hospitals during the period of the study. Out of this number, only 102 (17.3 %) had pneumonia. Presence of the pneumonia was only significantly (p < 0.05) associated with sex, type of stroke, lower limb muscle power, and outcome (died or alive). However, only those with ischaemic stroke are less likely to have pneumonia (Odds ratio= 0.467; CI: 0.275 to 0.791, p= 0.005), and patients who survived the stroke and are alive are less likely to develop pneumonia (Odds ratio= 0.150; CI: 0.092 to 0.245, p < 0.001).Conclusions: Pneumonia occurs to a large extent after stroke. Therefore, it is important measures are taken to prevent it or complications arising from it especially in those with a hemorrhagic stroke

Global Burden of Cardiovascular Diseases and Risks, 1990-2022

Age-standardized CVD mortality rates by regionranged from 73.6 per 100,000 in High-income Asia Pacific to432.3 per 100,000 in Eastern Europe in 2022. Global CVDmortality decreased by 34.9% from 1990 to 2022. Ischemicheart disease had the highest global age-standardized DALYsof all diseases at 2,275.9 per 100,000. Intracerebralhemorrhage and ischemic stroke were the next highest CVDcauses for age-standardized DALYs. Age-standardized CVDprevalence ranged from 5,881.0 per 100,000 in South Asia to11,342.6 per 100,000 in Central Asia. High systolic bloodpressure accounted for the largest number of attributableage-standardized CVD DALYs at 2,564.9 per 100,000globally. Of all risks, household air pollution from solid fuelshad the largest change in attributable age-standardizedDALYs from 1990 to 2022 with a 65.1% decrease

Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950–2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

Background: Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020–21 COVID-19 pandemic period. Methods: 22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution. Findings: Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5–65·1] decline), and increased during the COVID-19 pandemic period (2020–21; 5·1% [0·9–9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98–5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50–6·01) in 2019. An estimated 131 million (126–137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7–17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8–24·8), from 49·0 years (46·7–51·3) to 71·7 years (70·9–72·5). Global life expectancy at birth declined by 1·6 years (1·0–2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67–8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4–52·7]) and south Asia (26·3% [9·0–44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations. Interpretation: Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic. Funding: Bill &amp; Melinda Gates Foundation.</p

Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950–2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BackgroundEstimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020–21 COVID-19 pandemic period.Methods22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution.FindingsGlobal all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5–65·1] decline), and increased during the COVID-19 pandemic period (2020–21; 5·1% [0·9–9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98–5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50–6·01) in 2019. An estimated 131 million (126–137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7–17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8–24·8), from 49·0 years (46·7–51·3) to 71·7 years (70·9–72·5). Global life expectancy at birth declined by 1·6 years (1·0–2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67–8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4–52·7]) and south Asia (26·3% [9·0–44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations.InterpretationGlobal adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic

Burden of disease scenarios for 204 countries and territories, 2022–2050: a forecasting analysis for the Global Burden of Disease Study 2021

BackgroundFuture trends in disease burden and drivers of health are of great interest to policy makers and the public at large. This information can be used for policy and long-term health investment, planning, and prioritisation. We have expanded and improved upon previous forecasts produced as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) and provide a reference forecast (the most likely future), and alternative scenarios assessing disease burden trajectories if selected sets of risk factors were eliminated from current levels by 2050.MethodsUsing forecasts of major drivers of health such as the Socio-demographic Index (SDI; a composite measure of lag-distributed income per capita, mean years of education, and total fertility under 25 years of age) and the full set of risk factor exposures captured by GBD, we provide cause-specific forecasts of mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) by age and sex from 2022 to 2050 for 204 countries and territories, 21 GBD regions, seven super-regions, and the world. All analyses were done at the cause-specific level so that only risk factors deemed causal by the GBD comparative risk assessment influenced future trajectories of mortality for each disease. Cause-specific mortality was modelled using mixed-effects models with SDI and time as the main covariates, and the combined impact of causal risk factors as an offset in the model. At the all-cause mortality level, we captured unexplained variation by modelling residuals with an autoregressive integrated moving average model with drift attenuation. These all-cause forecasts constrained the cause-specific forecasts at successively deeper levels of the GBD cause hierarchy using cascading mortality models, thus ensuring a robust estimate of cause-specific mortality. For non-fatal measures (eg, low back pain), incidence and prevalence were forecasted from mixed-effects models with SDI as the main covariate, and YLDs were computed from the resulting prevalence forecasts and average disability weights from GBD. Alternative future scenarios were constructed by replacing appropriate reference trajectories for risk factors with hypothetical trajectories of gradual elimination of risk factor exposure from current levels to 2050. The scenarios were constructed from various sets of risk factors: environmental risks (Safer Environment scenario), risks associated with communicable, maternal, neonatal, and nutritional diseases (CMNNs; Improved Childhood Nutrition and Vaccination scenario), risks associated with major non-communicable diseases (NCDs; Improved Behavioural and Metabolic Risks scenario), and the combined effects of these three scenarios. Using the Shared Socioeconomic Pathways climate scenarios SSP2-4.5 as reference and SSP1-1.9 as an optimistic alternative in the Safer Environment scenario, we accounted for climate change impact on health by using the most recent Intergovernmental Panel on Climate Change temperature forecasts and published trajectories of ambient air pollution for the same two scenarios. Life expectancy and healthy life expectancy were computed using standard methods. The forecasting framework includes computing the age-sex-specific future population for each location and separately for each scenario. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline.FindingsIn the reference scenario forecast, global and super-regional life expectancy increased from 2022 to 2050, but improvement was at a slower pace than in the three decades preceding the COVID-19 pandemic (beginning in 2020). Gains in future life expectancy were forecasted to be greatest in super-regions with comparatively low life expectancies (such as sub-Saharan Africa) compared with super-regions with higher life expectancies (such as the high-income super-region), leading to a trend towards convergence in life expectancy across locations between now and 2050. At the super-region level, forecasted healthy life expectancy patterns were similar to those of life expectancies. Forecasts for the reference scenario found that health will improve in the coming decades, with all-cause age-standardised DALY rates decreasing in every GBD super-region. The total DALY burden measured in counts, however, will increase in every super-region, largely a function of population ageing and growth. We also forecasted that both DALY counts and age-standardised DALY rates will continue to shift from CMNNs to NCDs, with the most pronounced shifts occurring in sub-Saharan Africa (60·1% [95% UI 56·8–63·1] of DALYs were from CMNNs in 2022 compared with 35·8% [31·0–45·0] in 2050) and south Asia (31·7% [29·2–34·1] to 15·5% [13·7–17·5]). This shift is reflected in the leading global causes of DALYs, with the top four causes in 2050 being ischaemic heart disease, stroke, diabetes, and chronic obstructive pulmonary disease, compared with 2022, with ischaemic heart disease, neonatal disorders, stroke, and lower respiratory infections at the top. The global proportion of DALYs due to YLDs likewise increased from 33·8% (27·4–40·3) to 41·1% (33·9–48·1) from 2022 to 2050, demonstrating an important shift in overall disease burden towards morbidity and away from premature death. The largest shift of this kind was forecasted for sub-Saharan Africa, from 20·1% (15·6–25·3) of DALYs due to YLDs in 2022 to 35·6% (26·5–43·0) in 2050. In the assessment of alternative future scenarios, the combined effects of the scenarios (Safer Environment, Improved Childhood Nutrition and Vaccination, and Improved Behavioural and Metabolic Risks scenarios) demonstrated an important decrease in the global burden of DALYs in 2050 of 15·4% (13·5–17·5) compared with the reference scenario, with decreases across super-regions ranging from 10·4% (9·7–11·3) in the high-income super-region to 23·9% (20·7–27·3) in north Africa and the Middle East. The Safer Environment scenario had its largest decrease in sub-Saharan Africa (5·2% [3·5–6·8]), the Improved Behavioural and Metabolic Risks scenario in north Africa and the Middle East (23·2% [20·2–26·5]), and the Improved Nutrition and Vaccination scenario in sub-Saharan Africa (2·0% [–0·6 to 3·6]).InterpretationGlobally, life expectancy and age-standardised disease burden were forecasted to improve between 2022 and 2050, with the majority of the burden continuing to shift from CMNNs to NCDs. That said, continued progress on reducing the CMNN disease burden will be dependent on maintaining investment in and policy emphasis on CMNN disease prevention and treatment. Mostly due to growth and ageing of populations, the number of deaths and DALYs due to all causes combined will generally increase. By constructing alternative future scenarios wherein certain risk exposures are eliminated by 2050, we have shown that opportunities exist to substantially improve health outcomes in the future through concerted efforts to prevent exposure to well established risk factors and to expand access to key health interventions.FundingBill & Melinda Gates Foundation.</p