Shoes are effective for blocking soil-transmitted helminths (STHs) that penetrate the skin. Unfortunately, shoe-wearing is uncommon in many areas where STHs are prevalent, in part because local populations are unaware of the health benefits of wearing shoes. This is especially true in low-literacy populations, where information dissemination through written messages is not possible. We launched a public health intervention that combines a public health image with sandals. The image is a "lenticular image" that combines two alternating pictures to depict the efficacy of shoes for preventing STH infection. This image is adhered to the shoe, such that the message is linked directly to the primary means of prevention. To create a culturally appropriate image, we conducted five focus group discussions, each with a different gender and age combination. Results of focus group discussions reinforced the importance of refining public health messages well in advance of distribution so that cultural acceptability is strong. After the image was finalized, we deployed shoes with the image in communities in western Uganda where hookworm is prevalent. We found that the frequency of shoe-wearing was 25% higher in communities receiving the shoes than in control communities. Microscopic analyses of fecal samples for parasites showed a sustained reduction in infection intensity for parasites transmitted directly through the feet when people received shoes with a public health image. Our results show that combining culturally appropriate images with public health interventions can be effective in low-literacy populations.

Abstract

Background Since climate change, pandemics and population mobility are challenging healthcare systems, an empirical and integrative research to studying and help improving the health systems resilience is needed. We present an interdisciplinary and mixed-methods research protocol, ClimHB, focusing on vulnerable localities in Bangladesh and Haiti, two countries highly sensitive to global changes. We develop a protocol studying the resilience of the healthcare system at multiple levels in the context of climate change and variability, population mobility and the Covid-19 pandemic, both from an institutional and community perspective. Methods The conceptual framework designed is based on a combination of Levesque’s Health Access Framework and the Foreign, Commonwealth and Development Office’s Resilience Framework to address both outputs and the processes of resilience of healthcare systems. It uses a mixed-method sequential exploratory research design combining multi-sites and longitudinal approaches. Forty clusters spread over four sites will be studied to understand the importance of context, involving more than 40 healthcare service providers and 2000 households to be surveyed. We will collect primary data through questionnaires, in-depth and semi-structured interviews, focus groups and participatory filming. We will also use secondary data on environmental events sensitive to climate change and potential health risks, healthcare providers’ functioning and organisation. Statistical analyses will include event-history analyses, development of composite indices, multilevel modelling and spatial analyses. Discussion This research will generate inter-disciplinary evidence and thus, through knowledge transfer activities, contribute to research on low and middle-income countries (LMIC) health systems and global changes and will better inform decision-makers and populations.

Acknowledgements: This work was funded by a Leverhulme Trust Research Grant F/00182/BI. Part of the logistic support was provided by the Centre Français d'Etude Ethiopienne. We are particularly grateful to the people of the Hitoya and Tiyo districts, Arsi zone, Oromia region, for their warm welcome and for facilitating this research. We thank the field team for many months of hard work on the field on data collection. Suggestions provided by James Holland Jones, Aurelie Cailleau and Sid Karunaratne are greatly appreciated. Finally we thank the anonymous reviewers for their helpful comments and feedback.

Bangladesh is one of the countries most affected by climate change. Internal migration is often presented as a response to environmental degradation in rural areas. Here, we hypothesise that climate-induced changes and adaptations impact local production and the local labour market, seasonally pushing out unskilled landless workers. We focus on different categories of livelihoods and their interactions to understand the local socio-ecological context for unskilled landless workers. We conducted fourteen semi-directed interviews and six focus group discussions with villagers in March-April 2022. We use a configurational approach considering changes>impacts> responses>impacts of responses to analyse our data for agricultural farmers, fish farmers, independent fishermen and unskilled workers. We conducted rainfall analysis on Chirps data for 1981-2021 to confront perception of changes to climate data.Villagers reported that waterlogging was the most significant change. Covid-19 lockdowns were cited as an aggravating factor. Most climate-induced changes began to occur gradually over the past 25 years. Climate data compared with emic perception confirm these results. We find that changes, particularly climate-induced changes, increase local inequalities. The shift in land use to fish farming, partly driven by the motivation to adapt to waterlogging and salinisation, increases the waterlogging problem locally. As a result, farms are submerged, production is lost, and fewer jobs are available locally. Smallholder farmers suffer more than wealthier farmers and have more difficulty covering the losses associated with these changes and the costs associated with adaptations. Fishermen are converting to unskilled work, and unskilled and landless workers migrate to other rural destinations for labour.