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Alcohol-related harm has gained increased attention in high-income countries (HICs) in recent years which, alongside government regulation, has effected a reduction in alcohol consumption. The alcohol industry has turned its attention to low-income and middle-income country (LMIC) markets as a new source of growth and profit, prompting increased consumption in LMICS. Alcohol use in LMICs is also increasing. There is a need to understand particularly in LMICs the impact of industry strategy in shaping local contexts of alcohol use. We draw on conceptualisations from food systems research, and research on the commercial determinants of health, to develop a new approach for framing alcohol research and discuss implications for alcohol research, particularly in LMICs, focusing on South Africa as an illustrative example. We propose a conceptualisation of the ‘alcohol environment’ as the system of alcohol provision, acquisition and consumption—including, critically, industry advertising and marketing—along with the political, economic and regulatory context of the alcohol industry that mediates people’s alcohol drinking patterns and behaviours. While each country and region is different in terms of its context of alcohol use, we contrast several broadly distinct features of alcohol environments in LMICs and HICs. Improving understanding of the full spectrum of influences on drinking behaviour, particularly in LMICs, is vital to inform the design of interventions and policies to facilitate healthier environments and reduce the harms associated with alcohol consumption. Our framework for undertaking alcohol research may be used to structure mixed methods empirical research examining the role of the alcohol environment particularly in LMICs.

Correspondence to: F Baumfran.baum@flinders.edu.auFran Baum and colleagues discuss the factors that affected prediction of the success of national responses to covid-19 and will influence future pandemic preparedness

Background Operations of transnational corporations (TNCs) affect population health through production methods, shaping social determinants of health, or by influencing regulation of their activities. Research on community exposures to TNC practices and policies has been limited. Our research on extractive industries examined Rio Tinto in Australia and Southern Africa to test methods for assessing the health impacts of corporates in high and middle income jurisdictions with different regulatory frameworks. Methods We adapted existing Health Impact Assessment methods. Data identifying potential impacts were sourced through media analysis, document analysis, company literature and semi-structured interviews. The data were mapped against a corporate health impact assessment framework (CHIA) which included Rio Tinto’s political and business practices; productions; and workforce, social, environmental and economic conditions. Results Both positive and detrimental aspects of Rio Tinto’s operations were identified. Requirements imposed by Rio Tinto on its global supply chain are likely to have positive health impacts for workers. However, political lobbying and membership of representative organisations can influence government policy in ways that are unfavourable to health and equity. Positive impacts include provision of direct employment under decent working conditions, but countered by an increase in precariousness of employment. Commitments to upholding sustainable development principles are undermined by limited site remediation and other environmental impacts. Positive contributions are made to national and local economies but then undermined by business strategies that include tax minimisation. Conclusion Our study confirmed that it is possible to undertake a CHIA on an extractive industry TNC. The different methods provided sufficient information to understand the need to strengthen regulations that are conducive to health; the opportunity for Rio Tinto to extend corporate responsibility initiatives and support their social licence to operate; and for civil society actors to inform their advocacy towards improving health and equity outcomes from TNC operations.

The response of the World Health Organization (WHO) to the Ebola outbreak in West Africa in 2015 demonstrated that the global health system is unprepared to address what should be its primary mission, control of disease epidemics while protecting health workers. Critics blamed WHO politics and its rigid culture for the poor response to the epidemic. We find that United Nations agencies, WHO and the International Labor Organization (ILO), are faced with the global problem of inadequate worker protections and a growing crisis in occupational health. The WHO and ILO are given monumental tasks but only trivial budgets, and funding trends show UN agency dependence on private donations which are far larger than funds contributed by member states. The WHO and ILO have limited capacity to make the necessary changes occupational health and safety demand. The UN could strengthen the national and global civil society voice in WHO and ILO structures, and by keeping conflict of interest out of policy decisions, ensure greater freedom to operate without interference.

Background Acute pesticide poisoning (APP) is reported to affect community health worldwide but its burden in Tanzania is unknown particularly in women. This study examines APP involving adult females and adolescent girls 10 to 19 years in 3 regions of Tanzania which are famous for coffee and vegetable production. Methods Over the period of 12 months, health facility-based surveillance for cases of APP was implemented in 10 Tanzanian healthcare facilities in 2006. Results The study identified 108 APP cases of whom 31 (28.7%) occurred amongst adolescent girls. Suicide was the leading poisoning circumstances (60.2%) and the most vulnerable women were 20–29 years old who comprised 38.4% of all cases with suicide as circumstance. Organophosphates (OPs), zinc phosphide, paraquat and endosulfan were common amongst known reported poisoning agents. The annual APP incidence, mortality and Case Fatality Rate for women were 5.1/100,000, 0.2/100,000 and 3.7/100, respectively. Conclusion APP amongst women in Tanzania is common and this call for diverse preventive interventions to reduce poisoning incidents.

ObjectivesThe Cardiff Model of data sharing for violence prevention is premised on the idea that the majority of injury cases presenting at health facilities as a result of interpersonal violence will not be reported to the police. The aim of this study was to determine the concordance between violent crimes reported to the police with violence-related injuries presenting at health facilities in Cape Town, South Africa.MethodsWe conducted a retrospective analysis of secondary cross-sectional health and police data, from three health facilities and three police stations in the community of Khayelitsha, Cape Town. 781 cases of injuries arising from interpersonal violence seen at health facilities were compared with 739 violence-related crimes reported at police stations over five separate week-long sampling periods from 2013 to 2015. Personal identifiers, name and surname, were used to match cases.ResultsOf the 708 cases presenting at health facilities, 104 (14.7%) were matched with police records. The addition of non-reported cases of violence-related injuries from the health dataset to the police-reported crime statistics resulted in an 81.7% increase in potential total violent crimes over the reporting period. Compared with incidents reported to the police, those not reported were more likely to involve male patients (difference: +47.0%; p<0.001) and sharp object injuries (difference: +24.7%; p<0.001). Push/kick/punch injuries were more frequent among reporting than non-reporting patients (difference: +17.5%; p<0.001).ConclusionThese findings suggest that the majority of injuries arising from interpersonal violence presenting at health facilities in Khayelitsha are not reported to the police. A data-sharing model between health services and the police should be implemented to inform violence surveillance and reduction.

Background Health systems worldwide increasingly involve non-state actors in governance and service provision, often to address perceived limitations in public sector capacity to achieve or maintain universal health coverage. Contracts are a key mechanism for structuring such cooperation, enabling governments to define public priorities, specify the resources and services required to achieve them, establish performance requirements for contractors, and define accountability mechanisms. Moreover, community participation in the design and monitoring—or governance—of contracts could enhance the effectiveness of contracting by making services more locally responsive and accountable. This article reviews the global evidence on contracting out—with and without community participation—and its effects on access to primary care services, the quality of these services, and equity in health. Methods A scoping review was undertaken following the PRISMA checklist for evidence synthesis. A common search string was applied to five databases – SciELO, LILACS, EBSCOhost, Scopus, and Google Scholar – to search for articles relating to our research questions in English, Spanish and Portuguese, with no restrictions on publication date. After three rounds of review, 81 articles were selected from a universe of 3,276 articles and subjected to full data analysis. These were complemented by 14 handpicked articles meeting our study criteria and 26 supplementary references. Results We find that community participation in the governance of contracting is rare, but can promote access and quality. However, it requires a contracting environment that supports transparency, cooperation from governments and providers, and resourcing commitments. More generally, contracting is often associated with access gains, but the evidence on quality and equity is mixed. Conclusions Contracting of non-state providers in pluralistic primary care systems that incorporates the participation of communities in its governance could be a feasible policy to promote universal health coverage while also effecting democratic rights of citizens to participate in healthcare governance. Primary research is required to better understand how to promote meaningful community participation, and to identify the contractual details and features of specific contractual environments that are connected to better outcomes.

BackgroundInternational literature has evidenced that Deaf people have been disadvantaged during the COVID-19 pandemic; however, there is currently little research published within the South African context.ObjectivesThis study investigated the ways in which the COVID-19 pandemic and its consequent response measures impacted Deaf adults in Cape Town.MethodUsing a descriptive approach, semi-structured, qualitative interviews were held with 15 Deaf adults in Cape Town, South Africa. Participants were purposively selected through a local Deaf organisation. Data were analysed using thematic analysis.ResultsData revealed the challenges experienced when accessing information, the impact of communication barriers on daily life, and how the response measures impacted access to healthcare.ConclusionThe findings of this study demonstrate how the needs of the Deaf community were overlooked and their voices disregarded during the planning of the national pandemic response, ultimately having detrimental consequences. Therefore, the authors argue for greater inclusion of Deaf representatives to ensure equal access to information and resources, especially during a crisis.ContributionThis study contributes to the growing body of knowledge on the consequences of the COVID-19 pandemic in the field of disability and insights can inform both future research and interventions to promote equity and inclusion for Deaf people.

South Africa (SA) is reforming its health system in preparation for an anticipated national health insurance (NHI) scheme that aims to improve the delivery of affordable, equitable, accessible health care. Public health (PH) language is explicit in the policy and skilled PH professionals would be expected to play a key role in its implementation. In South Africa, training of doctors as Public Health Medicine (PHM) specialists is funded by the state, yet there are few positions for PHM specialists in the health services. We explored stakeholders' perspectives about this absence, and their views on PHM specialist' roles and contribution in an era of health reform. A qualitative study was conducted in 2012-13, using in-depth interviews with thematic analysis, which elicited perspectives of 31 key stakeholders nationally reflecting diverse employer and institutional backgrounds. While some were surprised by the absence of PH professionals in SA's health system, most agreed the reason was due to factors internal to the profession, such as its low profile and uncertain identity. External factors such as legislation and political preferences for health managers impacted on the employment of PH professionals. However, given the competencies required to implement an ambitious restructuring of the health sector, all believed that PH and PHM personnel were vital. In view of the health system's dominant curative orientation, embedding PH personnel in the services should ensure that health protection, promotion and prevention strategies will inform health priorities. This study, the first known from a low and middle-income country, contributes to the international literature about the identity and roles of PHM physicians, who are versatile professionals with broad skills-sets. In SA, through consultation with health sector employers about potential roles, curricular redesign and trainee recruitment, PHM can graduate fit-for-purpose specialists to work in a range of institutions to address health system reform.