Inadequate water, sanitation and hygiene in the South Pacific: how might it be impacting children?

It is detrimental to anyone’s health to live with conditions of inadequate water, sanitation and hygiene (WaSH). Research suggests that the impact is greatest on children, and that poor WaSH conditions during the formative years can lead to decreased physical, mental and social well-being throughout one’s life. Little research has investigated how such poor WaSH conditions are negatively impacting children in the South Pacific region, and hence contributing to disease and social burden. To increase children’s opportunities to develop physically and intellectually in a healthy and sustained manner, it is important that practitioners take a holistic approach to improving WaSH by acknowledging it as a core component of environmental health

Water Exchange Systems

In this chapter we present an exchange systems approach to evaluate the potential of water markets to provide sustainable and equitable access for all. The approach is sourced from marketing theory, which in turn is constructed on a social exchange and general systems theory platform (Bagozzi, 1978; Layton, 2007). The exchange systems concept offers a systemic view of exchange that allows for the integration of broader economic and social considerations into the design of water markets. We illustrate different types of exchange systems to offer the reader a broader perspective on water markets. Such a perspective can enable new thinking in how water provision systems can contribute to improved human health. We begin with a general introduction to the marketing exchange concept and subsequently trace its evolution to exchange systems

Drivers of menstrual material disposal and washing practices: A systematic review

Background Disposal and washing facilities and services for menstrual materials are often designed based upon technical specifications rather than an in-depth understanding of what drives peoples’ choices of practices. Objectives and data sources This systematic review identified and summarised the main behavioural drivers pertaining to the choice of disposal and washing practices of menstrual materials through the thematic content analysis and study appraisal of 82 publications (80 studies) on menstrual health and hygiene published since 1999, reporting the outcomes of primary research across 26 countries. Results Disposal and washing behaviours are primarily driven by the physical state of sanitation facilities; however, this is intrinsically linked to taboos surrounding and knowledge of menstruation. Implications Using reasons given for disposal and washing practices by menstruators or those who know them well, or inferred by authors of the reviewed studies, we identify the key considerations needed to design facilities and services which best suit the desired behaviours of both planners and those who menstruate. Inclusivity The term menstruators is used throughout to encompass all those mentioned in the studies reviewed (girls and women); although no studies explicitly stated including non-binary or transgender participants, this review uses inclusive language that represents the spectrum of genders that may experience menstruation. Registration The review protocol is registered on PROSPERO: 42019140029

Social and Environmental Justice for Communities of the Mekong River

During the mid-twentieth century the construction of hydroelectric dams in developing countries became a contentious issue in economic and political arenas. Governments and pro-damming parties, particularly those with a direct commercial interest, often consider the dams to be necessary for economic growth, as well as being in the national interest. Others directly impacted by the altered hydrology and ecology, as well as experts concerned with environmental and demographic impacts, are less sure about the benefits of hydro-electric dams. Concerns about the environmental and human impacts of dams are heightened on a waterway such as the Mekong River, which flows through six sovereign states. When the impacts are to be felt across entire regions, ensuring just outcomes for all the stakeholders is crucial to long-term regional political stability and economic wellbeing. Engineers are pivotal in the design and construction of dams, and engineering teams also play an increasingly important role in assisting communities impacted by the altered hydrology. This article focuses on the community and environmental implications of engineering decisions on the Mekong River, and suggests ways in which engineers involved in dam design and construction can play a role in ensuring that socially and environmentally just outcomes are achieve

Maximum tumor diameter is associated with event-free survival in PET-negative patients with stage I/IIA Hodgkin lymphoma.

Introduction: the high cure rates achieved in early-stage (ES) Hodgkin lymphoma (HL) are one of the great successes of hemato-oncology, but late treatment-related toxicity undermines long-term survival. Improving overall survival and quality of life further will require maintaining disease control while potentially de-escalating chemotherapy and/or omitting radiotherapy to reduce late toxicity. Accurate stratification of patients is required to facilitate individualized treatment approaches. Response assessment using 18F-fluorodeoxyglucose positron emission tomography (PET) is a powerful predictor of outcome in HL,1,2 and has been used in multiple studies, including the United Kingdom National Cancer Research Institute Randomised Phase III Trial to Determine the Role of FDG–PET Imaging in Clinical Stages IA/IIA Hodgkin’s Disease (UK NCRI RAPID) trial, to investigate whether patients achieving complete metabolic remission (CMR) can be treated with chemotherapy alone.3-5 These PET-adapted trials have demonstrated that omitting radiotherapy results in higher relapse rates, but without compromising overall survival.3-5 For the 75% of patients who achieved CMR in RAPID, neither baseline clinical risk stratification (favorable/unfavorable) nor PET (Deauville score 1/2) predicted disease relapse; additional biomarkers are needed.1 Tumor bulk has long been recognized as prognostic in HL,1,6 but there remains uncertainty about the significance and definition of bulk in the era of PET-adapted treatment.7 We performed a subsidiary analysis of RAPID to assess the prognostic value of baseline maximum tumor dimension (MTD) in patients achieving CMR. Methods: ee have previously reported the RAPID trial design, primary results, and outcomes according to pretreatment risk stratification and PET score.1,3 Patients were aged 16 to 75 years with untreated ES-HL and without B-symptoms or mediastinal bulk (mass > 1/3 internal mediastinal diameter at T5/6).6 Metabolic response after 3 cycles of ABVD chemotherapy (doxorubicin, bleomycin, vinblastine, and dacarbazine) was centrally assessed using PET (N = 562). Patients with CMR (ie, Deauville score 1-2) were randomly assigned to receive involved field radiotherapy (IFRT; n = 208) or no further therapy (NFT; n = 211). PET-positive patients (score, 3-5; n = 143) received a fourth cycle of ABVD and IFRT. Baseline disease assessment was performed by computed tomography, and bidimensional target lesion measurements were reported by local radiologists in millimeters. The association of baseline MTD with HL-related event-free survival (EFS: progression or HL-related death) and progression-free survival (PFS) (progression or any-cause death) was assessed using Kaplan-Meier and Cox regression analyses. Non-HL deaths were either related to primary treatment toxicity or occurred in HL remission.1 United Kingdom ethical approval for the RAPID trial was via the UK Multicentre Research ethics committee. Results and discussion: baseline patient characteristics have been previously described.1 Median age was 34 years (range, 16-75 years); 184 (37.4%) of 492 patients had unfavorable risk by European Organisation for Research and Treatment of Cancer criteria, and 155 (32.3%) of 480 by German Hodgkin Study Groupcriteria. Median MTD for patients achieving CMR was 3.0 cm (interquartile range, 2.0-4.0 cm) and 3.0 cm (interquartile range, 1.8-4.5 cm) in the NFT and IFRT groups, respectively, whereas PET-positive patients had a median MTD of 3.9 cm (interquartile range, 2.8-5.1 cm). After a median follow-up of 61.6 m, 44 HL progression events occurred: 21 NFT, 9 IFRT and 14 PET-positive. No patient received salvage treatment without documented progression. Only 5 HL-related deaths occurred (1 IFRT, 4 PET-positive), and 12 non-HL deaths (4 NFT, 6 IFRT, 2 PET-positive).1 For patients with CMR (N = 419), there was a strong association between MTD and EFS (hazard ratio [HR], 1.19; 95% confidence interval [CI], 1.02-1.39; P = .02), adjusting for treatment group, with an approximate 19% increase in HL risk per centimeter increase in MTD. The association was similar in both treatment groups (NFT HR, 1.20 [95% CI, 0.99-1.44; P = .06]; IFRT HR, 1.19 [95% CI, 0.92-1.55; P = .19]). The observed effect sizes did not markedly change after adjusting for baseline clinical risk factors, and similar results were observed for PFS (supplemental Table 1). In contrast, for PET-positive patients, there was no association between MTD and EFS (HR, 0.88; 95% CI, 0.70-1.11; P = .29) or PFS (HR, 0.87; 95% CI, 0.70-1.08; P = .21). In an exploratory analysis within the NFT group, MTD was dichotomized using increasing 1-cm intervals to investigate the relationship between MTD thresholds and EFS. The largest effect size was observed with an MTD threshold of ≥5 cm (Table 1). Similar results were observed for PFS; this threshold also performed best in time-dependent receiver operating characteristic curve analyses. It was not possible to assess MTD thresholds in the IFRT group with only 9 events. Among all randomized patients, 79 (18.9%) had MTD of ≥5 cm, the majority with mediastinal (n = 43), supraclavicular (n = 17), or cervical (n = 16) locations. Five-year EFS for patients with MTD of ≥5 cm randomly assigned to NFT and IFRT was 79.3% (n = 39; 95% CI, 66.6%-92.0%) and 94.9% (n = 40; 95% CI, 88.0%-100%), respectively (P = .03; Figure 1)

Some lessons learned from engaging in WaSH participatory action research in Melanesian informal settlements

In Melanesian countries there has been a large flux of people from rural to urban and peri-urban areas, resulting an in increased number living in informal settlements. These settlements often lack connections to mains water and sewerage lines and formal solid waste collection. Our project used a participatory action research (PAR) approach to work in partnership with informal settlement communities and enabling actors to achieve the self-determined WaSH conditions which participants felt would improve the well-being of those living in informal settlements. Because the PAR approach encourages reflection and adaptation, we learned lessons that were incorporated into the design of ongoing and future processes, and this paper presents five such lessons which we judge to be of practical use for WaSH enabling actors

Sustainable sanitation jobs: prospects for enhancing the livelihoods of pit-emptiers in Bangladesh

Manual pit-emptying – the removal of faecal sludge from pits and tanks using hands or basic tools – is a widespread practice in Bangladesh, and in other low- and middle-income countries. Despite this, little is known about the livelihoods of pit-emptiers. This paper analyses data from six cases of pit-emptying in three cities in Bangladesh, across three different operational modes: private cooperatives, government employees and self-employed workers. These cases describe the experiences of emptiers from diverse socio-economic, religious and ethnic backgrounds, operating across a formal–informal spectrum. We find that government employees and self-employed groups are deprived of basic rights, fear a loss of income brought about by mechanisation and cannot access alternative livelihoods. While the status of emptiers in private cooperatives has improved recently due to the support of governmental oranisations (GOs) and non-governmental organisations (NGOs), the extent to which these cooperatives are sustainable, without the ongoing support of NGOs or GOs, remains unclear. In all modes, sustainable livelihoods are hindered by deep-rooted social and financial barriers. Organisations can support pit-emptiers by designing sanitation interventions that prioritise the human right to decent work, focussing not only on the beneficiaries of universal sanitation, but also on those who work to implement this ambitious goal

Experiences of menstruation in high income countries: A systematic review, qualitative evidence synthesis and comparison to low- and middle-income countries

Background There is growing recognition of the importance of menstruation in achieving health, education, and gender equality for all. New policies in high income countries (HICs) have responded to anecdotal evidence that many struggle to meet their menstrual health needs. Qualitative research has explored lived experiences of menstruating in HICs and can contribute to designing intervention approaches. To inform the growing policy attention to support people who menstruate, here we review and synthesise the existing research. Methods and findings Primary, qualitative studies capturing experiences of menstruation in HICs were eligible for inclusion. Systematic database and hand searching identified 11485 records. Following screening and quality appraisal using the EPPI-Centre checklist, 104 studies (120 publications) detailing the menstrual experiences of over 3800 individuals across sixteen countries were included. We used the integrated model of menstrual experiences developed from studies in low- and middle-income countries (LMICs) as a starting framework and deductively and inductively identified antecedents contributing to menstrual experiences; menstrual experiences themselves and impacts of menstrual experiences. Included studies described consistent themes and relationships that fit well with the LMIC integrated model, with modifications to themes and model pathways identified through our analysis. The socio-cultural context heavily shaped menstrual experiences, manifesting in strict behavioural expectations to conceal menstruation and limiting the provision of menstrual materials. Resource limitations contributed to negative experiences, where dissatisfaction with menstrual practices and management environments were expressed along with feelings of disgust if participants felt they failed to manage their menstruation in a discrete, hygienic way. Physical menstrual factors such as pain were commonly associated with negative experiences, with mixed experiences of healthcare reported. Across studies participants described negative impacts of their menstrual experience including increased mental burden and detrimental impacts on participation and personal relationships. Positive experiences were more rarely reported, although relationships between cis-women were sometimes strengthened by shared experiences of menstrual bleeding. Included studies reflected a broad range of disciplines and epistemologies. Many aimed to understand the constructed meanings of menstruation, but few were explicitly designed to inform policy or practice. Few studies focused on socioeconomically disadvantaged groups relevant to new policy efforts. Conclusions We developed an integrated model of menstrual experience in HICs which can be used to inform research, policy and practice decisions by emphasising the pathways through which positive and negative menstrual experiences manifest

Water, sanitation and hygiene systems in Pacific Island schools to promote the health and education of girls and children with disability: a systematic scoping review

Water, sanitation and hygiene (WASH) systems in schools contribute to successful education by promoting good health and supporting school attendance. Girl students and students with disability face significant challenges when there are inadequate WASH systems. Pacific Island Countries and Territories (PICTs) have some of the lowest levels of improved WASH systems on earth. The aim of this review was to document the characteristics and effectiveness of approaches to improve WASH systems that promote the health and education of girl students, and students with disability in PICTs. This systematic scoping review comprehensively searched peer-reviewed and grey literature about WASH, PICTs, schoolgirls and students with disability. At best, there are only fleeting mentions in the grey literature about WASH and disability in schools in PICTs. Inclusion and exclusion criteria resulted in 12 publications being included: 1 review; 7 original research; 4 commentaries/project reports. A holistic approach to WASH in schools in PICTs must consider how the entire school WASH system can be inclusive of girls and children with disability. Incorporating local PICT learning epistemologies (ways of knowing) and local PICT pedagogies (ways of learning) are required to ensure new WASH systems reduce existing inequalities for girls and students with disability