This study examined drivers and barriers of water, sanitation, and hygiene (WASH) policies in urban informal settlements in low and middle-income countries. We conducted a search of peer-reviewed and grey literature published between January 2000 and April 2018. We organized evidence into six domains of drivers and barriers: economic, spatial, social, institutional, political, and informational. Key drivers included donor prioritization and collective action, while key barriers included social exclusion, lack of land or dwelling tenure status, the political economy of decision-making, and insufficient data. Ensuring responsive water and sanitation policies for informal settlements will require inter-disciplinary collaboration and both top-down and bottom-up approaches.

Introduction Increasing urban populations have led to the growth of informal settlements, with contaminated environments linked to poor human health through a range of interlinked pathways. Here, we describe the design and methods for the Revitalising Informal Settlements and their Environments (RISE) study, a transdisciplinary randomised trial evaluating impacts of an intervention to upgrade urban informal settlements in two Asia-Pacific countries. Methods and analysis RISE is a cluster randomised controlled trial among 12 settlements in Makassar, Indonesia, and 12 in Suva, Fiji. Six settlements in each country have been randomised to receive the intervention at the outset; the remainder will serve as controls and be offered intervention delivery after trial completion. The intervention involves a water-sensitive approach, delivering site-specific, modular, decentralised infrastructure primarily aimed at improving health by decreasing exposure to environmental faecal contamination. Consenting households within each informal settlement site have been enrolled, with longitudinal assessment to involve health and well-being surveys, and human and environmental sampling. Primary outcomes will be evaluated in children under 5 years of age and include prevalence and diversity of gastrointestinal pathogens, abundance and diversity of antimicrobial resistance (AMR) genes in gastrointestinal microorganisms and markers of gastrointestinal inflammation. Diverse secondary outcomes include changes in microbial contamination; abundance and diversity of pathogens and AMR genes in environmental samples; impacts on ecological biodiversity and microclimates; mosquito vector abundance; anthropometric assessments, nutrition markers and systemic inflammation in children; caregiver-reported and self-reported health symptoms and healthcare utilisation; and measures of individual and community psychological, emotional and economic well-being. The study aims to provide proof-of-concept evidence to inform policies on upgrading of informal settlements to improve environments and human health and well-being. Ethics Study protocols have been approved by ethics boards at Monash University, Fiji National University and Hasanuddin University. Trial registration number ACTRN12618000633280; Pre-results.

Data on the prevalence of heavy menstrual bleeding in low-income and middle-income countries (LMICs) are scarce. We aimed to assess the validity of a scale to measure heavy menstrual bleeding and calculate its prevalence in southern Asia and sub-Saharan Africa, and to examine associations between heavy menstrual bleeding and health outcomes. Between Aug 2, 2021 and June 14, 2022, we surveyed 6626 women across ten cities (Meherpur and Saidpur, Bangladesh; Warangal, Narsapur, and Tiruchirappalli, India; Kathmandu, Nepal; Dakar, Senegal; Nairobi, Kenya; Kampala, Uganda; and Lusaka, Zambia), including questions on demographics, health, and the SAMANTA scale, a six-item measure of heavy menstrual bleeding. We conducted confirmatory factor analysis to assess construct validity of the SAMANTA scale, calculated the prevalence of heavy menstrual bleeding, and used regression analyses to examine associations of heavy menstrual bleeding with health outcomes. 4828 women were included in the final analytic sample. Factor analysis indicated a one-factor model representing heavy menstrual bleeding. In the pooled analytic sample, 2344 (48·6%) of 4828 women were classified as experiencing heavy menstrual bleeding, and the prevalence was lowest in Dakar (126 [38·3%] of 329 women) and Kampala (158 [38·4%] of 411 women) and highest in Kathmandu (326 [77·6%] of 420 women). Experiencing heavy menstrual bleeding was significantly associated with feeling tired or short of breath during the menstrual period (risk ratio 4·12 (95% CI 3·45 to 4·94) and reporting worse self-rated physical health (adjusted odds ratio 1·27, 95% CI 1·08 to 1·51), but was not associated with subjective wellbeing (β -3·34, 95% CI -7·04 to 0·37). Heavy menstrual bleeding is highly prevalent and adversely impacts quality of life in women across LMIC settings. Further attention is urgently needed to understand determinants and identify and implement solutions to this problem. Bill & Melinda Gates Foundation, United States Agency for International Development, National Institutes of Health.

The government of Bangladesh has implemented multiple policies since 1971 to provide the population with more diverse and nutritious diets. The aim of this study was to examine the drivers of dietary change over time and the roles agriculture and economic development have played. We used principal component analysis to derive dietary patterns from 7 cross-sectional rounds of the Bangladesh Household [Income and] Expenditure Survey. We then used linear probability models to estimate associations of adherence to dietary patterns with socio-economic characteristics of households, and with agricultural production on the household and regional level. For dietary patterns that increased or decreased over time, Blinder–Oaxaca decomposition was used to assess factors associated with these changes. Seven dietary patterns were identified: modern, traditional, festival, winter, summer, monotonous, and spices. All diets were present in all survey rounds. In 1985, over 40% of households had diets not associated with any identified pattern, which declined to 12% by 2010. The proportion of the population in households adhering to the modern, winter, summer, and monotonous diets increased over time, whereas the proportion adhering to the traditional diet decreased. Although many factors were associated with adherence to dietary patterns in the pooled sample, changes in observed factors only explained a limited proportion of change over time due to variation in coefficients between periods. Increased real per capita expenditure was the largest driver of elevated adherence to dietary patterns over time, whereas changes in the agricultural system increased adherence to less diverse dietary patterns. These findings highlight the need for both diversified agricultural production and a continued reduction in poverty in order to drive dietary improvement. This study lays the groundwork for further analysis of the impact of changing diets on health and nutrition.