A planetary health model for reducing exposure to faecal contamination in urban informal settlements: Baseline findings from Makassar, Indonesia

Daniel Reidpath - ORCID: 0000-0002-8796-0420 https://orcid.org/0000-0002-8796-0420Background The intense interactions between people, animals and environmental systems in urban informal settlements compromise human and environmental health. Inadequate water and sanitation services, compounded by exposure to flooding and climate change risks, expose inhabitants to environmental contamination causing poor health and wellbeing and degrading ecosystems. However, the exact nature and full scope of risks and exposure pathways between human health and the environment in informal settlements are uncertain. Existing models are limited to microbiological linkages related to faecal-oral exposures at the individual level, and do not account for a broader range of human-environmental variables and interactions that affect population health and wellbeing. Methods We undertook a 12-month health and environmental assessment in 12 flood-prone informal settlements in Makassar, Indonesia. We obtained caregiver-reported health data, anthropometric measurements, stool and blood samples from children < 5 years, and health and wellbeing data for children 5–14 years and adult respondents. We collected environmental data including temperature, mosquito and rat species abundance, and water and sediment samples. Demographic, built environment and household asset data were also collected. We combined our data with existing literature to generate a novel planetary health model of health and environment in informal settlements. Results Across the 12 settlements, 593 households and 2764 participants were enrolled. Two-thirds (64·1%) of all houses (26·3–82·7% per settlement) had formal land tenure documentation. Cough, fever and diarrhoea in the week prior to the survey were reported among an average of 34.3%, 26.9% and 9.7% of children aged < 5 years, respectively; although proportions varied over time, prevalence among these youngest children was consistently higher than among children 5–14 years or adult respondents. Among children < 5 years, 44·3% experienced stunting, 41·1% underweight, 12.4% wasting, and 26.5% were anaemic. There was self- or carer-reported poor mental health among 16.6% of children aged 5–14 years and 13.9% of adult respondents. Rates of potential risky exposures from swimming in waterways, eating uncooked produce, and eating soil or dirt were high, as were exposures to flooding and livestock. Just over one third of households (35.3%) had access to municipal water, and contamination of well water with E. coli and nitrogen species was common. Most (79·5%) houses had an in-house toilet, but no houses were connected to a piped sewer network or safe, properly constructed septic tank. Median monthly settlement outdoor temperatures ranged from 26·2 °C to 29.3 °C, and were on average, 1·1 °C warmer inside houses than outside. Mosquito density varied over time, with Culex quinquefasciatus accounting for 94·7% of species. Framed by a planetary health lens, our model includes four thematic domains: (1) the physical/built environment; (2) the ecological environment; (3) human health; and (4) socio-economic wellbeing, and is structured at individual, household, settlement, and city/beyond spatial scales. Conclusions Our planetary health model includes key risk factors and faecal-oral exposure pathways but extends beyond conventional microbiological faecal-oral enteropathogen exposure pathways to comprehensively account for a wider range of variables affecting health in urban informal settlements. It includes broader ecological interconnections and planetary health-related variables at the household, settlement and city levels. It proposes a composite framework of markers to assess water and sanitation challenges and flood risks in urban informal settlements for optimal design and monitoring of interventions.https://doi.org/10.1016/j.envint.2021.106679155pubpu

Study design, rationale and methods of the Revitalising Informal Settlements and their Environments (RISE) study: a cluster randomised controlled trial to evaluate environmental and human health impacts of a water-sensitive intervention in informal settlements in Indonesia and Fiji

Introduction: Increasing urban populations have led to the growth of informal settlements, with contaminated environments linked to poor human health through a range of interlinked pathways. Here, we describe the design and methods for the Revitalising Informal Settlements and their Environments (RISE) study, a transdisciplinary randomised trial evaluating impacts of an intervention to upgrade urban informal settlements in two Asia-Pacific countries. Methods and analysis: RISE is a cluster randomised controlled trial among 12 settlements in Makassar, Indonesia, and 12 in Suva, Fiji. Six settlements in each country have been randomised to receive the intervention at the outset; the remainder will serve as controls and be offered intervention delivery after trial completion. The intervention involves a water-sensitive approach, delivering site-specific, modular, decentralised infrastructure primarily aimed at improving health by decreasing exposure to environmental faecal contamination. Consenting households within each informal settlement site have been enrolled, with longitudinal assessment to involve health and well-being surveys, and human and environmental sampling. Primary outcomes will be evaluated in children under 5 years of age and include prevalence and diversity of gastrointestinal pathogens, abundance and diversity of antimicrobial resistance (AMR) genes in gastrointestinal microorganisms and markers of gastrointestinal inflammation. Diverse secondary outcomes include changes in microbial contamination; abundance and diversity of pathogens and AMR genes in environmental samples; impacts on ecological biodiversity and microclimates; mosquito vector abundance; anthropometric assessments, nutrition markers and systemic inflammation in children; caregiver-reported and self-reported health symptoms and healthcare utilisation; and measures of individual and community psychological, emotional and economic well-being. The study aims to provide proof-of-concept evidence to inform policies on upgrading of informal settlements to improve environments and human health and well-being. Ethics: Study protocols have been approved by ethics boards at Monash University, Fiji National University and Hasanuddin University. Trial registration number: ACTRN12618000633280; Pre-results

Green Infrastructure for Sanitation in Settlements in the Global South: A Narrative Review of Socio-Technical Systems

In the developing economies of the Global South, a fundamental challenge in the transition of settlements from rural or periurban to urban is increased environmental contamination as a result of poor sanitation and sanitation management. With governments’ limited ability to connect all neighbourhoods to a city’s existing municipal water, sewerage and other services, decentralised approaches using green infrastructure offer potential to address this challenge. In addition, green infrastructure might facilitate a move towards a holistic response to manage the full water cycle. This paper presents a narrative review of green infrastructure projects, involving constructed wetlands or their variants for wastewater treatment, within vulnerable communities in the Global South. It describes the scale and scope of each project, identifies the challenges of implementation, and reflects on their outcomes for different stakeholder groups. The review demonstrates that decentralised sanitation programs using constructed wetlands for wastewater treatment can provide a range of advantages/benefits/services, dependant on the specific sociocultural, political and biogeophysical contexts of each. Issues of governance and sociocultural appropriateness, rather than technical issues, challenged the implementation of green infrastructure for sanitation in these projects. Projects must be a collaboration between the government, nongovernment organisations and the community. Whether the project is organised from top-down or bottom-up, community consultation is essential. Context will determine the role of the community in the consultation process and the type of information required to guide the design, implementation and governance of the system. In every project to provide decentralised sanitation systems, the community must be participants, not simply beneficiaries

Mapping an alternative community river: the case of the Ciliwung

Dense, self-built settlements along riverbanks within Asian cities are often excluded from the planning realm, which ensures governments lack knowledge of how particular communities function. The magnitude of land area and population, dynamic local economies, organic policy making processes, and scarcity and consistency of data challenge research on flood impacts and possible solutions in Asian cities. Resultantly, a deeper understanding of alternative and more dynamic forms of environmental management is necessary. The focus of this paper is to analyze the usefulness and challenges of participatory mapping in relation to urban floods, particularly community mapping and crowd-sourced mapping. This analysis is based on the assumption of participatory mapping discourse that participatory mapping increases communities\u27 negotiation power to improve their livelihood. This paper employs participant observation and ethnographic interviews within the Ciliwung River corridor in Jakarta. Specifically it focuses on activists and residents in river communities in relation to participatory community mapping exercises conducted since 2012 and a new crowd-sourced flood mapping system launched in December 2014. Participatory community mapping and crowd-sourced flood mapping, as two forms of community-based mapping approaches to floods, are viewed as potential tools to overcome urban flood hazards while raising disaster awareness among city residents. Community mapping is a method of visualizing a neighborhood\u27s communal memories and embedded power relations, while a crowd-sourced flood map visualizes vulnerabilities and may become a tool for information sharing for the betterment of the spatially and socially fragmented city

Key mechanisms of a gender and socially inclusive community engagement and participatory design approach in the RISE program in Makassar, Indonesia and Suva, Fiji

Globally, more than one billion people live in urban informal settlements and experience suboptimal access to safe water, sanitation and hygiene (WASH). Participatory approaches are increasingly being promoted in WASH interventions, but the key elements of these approaches are not well-defined. The Revitalising Informal Settlements and their Environments (RISE) program launched in 2017 uses a participatory approach to co-design water-sensitive infrastructure with residents of 24 urban informal settlements in Makassar, Indonesia and Suva, Fiji. Our objective was to identify key mechanisms of a gender and socially inclusive participatory approach for engaging diverse people in RISE. We conducted and analysed semi-structured in-depth interviews (IDIs) with 49 RISE program staff; IDIs with 29 residents from RISE settlements in Indonesia and Fiji; and 6 focus group discussions (FGDs) with RISE residents in Fiji in 2020–2021, after participatory design activities were complete. Resident participants were purposively selected for representation of women and men; high and low participation in RISE; and different levels of disability/impairment. The question guides were informed by the Consolidated Framework for Implementation Research (CFIR), which defines 39 constructs (grouped into five domains) that describe an intervention. The IDI and FGD transcripts were analysed thematically with deductive codes based on the CFIR. For each of the five CFIR domains, the construct that was most relevant to mechanisms for the engagement of diverse people was used for the final analysis. The findings identified several key mechanisms for engaging diverse residents in programs like RISE. Four of these are recommended for future implementation and scale-ups of RISE and similar programs: engaging with residents at the household level (and potentially the individual level); incorporating flexibility and adaptability throughout the program; having a diverse team; and maintaining regular contact and positive rapport between the staff and participants

Thigh-length compression stockings and DVT after stroke

Controversy exists as to whether neoadjuvant chemotherapy improves survival in patients with invasive bladder cancer, despite randomised controlled trials of more than 3000 patients. We undertook a systematic review and meta-analysis to assess the effect of such treatment on survival in patients with this disease

Demographic and Clinical Factors Associated With SARS-CoV-2 Spike 1 Antibody Response Among Vaccinated US Adults: the C4R Study

Abstract This study investigates correlates of anti-S1 antibody response following COVID-19 vaccination in a U.S. population-based meta-cohort of adults participating in longstanding NIH-funded cohort studies. Anti-S1 antibodies were measured from dried blood spots collected between February 2021-August 2022 using Luminex-based microsphere immunoassays. Of 6245 participants, mean age was 73 years (range, 21-100), 58% were female, and 76% were non-Hispanic White. Nearly 52% of participants received the BNT162b2 vaccine and 48% received the mRNA-1273 vaccine. Lower anti-S1 antibody levels are associated with age of 65 years or older, male sex, higher body mass index, smoking, diabetes, COPD and receipt of BNT16b2 vaccine (vs mRNA-1273). Participants with a prior infection, particularly those with a history of hospitalized illness, have higher anti-S1 antibody levels. These results suggest that adults with certain socio-demographic and clinical characteristics may have less robust antibody responses to COVID-19 vaccination and could be prioritized for more frequent re-vaccination