Vulnerability of Urban Populations to Ambient Air Pollution

~Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

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Dannenberg et al. 2011

Urban populations have always been exposed to ambient (outdoor) air pollution because urban regions have high-density industries and populations (Dannenberg et al., 2011). High levels of pollution result from the concentration of sources of combustion (Dannenberg et al., 2011). There are two types of pollutants: primary and secondary. Primary pollutants are those that are directly emitted (Dannenberg et al., 2011). These include sulfur dioxide, which is released from power plants, and carbon monoxide from fossil fuel combustion (Dannenberg et al., 2011). In contrast, secondary pollutants result from the physical and secondary conversion of other pollutants (Dannenberg et al., 2011). Tropospheric ozone is one example; it forms through the chemical reactions of anthropogenic and biogenic precursors (Dannenberg et al., 2011).

Both primary and secondary pollutants lead to negative health consequences, including eye irritation, fatigue, headaches and more severe effects such as bronchoconstriction, lung impairment and neurological damage (Dannenberg et al., 2011). Certain populations are particularly vulnerable to ambient air pollution. For example, as a result of physiological and psychological factors, children are more sensitive to ambient pollution (Vanos, 2015). Furthermore, those with less education and lower socio-economic status also face a greater risk of exposure to ambient air pollution; thus, highlighting pollution an issue of environmental justice as well (Dannenberg et al., 2011).

Since air pollution is multifaceted, it is not easy to determine a solution. More research is required, to determine the severity of ambient air pollutants in different regions and how different populations are impacted. Furthermore, it is important to develop and implement policies that will reduce the prevalence of ambient air pollutants and their health consequences. For example, in order to provide evidence-based advice on the impacts of air pollution on health, the WHO Regional Office for Europe developed two projects-the “Review of Evidence on Health Aspects of Air Pollution” (REVIHAAP) and the “Health Risks of Air Pollution in Europe” (HRAPIE), which were completed in 2013 (WHO, 2013). The findings from these projects guided changes in the EU air quality policies that were implemented that same year (WHO, 2013).

The built environment also plays an important role in mitigating air pollution. Regions should employ sustainable development practices to ensure energy-efficient land use and transportation systems to reduce emissions (Dora et al., 2015). Moreover, attention should be given to the proximity of homes and schools to sources of pollution (Dannenberg et al., 2011). Urban Structure Types (USTs) is one method that could be used, as it is a spatial indicator that describes urban regions through the assessment of land use, physical properties and environmental characteristics (Réquia Júnior et al., 2015). The UST method assesses the morphology of housing, green spaces and industrial buildings which can be compared, to assess the relationship with a health risk (Réquia Júnior et al., 2015).

Like other global health problems, air pollution is complex. It is not unique to one region because it reaches across borders. As a result, governments and organizations from various regions need to work together to mitigate this problem.

References:

Dannenberg, A. L., Frumkin, H., & Jackson, R. J. (2011). Making Healthy Places:

Designing and Building for Health, Well-Being, and Sustainability. Washington: Island Press.

Dora, C., Haines, A., Balbus, J., Fletcher, E., Adair-rohani, H., Alabaster, G., … Neira, M. (2015). Indicators linking health and sustainability in the post-2015. The Lancet, 385(9965), 380–391. doi:10.1016/S0140-6736(14)60605-X

Réquia Júnior, W. J., Roig, H. L., & Koutrakis, P. (2015). A novel land use approach for assessment of human health: The relationship between urban structure types and cardiorespiratory disease risk. Environment International, 85, 334–342. doi:10.1016/j.envint.2015.09.026

Vanos, J. K. (2015). Children’s health and vulnerability in outdoor microclimates: A comprehensive review. Environment International, 76, 1–15. doi:10.1016/j.envint.2014.11.016

World Health Organization. (2013). Health risks of air pollution in Europe-HRAPIE project

Part I- To Get Inspired, Build Empathy into Your Project Plan

~Written by Lauren Spigel, Monitoring and Evaluation Coordinator (Contact: lauren.spigel@vaxtrac.com; Twitter: @vaxtrac)

Also published on VaxTrac blog

Build Empathy First
In our first blog post about human centered design, we talked about building empathy for design thinking. But what does “empathy” really mean, and how does it translate into research methodology?

To have empathy is to understand another’s perspective. If your goal is to build empathy with the community you’re designing for, it’s important to budget time, space and resources to talk to a variety of project stakeholders about the challenge you’d like to solve before the project starts. While it’s difficult to convince donors to spend money on an extended R&D phase, giving communities a voice at the onset of your project can save your organization time and money by allowing stakeholders to voice their opinions and be active participants in the design process.

The methods we use to build empathy are reminiscent of the research methods found in academic settings. Human centered design is especially akin to the philosophy of community based participatory research (CBPR), which also recognizes that when given a voice, communities are best equipped to identify sustainable solutions to challenges they face. Like CBPR and more traditional qualitative research methods, human centered design relies on interviews, focus groups, observations, surveys, card sorts, among other interactive methods, such as role plays, immersion and community mapping to elicit feedback from stakeholders.

Let’s dive into the case example of how we are building empathy with health workers in Nepal to improve our user interface and workflow.

The Problem
The clinics we work with in Nepal are fundamentally different than the clinics we work with in Benin. In Benin, the clinics are urban and busy. There are vaccination sessions almost every day. Caregivers bring their children to the clinics for vaccinations.

By contrast, the clinics we work with in Nepal are rural. The population is dispersed. As a result, vaccinations only happen a few days a month. There may be one or two sessions that take place at the main clinic, but there are usually also a number of outreach sessions, in which the health workers walk several hours to sub-health posts within their catchment areas. Since the population is small, only a few children come to each session.

Building Empathy through Brainstorming and Workflow Cards
There are a number of methods we could use to get into the mindset of the health worker. The key is to remember that health workers are the experts. They understand their job better than anyone else. Our job is to listen, build empathy for what they experience in their jobs and translate that into our software design.

We are starting with the goal of understanding health workers’ workflows in different situations. In other words, what do health workers do to prepare for a vaccination session? What happens during a session? What happens after?

Our DC-based team started by brainstorming objects, people and actions involved in a vaccination session. We scoured the internet for images to represent everything that we came up with. We put together sample workflow cards and brought it to our project partners in Nepal.

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Draft Workflow Cards (Source: vaxtrac.com)

Seeing the sample workflow cards inspired our in-country partners Amakomaya to continue the brainstorm. They looked at our cards and told us what images worked and which images did not convey the right meaning. They grabbed a marker and started brainstorming their own list. We sketched images together.

We designed an interactive activity with health workers to use the workflow cards to get a better understanding of the different workflows they use during vaccination sessions. We are currently working to add Amakomaya’s feedback into an updated version of the workflow cards, which we will test out with a group of health workers early this year.
Using cards with simple images on them is a great way to get health workers talking about how they do their work. Cards are tangible objects that health workers can put in their hands and arrange in different ways. It gives the group a visual to refer to when someone has a question. It allows our team and health workers to identify gaps in the work flow as well as pain points.

We hope that by understanding current workflows and processes, we can understand the challenges that health workers face in their daily jobs and iterate our software so that it improves their workflow.

Check out our next post in our series about human centered design next week, where we’ll give examples of how we’ve been prototyping a monitoring and evaluation dashboard with our team in Benin.
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To learn more about incorporating design thinking into your projects, contact Lauren at lauren.spigel@vaxtrac.com or check out IDEO’s resources

Medical Research - An Evidence Based Approach to Global Health

~Written by Mike Emmerich, Specialist Emergency Med & ERT Africa consultant (Contact: mike@nexusmedical.co.za)

https://twitter.com/MikeEmmerich_

A question posed by Jessica Taaffe on twitter, who is a TWIGH panelist, is my inspiration for this weeks blog. The question posed was: If you were to list three major research gaps for access to medicines what would they be? I posted 2 comments to that statement, the 140 characters per tweet, was not enough to fully weigh into the matter, so I am using this weeks post as a soapbox to expand further.

Firstly you might be asking what does this have to do with global health? In a nutshell, it has a huge impact, access to medicines, is dependent on the research that underpins it, it is the foundation on which medicine that we use stands. How firmly it stands depends on the strength of the research. If the road travelled to arrive at the end product is not evidence based (we will discuss the vagaries of this shortly), we then run the risk of having a flawed product, or even in some cases a product that never sees the light of day, (see my blog on Politics and Medicine).

The two comments I posted to twitter stated that evidence based medicine must be driven by independent clinicians, scientists and medical policy makers. Furthermore I stated that /Levels of Evidence A/(LOE - A) must be the benchmark. We cannot just be led by the large multinationals (Pharma and Medical Device Industries), they can most certainly push money into research, but the parameters of that research must be in the hands of independent clinicians, shared decision making can and must play a key role. This is a huge challenge but must be addressed, we need to claim back the labs and work alongside the drug and medical device industries.

So what is evidence based medicine http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2349778/?page=1, why is it important and why do I say the we need to adhere to LOE -A?

Evidence based medicine grew out of critical appraisal, when Gordon Guyatt took over as the director of the internal medicine registry programme at McMaster University. He wanted to change the program so that physicians managed patients based not on what authorities told them to do but on what the evidence showed worked. It then appeared in an article in “The Rational Clinical Examination” series in Journal of the American Medical Association (JAMA)in 1992.

The strength of evidence is assessed by a specific grading system which, in fact, is quite simple. It combines a description of the existence and types of studies supporting a certain recommendation.

-Level of evidence A: recommendation based on evidence from multiple randomized trials or meta-analyses -Level of evidence B: recommendation based on evidence from a single randomized trial or non-randomized studies -Level of evidence C: recommendation based on expert opinion, case studies, or standards of care.

So the highest standard to attain is LOE – A, is this always the case? In 2009, a very interesting paper http://jama.jamanetwork.com/article.aspx?articleid=183453 was published in JAMA, assessing the strength of evidence underlying the American College of Cardiology (ACC) and the American Heart Association (AHA) practice guidelines. They were reviewing recommendations to see if they were based on strong levels of evidence (LOE – A) and how much is based on "expert” opinion.

In only 11% of the guidelines published was LOE – A the benchmark, and most of the current guidelines included more than 50% of LOE – C as the standard! The authors correctly concluded that “expert opinion remains a dominant driver of clinical practice, particularly in certain topic areas, highlighting the need for clinical research in these fields”. I am sure if we had to review other areas of medical research we will be in a similar ballpark.

I can cite numerous examples from my own area of speciality where we have used certain drugs for years, with no studies definitely stating that they were beneficial to the patient, but there use was continued because of expert opinion, what drove that expert opinion is open to debate.

The Internet has also allowed incredible access to masses of data and information. However, we must be careful with an overabundance of "unfiltered" data. As history, as clearly shown us, evidence and data do not immediately translate into evidence based practice.

This is where the Cochrane Review stands the test of time, as it enable the practice of evidence-based health care, where health care decisions can be made based on the best available research, which is systematically assessed and summarised in a Cochrane Review http://www.cochrane.org/cochrane-reviews. Cochrane Reviews are systematic reviews http://www.cochrane.org/about-us/evidence-based-health-care of primary research in human health care and health policy, and are internationally recognised as the highest standard in evidence-based health care http://www.cochrane.org/about-us/evidence-based-health-care.

In closing then, to come back to the original question; what three major research gaps for access to medicines:

1. Research must be evidence based with LOE-A as the gold standard
2. Research must be driven by independent clinicians, scientists and medical policy makers
3. Research needs to be taken back to the labs and institutions who will research what is needed globally.

We would need large NGO's such as the WHO and the European Research Council (amongst others) to monitor and guide where research needs to be focussed. We need to thank all scientists, inventors, and researchers who are motivated by the need to know, the thrill of discovery,and the desire to make a positive contribution to mankind as a whole and acknowledge the right of people to the common ownership of medicines/vaccines etc. which are as basic to their common and individual well being, as to life itself.

As the cognitive linguist George Lakoff http://www.huffingtonpost.com/george-lakoff/empathy-sotomayor-and-dem_b_209406.html puts it, “Empathy is at the heart of real rationality, because it goes to the heart of our values, which are the basis of our sense of justice. Empathy is the reason we have the principles of freedom and fairness, which are necessary components of justice.”