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Abstract Objectives Malnutrition is a persistent health concern throughout the world. Globally, Indigenous peoples experience poorer health outcomes compared to their non-Indigenous neighbours. Despite this, malnutrition among Indigenous populations is poorly understood. This analysis estimated the prevalence, and modeled possible determinants of, moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) for Indigenous Batwa and non-Indigenous Bakiga of Kanungu District in Southwestern Uganda. We then characterize possible mechanisms driving differences in malnutrition. Methods Retrospective cross-sectional surveys were administered to 10 Batwa communities and 10 matched Bakiga Local Councils during April of 2014 (n = 1167). Individuals were classified as MAM and SAM based on middle upper-arm circumference (MUAC) for their age-sex strata. Mixed-effects regression models quantified the variation in malnutrition occurrence, considering individual, household, and community-ethnicity level effects. Models controlled for age, sex, number of dependents, education, and relative wealth. Results Malnutrition is high among Batwa children and adults, with nearly half of Batwa adults (45.34%, 95% CI 34.82 to 55.86 for males; 45.86%, 95% CI 37.39 to 54.33 for females) and nearly a quarter of Batwa children (20.31%, 95% CI 13.07 to 26.93 for males; 25.81%, 95% CI 17.56 to 32.84 for females) meeting MAM criteria. SAM prevalence is lower than MAM prevalence, with SAM highest among adult Batwa males (11.60%, 95% CI 4.83 to 18.37) and adult Batwa females (3.00%, 95% CI 0.10 to 5.90). SAM prevalence among children was higher for Batwa males (7.03%, 95% CI 1.36 to 12.70) compared to Bakiga males (0.57%, 95% CI 0 to 1.69). Models that incorporated community ethnicity explained the greatest variance (>60%) in MUAC values. Conclusion This research demonstrates a malnutrition inequality between the Indigenous Batwa and non-Indigenous Bakiga of Kanungu District, Uganda, with model results suggesting further investigation into the role of ethnicity as an upstream social determinant of health. Highlights • Malnutrition disparities exist among Indigenous and non-Indigenous groups in Uganda. • Distinct malnutrition factors appear at individual, household, and community levels. • Ethnic distinction within communities may act as an upstream determinant of health. [ABSTRACT FROM AUTHOR]

Maternal and newborn health disparities and the health impacts of climate change present grand challenges for global health equity, and there remain knowledge gaps in our understanding of how these challenges intersect. This study examines the pathways through which mothers are affected by seasonal and meteorological factors in sub-Saharan Africa in general, and Kanungu District (Uganda), in particular. We conducted a community-based study consisting of focus group discussions with mothers and interviews with health care workers in Kanungu District. Using a priori and a posteriori coding, we found a diversity of perspectives on the impacts of seasonal and weather exposures, with reporting of more food available in the rainy season. The rainy season was also identified as the period in which women performed physical labour for longer time periods, while work conditions in the dry season were reported to be more difficult due to heat. The causal pathways through which weather and seasonality may be affecting size at birth as reported by Kanungu mothers were consistent with those most frequently reported in the literature elsewhere, including maternal energy balance (nutritional intake and physical exertion output) and seasonal illness. While both Indigenous and non-Indigenous mothers described similar pathways, however, the severity of these experiences differed. Non-Indigenous mothers frequently relied on livestock assets or opportunities for less taxing physical work than Indigenous women, who had fewer options when facing food shortages or transport costs. Findings point to specific entry points for intervention including increased nutritional support in dry season periods of food scarcity, increased diversification of wage labour opportunities, and increased access to contraception. Interventions should be particularly targeted towards Indigenous mothers as they face greater food insecurity, may have fewer sources of income, and face greater overall deprivation than non-Indigenous mothers. [ABSTRACT FROM AUTHOR]

Dengue is highly endemic in Peru, with increases in transmission particularly since vector re-infestation of the country in the 1980s. Pucallpa, the second largest city in the Peruvian Amazon, experienced a large outbreak in 2012 that caused more than 10,000 cases and 13 deaths. To date, there has been limited research on dengue in the Peruvian Amazon outside of Iquitos, and no published review or critical analysis of the 2012 Pucallpa dengue outbreak. This study describes the incidence, surveillance, and control of dengue in Ucayali to understand the factors that contributed to the 2012 Pucallpa outbreak. We employed a socio-ecological autopsy approach to consider distal and proximal contributing factors, drawing on existing literature and interviews with key personnel involved in dengue control, surveillance and treatment in Ucayali. Spatio-temporal analysis showed that relative risk of dengue was higher in the northern districts of Calleria (RR = 2.18), Manantay (RR = 1.49) and Yarinacocha (RR = 1.25) compared to all other districts between 2004 and 2014. The seasonal occurrence of the 2012 outbreak is consistent with typical seasonal patterns for dengue incidence in the region. Our assessment suggests that the outbreak was proximally triggered by the introduction of a new virus serotype (DENV-2 Asian/America) to the region. Increased travel, rapid urbanization, and inadequate water management facilitated the potential for virus spread and transmission, both within Pucallpa and regionally. These triggers occurred within the context of failures in surveillance and control programming, including underfunded and ad hoc vector control. These findings have implications for future prevention and control of dengue in Ucayali as new diseases such as chikungunya and Zika threaten the region. [ABSTRACT FROM AUTHOR]

Background Leishmaniasis has been estimated to cause the ninth largest burden amongst global infectious diseases. Occurrence of the disease has been anecdotally associated with periods of conflict, leading to its referral as a disease of ‘guerrilla warfare.’ Despite this, there have been few studies that quantitatively investigate the extent to which leishmaniasis coincides with conflict or political terror. Methodology This study employed a longitudinal approach to empirically test for an association between cutaneous and visceral leishmaniasis incidence with occurrence of conflict and political terror at the national level, annually for 15 years (1995–2010). Leishmaniasis incidence data were collected for 54 countries, and combined with UCDP/PRIO Armed Conflict and Amnesty International political terror datasets. Mixed effects negative binomial regression models clustered at the country-level were constructed to evaluate the incidence rate ratios against the predictors, while controlling for wealth. Additionally, to understand how and why conflict-terror may be associated with leishmaniasis incidence, we conducted a historical analysis. We identify and discuss posited causal mechanisms in the literature, and critically assessed pathways by which leishmaniasis might occur in places and times of conflict-terror. Results There was a significant dose-response relationship for disease incidence based on increasing levels of conflict and terror. Country-years experiencing very high levels of conflict-terror were associated with a 2.38 times higher [95% CI: 1.40–4.05] and 6.02 times higher [95% CI: 2.39–15.15] incidence of cutaneous and visceral leishmaniasis, respectively. Historical analysis indicated that conflict and terror contribute to—or coincide with—leishmaniasis incidence through processes of population displacement and health system deterioration. Conclusions This research highlights the potentially increased risks for cutaneous and visceral leishmaniasis incidence in areas of high conflict-terror. Notably, conflict-terror may act as an empirical proxy for indirect and concomitant processes of social breakdown, migration, and instability, which emerge as the dominant processes associated with disease incidence. [ABSTRACT FROM AUTHOR]

Abstract: In much of sub-Saharan Africa, availability of standardized and reliable public health data is poor or negligible. Despite continued calls for the prioritization of improved health datasets in poor regions, public health surveillance remains a significant global health challenge. Alternate approaches to surveillance and collection of public health data have thus garnered increasing interest, though there remains relatively limited research evaluating these approaches for public health. Herein, we present a case study applying and evaluating the use of expert knowledge sources for public health dataset development, using the case of vector distributions of Human African Trypanosomiasis (HAT) in Uganda. Specific objectives include: 1) Review the use of expert knowledge sourcing methods for public health surveillance, 2) Review current knowledge on tsetse vector distributions of public health importance in Uganda and the methods used for tsetse mapping in Africa; 3) Quantify confidence of the presence or absence of tsetse flies in Uganda based on expert informant reports, and 4) Assess the reliability and potential utility of expert knowledge sourcing as an alternative or complimentary method for public health surveillance in general and tsetse mapping in particular. Information on tsetse presence or absence, and associated confidence, was collected through interviews with District Entomologist and Veterinary Officers to develop a database of tsetse distributions for 952 sub-counties in Uganda. Results show high consistency with existing maps, indicating potential reliability of modeling approaches, though failing to provide evidence for successful tsetse control in past decades. Expert-sourcing methods provide a novel, low-cost and rapid complimentary approach for triangulating data from prediction modeling where field-based validation is not feasible. Data quality is dependent, however, on the level of expertise and documentation to support confidence levels for data reporting. Results highlight the need for increased evaluation of alternate approaches and methods to data collection. [Copyright &y& Elsevier]

Abstract: Human African Trypanosomiasis (HAT) has reemerged in sub-Saharan Africa as a disease of major public health importance. The success of HAT elimination in sub-Saharan Africa is subject to the feasibility of controlling, eliminating, or mitigating the determinants of incidence in affected countries. Conflict has been widely recognized and cited as a contributing factor to the resurgence of HAT in many countries, as well as to continuing HAT incidence in politically unstable and resource-poor regions. Despite extensive anecdotal and qualitative recognition of the role of conflict, there has been no quantitative research of this topic at the population level in affected African countries. We characterize the qualitative and quantitative associations between HAT incidence and conflict-related processes in HAT-affected African countries over the past 30 years. HAT and conflict-related data were collected for 35 affected countries in sub-Saharan Africa for the years 1976–2004. Descriptive and univariate inferential statistics, as well as negative binomial regression modeling, are used to assess the associations between HAT and conflict. A space-time scan statistic is used to identify significant incidence clusters. Clusters of HAT incidence over the past 30 years have predominantly coincided with periods of conflict or socio-political instability. HAT cases occurred significantly more often in countries and during years with conflict, high political terror, and internationalized civil war. The results indicate a lag period between the start of conflict events and a peak in incidence of approximately 10 years. We recommend explicit consideration and quantification of socio-political measures such as conflict and terror indices in GIS (Geographic Information Systems)-based risk assessments for HAT policy and intervention. [Copyright &y& Elsevier]

Abstract Local public health authorities often lack the capacity to adapt to climate change, despite being on the 'front lines' of climate impacts. Upper-level governments are well positioned to create an enabling environment for adaptation and build local public health authorities' capacity, yet adaptation literature has not specified how upper-level governments can build local-level adaptive capacity. In this paper we examine how federal and regional governments can contribute to enabling and supporting public health adaptation to climate change at the local level in federal systems. We outline the local level's self-assessed adaptive capacity for public health adaptation in Canadian and German comparative case studies, in terms of funding, knowledge and skills, organizations, and prioritization, drawing upon 30 semi-structured interviews. Based on interviewees' recommendations and complemented by scientific literature, we develop a set of practical measures that could enable or support local-level public health adaptation. We find that adaptive capacity varies widely between local public health authorities, but most report having insufficient funding and staff for adaptation activities. We propose 10 specific measures upper-level governments can take to build local public health authorities' capacity for adaptation, under the interrelated target areas of: building financial capital; developing and disseminating usable knowledge; collaborating and coordinating for shared knowledge; and claiming leadership. Federal and regional governments have an important role to play in enabling local-level public health adaptation, and have many instruments available to them to fulfill that role. Selecting and implementing measures to enable local public health authorities' adaptive capacity will require tailoring to, and consideration, of the local context and needs. Highlights • Local public health authorities often lack capacity to adapt to climate change. • National and regional governments can play supportive or enabling role. • We propose 10 concrete measures to enable local public health adaptation. [ABSTRACT FROM AUTHOR]

Injury is the leading cause of death for Canadians aged 1 to 44, occurring disproportionately across regions and communities. In the Inuit territory of Nunavut, for instance, unintentional injury rates are over three times the Canadian average. In this paper, we develop a framework for assessing vulnerability to injury and use it to identify and characterize the determinants of injuries on the land in Nunavut. We specifically examine unintentional injuries on the land (outside of hamlets) because of the importance of land-based activities to Inuit culture, health, and well-being. Semi-structured interviews (n = 45) were conducted in three communities that have varying rates of search and rescue (SAR), complemented by an analysis of SAR case data for the territory. We found that risk of land-based injuries is affected by socioeconomic status, Inuit traditional knowledge, community organizations, and territorial and national policies. Notably, by moving beyond common conceptualizations of unintentional injury, we are able to better assess root causes of unintentional injury and outline paths for prevention. [ABSTRACT FROM AUTHOR]

Indigenous women world-wide are diverse and heterogenous, yet many have similar experiences of colonization, land dispossession, and discrimination. These experiences along with inequitable access to, and quality of, maternal healthcare increase adverse maternal health outcomes. To improve health outcomes for Indigenous women, studies must be conducted with Indigenous involvement and reflect Indigenous research principles. Objectives/Aim: The aim of this review was to explore the range, extent, and nature of Indigenous maternal health research and to assess the reporting of Indigenous research principles in the global Indigenous maternal health literature. Following a systematic scoping review protocol, four scholarly electronic databases were searched. Articles were included if they reported empirical research published between 2000 and 2019 and had a focus on Indigenous maternal health. Descriptive data were extracted from relevant articles and descriptive analysis was conducted. Included articles were also assessed for reporting of Indigenous research principles, including Indigenous involvement, context of colonization, Indigenous conceptualizations of health, community benefits, knowledge dissemination to participants or communities, and policy or intervention recommendations. Four-hundred and forty-one articles met the inclusion criteria. While studies were conducted in all continents except Antarctica, less than 3% of articles described research in low-income countries. The most researched topics were access to and quality of maternity care (25%), pregnancy outcome and/or complications (18%), and smoking, alcohol and/or drug use during pregnancy (14%). The most common study design was cross-sectional (49%), and the majority of articles used quantitative methods only (68%). Less than 2% of articles described or reported all Indigenous research principles, and 71% of articles did not report on Indigenous People's involvement. By summarizing the trends in published literature on Indigenous maternal health, we highlight the need for increased geographic representation of Indigenous women, expansion of research to include important but under-researched topics, and meaningful involvement of Indigenous Peoples. • Less than 3% of articles on Indigenous maternal health were conducted in low-income countries. • Colonialism was rarely mentioned in articles despite being an Indigenous determinant of health. • Few articles reported any Indigenous involvement (including consultation or permission). • Most articles did not report any Indigenous conceptualizations of maternal health. [ABSTRACT FROM AUTHOR]