What works to increase access to assistive technology in southern Africa

Access to assistive technologies (AT) is necessary to achieving all 17 sustainable development goals. Yet for most people who need AT in Southern Africa, AT is unaffordable, unavailable, and often inappropriate. My PhD research was guided by the core question: What works to increase access to assistive technology in Southern Africa? Organized into three sub-studies, my research aimed to identify and describe the facilitators and barriers to access AT and develop a theoretical model to inform strategies to increase AT access in Southern Africa. The first two sub-studies listed below were previously published and the full manuscripts are included as separate chapters within the thesis. The three sub-studies included: • Sub-study 1: A scoping review that characterized existing evidence on AT from resource limited environments. Evidence identified was limited in quantity and quality, and primarily focused on mobility and vision types of AT. • Sub-study 2: A secondary analysis (i.e., bivariate regressions) of national survey data from Botswana and Swaziland served to examine factors associated with higher levels of AT access. The type of disability (i.e., mobility vs. non-mobility) was found to be the most important factor in determining AT access in both countries. • Sub-study 3: A regional qualitative sub-study was conducted to increase the understanding of how a multitude of interrelated factors operate to increase the supply of and access to AT. An adapted health systems framework was applied to analyse multiple data sources including stakeholder interviews, documentation review and observations. The thesis is organized into seven chapters. In Chapter 1, I provide background information and conceptual framing of the research topic, assistive technology access within Southern Africa. The research questions and overview of the three sub-studies are included in this introductory chapter. Chapter 2 covers the research methods of all three sub-studies. For the first two sub-studies, a brief overview of data collection and analysis methods are included that reference the more detailed methods presented within each published manuscript. The first two sub-studies are presented as Chapter 3 (scoping review) and Chapter 4 (secondary analysis) within the thesis. The third sub-study (qualitative) provided the most comprehensive data of the three sub-studies and comprises findings presented in Chapter 5 and Chapter 6. In the final chapter, Chapter 7, I synthesize findings from all three sub-studies to identify prominent patterns and present models that aim to explain constraints within the AT sector. The synthesis of evidence showed that AT in Southern Africa does not operate as a sector but as a constellation of uncoordinated parts. The low prioritization of AT and high level of fragmentation within the system emerged as pervasive patterns. The combination of these two patterns result in a wasteful sector. This means that the limited resources invested in funding products and services, and in strengthening the national AT procurement and provision system are not used effectively to increase the supply of and access to appropriate AT. In my further interpretation of data to respond to the core research question: What works to increase access to assistive technology in Southern Africa? I then identify strategic levers to increase AT access. Strategic levers aim to increase resources invested in the AT sector while reducing system-wide inefficiencies. Finally, study limitations and conclusions are presented at the end of this final chapter

Access to assistive technology in two Southern African countries

Background Millions of people in Southern Africa are deprived of basic human rights such as the right to education and work because of the large and growing unmet demand for assistive technologies (AT). Evidence is needed to better characterize the lack of AT access. Methods This study serves to identify the sociodemographic factors that are associated with access to AT in two countries in Southern Africa, Botswana and Swaziland. To achieve this aim, logistics regression was applied to a subset of variables from two Living Conditions Studies, nationally representative surveys that were conducted in Southern Africa (2014 and 2010). Results In Botswana, 44% of people who needed AT did not receive it, while in Swaziland the unmet need was 67%. Among the sociodemographic variables tested, the type of disability was the most important factor in determining AT access in both countries. The likelihood of AT access was highest in both countries for those who had mobility limitations (i.e., difficulty walking/climbing stairs) [Botswana: 6.4 odds ratio (OR) = 6.4., 95% confidence internal (CI) (3.6–11.3); Swaziland: OR = 3.2, CI (1.4–7.3)], in comparison to those with non-mobility types of disabilities. Conclusions These findings provide support for governments and other stakeholders in the AT sector to prioritize AT to address the large unmet demand, and expand the range of AT products provided so that people with hearing, seeing, self-care, communication and cognition difficulties have equal access to AT as those with mobility impairments. A step toward achieving these aims is to inventory AT product types that are commonly covered through the public sector in each country, and identify common gaps (e.g., daily living aids). Advancing the AT sector as a whole within Southern Africa will require large scale qualitative studies that achieve a comprehensive understanding of the bottlenecks in regional AT supply, procurement, and delivery systems

Local sales restrictions significantly reduce the availability of menthol tobacco: findings from four Minnesota cities

BACKGROUND In 2017 and 2018, Minneapolis, St. Paul, Duluth and Falcon Heights, Minnesota were among the first US cities to restrict the sale of menthol tobacco to adult-only stores. The study examined changes in the availability and marketing of these products following policy implementation. METHODS Retail store audits were conducted approximately 2 months pre-policy and post-policy implementation. Tobacco retail stores (n=299) were sampled from tobacco licensing lists in Minneapolis, St. Paul, Duluth and Falcon Heights, as well as six comparison cities without menthol policies. The presence of menthol tobacco was assessed, along with the number of interior and exterior tobacco ads and promotions at each store. RESULTS The majority of policy intervention stores (grocery, convenience stores and pharmacies) were compliant (Minneapolis, 84.4%; Duluth, 97.5%; and St. Paul and Falcon Heights, 100.0%) and did not sell menthol tobacco. In contrast, menthol tobacco was available in all comparison city stores, and most (96.0%) exempted tobacco shops and liquor stores post-policy implementation. Two Minneapolis convenience stores added interior tobacco shops, allowing them to continue selling menthol tobacco. Significant decreases in menthol tobacco marketing post-policy were observed in the stores' interior in Minneapolis, St. Paul and Duluth (p<0.001) and on the stores' exterior in Duluth (p=0.023). CONCLUSIONS Findings demonstrate high rates of compliance, indicating that sales restrictions can significantly reduce the availability of menthol tobacco. However, challenges to policy adherence underscore the need for continued monitoring and enforcement action

Utility of natural and artificial geochemical tracers for leakage monitoring and quantification during an offshore controlled CO2 release experiment

To inform cost-effective monitoring of offshore geological storage of carbon dioxide (CO2), a unique field experiment, designed to simulate leakage of CO2 from a sub-seafloor storage reservoir, was carried out in the central North Sea. A total of 675 kg of CO2 were released into the shallow sediments (∼3 m below seafloor) for 11 days at flow rates between 6 and 143 kg d-1. A set of natural, inherent tracers (13C, 18O) of injected CO2 and added, non-toxic tracer gases (octafluoropropane, sulfur hexafluoride, krypton, methane) were used to test their applicability for CO2 leakage attribution and quantification in the marine environment. All tracers except 18O were capable of attributing the CO2 source. Tracer analyses indicate that CO2 dissolution in sediment pore waters ranged from 35 % at the lowest injection rate to 41% at the highest injection rate. Direct measurements of gas released from the sediment into the water column suggest that 22 % to 48 % of the injected CO2 exited the seafloor at, respectively, the lowest and the highest injection rate. The remainder of injected CO2 accumulated in gas pockets in the sediment. The methodologies can be used to rapidly confirm the source of leaking CO2 once seabed samples are retrieved

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

The Nuclear Contamination of Kazakhstan

This thesis studies the radioactive contamination of Kazakhstan\u27s environment, concentrating on the period between February 1989 and January 1993. For each type of nuclear degradation in Kazakhstan the thesis asks the questions: what is its cause and extent, what are its consequences for humans, and what are the human responses. The main causes of Kazakhstan\u27s nuclear devastation are atomic weapons\u27 tests, uranium mining, manufacturing of uranium fuel, and the operation of a fast breeder reactor power generator unit. The amount of radioactive contamination is colossal. The consequences for the health of the population, especially at Semey, are severe. The human responses have succeeded in stopping the testing, but additional steps should be taken. In the future Kazakhstan will need to deal with both the legacy it has inherited and with continuing nuclear activities--in order to save its land and people. Materials used in this study are in English or English translation

Assistive technology in resource-limited environments : a scoping review

Purpose: It is estimated that only 5–15% of people in low and middle income countries (LMICs) who need assistive technologies (AT) have access to them. This scoping review was conducted to provide a comprehensive picture of the current evidence base on AT within LMICs and other resource limited environments. Method: The scoping review involved locating evidence, extracting data, and summarizing characteristics of all included research publications. Results: Of the 252 publications included, over 80% focused on types of AT that address mobility (45.2%) and vision (35.5%) needs, with AT types of spectacles and prosthetics comprising over 50% of all publications. Evidence on AT that addresses hearing, communication, and cognition is the most underrepresented within the existing evidence base. The vast majority of study designs are observational (63%). Conclusions: Evidence on AT in resource-limited environments is limited in quantity and quality, and not evenly distributed across types of AT. To advance this field, we recommend using appropriate evidence review approaches that allow for heterogeneous study designs, and developing a common language by creating a typology of AT research focus areas. Funders and researchers must commit much greater resources to the AT field to ameliorate the paucity of evidence available.Implications for Rehabilitation An increase in the quality and quantity of research is required in resource limited environments, where 80% of the global population of people with disabilities reside. Improved and increased evidence is needed to identify and understand needs, inform policy and practice, and assess progress made in increasing access to and availability of appropriate AT. Over 80% of the existing research publications on assistive technologies in resource limited environments address mobility and vision. More research is needed on AT that address hearing, communication and cognition. The use of a common language would facilitate the advancement of the global AT research field. Specifically there is a need for researchers to use a common definition of AT (i.e., ISO 9999) and typology of AT research focus areas

Lessons from the pilot of a mobile application to map assistive technology suppliers in Africa

CITATION: Visagie, S. J., et al. 2018. Lessons from the pilot of a mobile application to map assistive technology suppliers in Africa. African Journal of Disability, 7:a422, doi:10.4102/ajod.v7i0.422.The original publication is available at https://ajod.orgA pilot project to develop and implement a mobile smartphone application (App) that tracks and maps assistive technology (AT) availability in southern Africa was launched in Botswana in 2016. The App was developed and tested through an iterative process. The concept of the App (AT-Info-Map) was well received by most stakeholders within the pilot country, and broader networks. Several technical and logistical obstacles were encountered. These included high data costs; difficulty in accessing AT information from the public healthcare sector, the largest supplier of AT; and the high human resource demand of collecting and keeping up-to-date device-level information within a complex and fragmented supply sector that spans private, public and civil society entities. The challenges were dealt with by keeping the data burden low and eliminating product-level tracking. The App design was expanded to include disability services, contextually specific AT categories and make navigation more intuitive. Long-term sustainability strategies like generating funding through advertisements on the App or supplier usage fees must be explored. Outreach and sensitisation programmes about both the App and AT in general must be intensified. The project team must continually strengthen partnerships with private and public stakeholders to ensure ongoing project engagement. The lessons learnt might be of value to others who wish to embark on initiatives in AT and/or implement Apps in health or disability in southern Africa and in low-resourced settings around the world.https://ajod.org/index.php/ajod/article/view/422Publisher's versio

Data for paper: Regulating the femtosecond excited-state lifetime of a single molecule

These data were collected by scanning tunnelling microscopy and concern the rate of manipulation of the chemisorbed toluene molecule on the Si(111)-7x7 surface. The details of this research are presented in the associated paper. Here we house the individual data points that are displayed in the work