Andrea Leuenberger

A growing body of work clearly documents the gendered inequalities in health. The COVID-19 pandemic further exposed these deep inequities: men appear to be more vulnerable to poorer outcomes, but most of the global health workforce is female who are at increased risk of exposure to hospital infection. However, researchers often fail to adequately embed gender as part of the public health research. This paper reports findings from a synthesis exercise that identified some of the challenges of integrating gender in the design and processes of research studies in four projects conducted in six low- and middle-income countries. Through a collective retrospective meta-synthesis process with researchers from each project, we identified two main themes; (i) we deep dive on two of the structural pillars of conducting public health research (design and process) and (ii) we describe some of the underlying opportunities and resistances to the integration of a gender perspective in these research projects. In conclusion, we suggest that public health funding bodies require researchers to integrate gender in public health research from early on as part of the design and to conduct gendered analysis, as part of the overall drive towards more equitable health systems delivery.

Background: Buruli ulcer, caused by Mycobacterium ulcerans, is a neglected tropical skin disease that is primarily endemic in West and Central Africa, including Côte d’Ivoire. Studies indicate that M. ulcerans infections are caused by contact with an environmental reservoir of the bacteria, governed by specific human biological conditions. Yet, the nature of this reservoir and the exact mode of transmission remain unknown. Methodology: To identify ecologic risk factors of Buruli ulcer in south-central Côte d’Ivoire, we pursued a qualitative study matched with geo-referencing inquiry. Embedded in a broader integrated wound management research project, we (i) mapped households and water sources of laboratory confirmed Buruli ulcer cases and (ii) interviewed 12 patients and four health care workers to assess exposure to surface water and to deepen the understanding of perceived transmission pathways. Principal findings: Water availability, accessibility, and affordability were reported as key determinants for choosing water resources. Furthermore, perceived risks were related to environmental, structural, and individual factors. Despite the presence of improved water sources (e.g., drilled wells), communities heavily relied on unprotected surface water for a multitude of activities. The nearby Bandama River and seasonal waterbodies were frequently used for washing, bathing, and collection of water for drinking and cooking. Many residents also reported to cross the river on a daily basis for agricultural chores, and hence, are exposed to stagnant water during farming activities. Conclusions/significance: Our study in two Buruli ulcer endemic villages in south-central Côte d’Ivoire revealed a wide range of water-related domestic activities that might expose people to an increased risk of contracting the disease. Environmental, biological, social, and cultural risk factors are closely interlinked and should be considered in future investigations of Buruli ulcer transmission. Active participation of the communities is key to better understand their circumstances to advance research and fight against Buruli ulcer and other neglected tropical diseases.

Background: Health equity features prominently in the 2030 Agenda for Sustainable Development, yet there are wide disparities in health between and within countries. In settings of natural resource extraction (e.g., industrial mines), the health of surrounding communities is affected through myriad changes in the physical, social, and economic environment. How changes triggered by such projects translate into health inequities is poorly understood. Methods: This qualitative study explores potential layers of inequities by systematically coding perceived inequities of affected communities. Drawing on the framework method, we thematically analyzed data from 83 focus group discussions, which enrolled 791 participants from 10 study sites in Burkina Faso, Mozambique, and Tanzania. Results: Participants perceived inequities related to their individual characteristics, intermediate factors acting on the community level, and structural conditions. Due to environmental pollution and land loss, participants were concerned about unsecured livelihoods. Positive impacts, such as job opportunities at the mine, remained scarce for local communities and were claimed not to be equally distributed among community members. Conclusion: Extractive industries bear considerable risks to widen existing health gaps. In order to create equal opportunities among affected populations, the wider determinants of health must be considered more explicitly in the licensing process of resource extraction projects.

Industrial mining projects can play an important role in global sustainable development if associated health risks are minimised and opportunities maximised. While a broad body of evidence from quantitative studies exists that establishes the interlinkages between mining operations and effects on public health, little research has been conducted investigating health impacts from the perspective of affected communities. This is particularly true in sub-Saharan Africa, where about a third of the remaining global mineral resources are endowed and health-related indicators for sustainable development are lagging behind. In this multi-country qualitative study, we explore community perceptions regarding impacts of industrial mining on their health and well-being. In nine study sites in Burkina Faso, Mozambique and Tanzania, we conducted 83 participatory focus group discussions with a total of 791 participants (385 men, 406 women). Our findings reveal a broad range of perceived impacts on environmental, economic and social determinants of health, with secondary health implications related to morbidity, mortality and well-being. Overall, perceived negative impacts prevailed, mainly related to environmental pollution, change in livelihoods or social disruption. Perceived positive impacts on health and well-being were related to interventions implemented by the mines such as new or improved water sources, health care facilities, roads and schools. The consistency of these findings across countries and study sites suggests a structural problem and indicates a pressing need to address health by acting on the wider determinants of health in mining regions. Participatory health impact assessment should be strengthened in host countries to foster strategic interventions, include marginalised population groups, and protect and promote the health of local communities. By including community perspectives on health before and during project implementation, policymakers can take advantage of economic opportunities while avoiding the pitfalls, bringing their communities closer to achieving good health and well-being goals by 2030 and beyond.

Mining projects affect the health of surrounding communities by inducing environmental, economic, social and cultural changes in different population groups. Health impact assessment (HIA) offers an opportunity to manage these impacts. This paper aims to explore gender differences of impacts on the wider determinants of health as described by communities impacted by industrial gold mining and consider the implications for impact assessment. We conducted 24 gender-separated, participatory focus group discussions at three study sites in northwestern Tanzania. Participants reported on a broad range of impacts on the wider determinants of health. Based on a thematic analysis, we identified gendered health impacts on men and women; in addition, children and adolescent boys and girls emerged as differently affected subpopulation groups. Located in the theory of the ‘triple role of women’, we suggest that different gender needs should be addressed more explicitly by HIA. Increased use of mitigation measures that recognise and address impacts on women’s engendered roles, and their health, through addressing women’s strategic gender needs, would strengthen HIA as a tool towards sustainable development.

Industrial mining transforms local landscapes, including important health determinants like clean water and sanitation. In this paper, we combined macro-level quantitative and micro-level qualitative data to show how mining projects affect water infrastructures and ultimately the health of affected communities. Although we observed a positive trend of water infrastructure in mining settings, surrounding communities are also characterized by water scarcity and degradation of water quality. The video at the core of this publication showcases inter-linkages of the findings obtained at both the macro- and the micro-levels, embedding our results in a geospatial context. While mining projects can have positive impacts on the development of local water infrastructure, improved management of negative impacts of mining projects is needed for promoting ‘Good health and well-being’ and ‘Clean water and sanitation’ as promulgated by the Sustainable Development Goals of the 2030 Agenda.

Artisanal and small-scale mining (ASM) is an important livelihood activity in many low- and middle-income countries. It is widely acknowledged that there are a myriad of health risk and opportunities associated with ASM. However, little is known with regard to which aspects of health have been studied in ASM settings. We conducted a scoping review of peer-reviewed publications, using readily available electronic databases (i.e., PubMed, Scopus, and Web of Science) from inception to 14 July 2020. Relevant information was synthesized with an emphasis on human and environmental exposures and health effects in a context of ASM. Our search yielded 2764 records. After systematic screening, 176 health studies from 38 countries were retained for final analysis. Most of the studies (n = 155) focused on health in ASM extracting gold. While many of the studies included the collection of environmental and human samples (n = 154), only few (n = 30) investigated infectious diseases. Little attention was given to vulnerable groups, such as women of reproductive age and children. Our scoping review provides a detailed characterisation of health studies in ASM contexts. Future research in ASM settings should address health more comprehensively, including the potential spread of infectious diseases, and effects on mental health and well-being.

Background: Natural resource extraction projects offer both opportunities and risks for sustainable development and health in host communities. Often, however, the health of the community suffers. Health impact assessment (HIA) can mitigate the risks and promote the benefits of development but is not routinely done in the developing regions that could benefit the most. Objective: Our study aims to investigate health and health determinants in regions affected by extractive industries in Burkina Faso, Ghana, Mozambique, and Tanzania. The evidence generated in our study will inform a policy dialogue on how HIA can be promoted as a regulatory approach as part of the larger research initiative called the HIA4SD (Health impact assessment for sustainable development) project. Methods: The study is a concurrent triangulation, mixed methods, multi-stage, multi-focus project that specifically addresses the topics of governance and policy, social determinants of health, health economics, health systems, maternal and child health, morbidity and mortality, and environmental determinants, as well as the associated health outcomes in natural resource extraction project settings across four countries. To investigate each of these health topics, the project will (1) use existing population-level databases to quantify incidence of disease and other health outcomes and determinants over time using time series analysis; (2) conduct two quantitative surveys on mortality and cost of disease in producer regions; and (3) collect primary qualitative data using focus groups and key informant interviews describing community perceptions of the impacts of extraction projects on health and partnership arrangements between the projects and local and national governance. Differences in health outcomes and health determinants between districts with and without an extraction project will be analyzed using matched geographical analyses in quasi-Poisson regression models and binomial regression models. Costs to the health system and to the households from diseases found to be associated with projects in each country will be estimated retrospectively. Results: Fieldwork for the study began in February 2019 and concluded in February 2020. At the time of submission, qualitative data collection had been completed in all four study countries. In Burkina Faso, 36 focus group discussions and 74 key informant interviews were conducted in three sites. In Ghana, 34 focus group discussions and 64 key informant interviews were conducted in three sites. In Mozambique, 75 focus group discussions and 103 key informant interviews were conducted in four sites. In Tanzania, 36 focus group discussions and 84 key informant interviews were conducted in three sites. Quantitative data extraction and collection is ongoing in all four study countries. Ethical approval for the study was received in all four study countries prior to beginning the fieldwork. Data analyses are underway and results are expected to be published in 2020 and 2021. Conclusions: Disentangling the complex interactions of resource extraction projects with their host communities requires an integrative approach drawing on many methodologies under the HIA umbrella. By using complementary data sources to address the question of population health in project areas from several angles, bias and missing data will be reduced, generating high-quality evidence to aid countries in moving toward sustainable development. International Registered Report Identifier (IRRID): DERR1-10.2196/17138

BACKGROUND Natural resource extraction projects offer both opportunities and risks for sustainable development and health in host communities. Often, however, the health of the community suffers. Health impact assessment (HIA) can mitigate the risks and promote the benefits of development but is not routinely done in the developing regions that could benefit the most. OBJECTIVE Our study aims to investigate health and health determinants in regions affected by extractive industries in Burkina Faso, Ghana, Mozambique, and Tanzania. The evidence generated in our study will inform a policy dialogue on how HIA can be promoted as a regulatory approach as part of the larger research initiative called the HIA4SD (Health impact assessment for sustainable development) project. METHODS The study is a concurrent triangulation, mixed methods, multi-stage, multi-focus project that specifically addresses the topics of governance and policy, social determinants of health, health economics, health systems, maternal and child health, morbidity and mortality, and environmental determinants, as well as the associated health outcomes in natural resource extraction project settings across four countries. To investigate each of these health topics, the project will (1) use existing population-level databases to quantify incidence of disease and other health outcomes and determinants over time using time series analysis; (2) conduct two quantitative surveys on mortality and cost of disease in producer regions; and (3) collect primary qualitative data using focus groups and key informant interviews describing community perceptions of the impacts of extraction projects on health and partnership arrangements between the projects and local and national governance. Differences in health outcomes and health determinants between districts with and without an extraction project will be analyzed using matched geographical analyses in quasi-Poisson regression models and binomial regression models. Costs to the health system and to the households from diseases found to be associated with projects in each country will be estimated retrospectively. RESULTS Fieldwork for the study began in February 2019 and concluded in February 2020. At the time of submission, qualitative data collection had been completed in all four study countries. In Burkina Faso, 36 focus group discussions and 74 key informant interviews were conducted in three sites. In Ghana, 34 focus group discussions and 64 key informant interviews were conducted in three sites. In Mozambique, 75 focus group discussions and 103 key informant interviews were conducted in four sites. In Tanzania, 36 focus group discussions and 84 key informant interviews were conducted in three sites. Quantitative data extraction and collection is ongoing in all four study countries. Ethical approval for the study was received in all four study countries prior to beginning the fieldwork. Data analyses are underway and results are expected to be published in 2020 and 2021. CONCLUSIONS Disentangling the complex interactions of resource extraction projects with their host communities requires an integrative approach drawing on many methodologies under the HIA umbrella. By using complementary data sources to address the question of population health in project areas from several angles, bias and missing data will be reduced, generating high-quality evidence to aid countries in moving toward sustainable development. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/17138