Reviewing the current state of legacy POP-brominated flame retardants in plastic childcare products and toys: a scoping review protocol.

BACKGROUND: Due to their adverse environmental and health impacts, brominated flame retardants (BFRs) are listed in Annex A of the Stockholm Convention for global elimination of production and use. Their health impacts include endocrine disruption, cancer, reproductive effects, and neurobehavioral and developmental disorders in children. Emerging literature suggests that legacy POP-BFRs are increasingly found in consumer products, including those used for and by children. The presence of legacy POP-BFRs in children's products is a big concern. Children are more vulnerable to chemical exposure risks than adults because their bodies are still developing and fragile. The rising problem is contributed to by the global push towards a circular economy that encourages responsible production and consumption by practising the recycling of waste materials. Waste materials such as electronic and electrical equipment plastics often contain POP-BFRs. POP-BFRs in waste materials are transferred into new products through recycling. The recycled products have become a potential source of exposure to legacy POP-BFRs for vulnerable populations, particularly children. Our scoping review aims to map and summarise the emerging literature. This information is needed to inform evidence-based policies to protect children from toxic exposures. METHODS: Our scoping review will follow a methodological framework proposed by Arksey and O'Malley. Peer-reviewed and grey literature on the topic will be retrieved from electronic databases and other relevant sites. Two reviewers will screen titles and abstracts, followed by a full-text review of studies for eligibility based on the established inclusion and exclusion criteria. Data will be extracted, and findings will be mapped in a table according to study settings, types of children's products tested, and concentration of legacy POP-BFRs in contaminated products. A map chart will be created to display how contaminated products are spread globally. DISCUSSION: Because of their unique vulnerabilities, children continue to suffer disproportionate exposures to toxic chemicals compared to adults. Information on potential exposures, particularly for children, is crucial to make evidence-based policies. We intend to map and summarise the emerging literature on legacy POP-BFRs in children's products. Findings will be disseminated to relevant stakeholders through publishing in a peer-reviewed scientific journal and policy briefs. SYSTEMATIC REVIEW REGISTRATION: The protocol is registered with the Open Science Framework ( https://doi.org/10.17605/OSF.IO/7KDE5 ).

Evaluating and Enhancing an Educational Intervention to Reduce Smallholder Farmers' Exposure to Pesticides in Uganda Through a Digital, Systematic Approach to Behavior Change: Protocol for a Cluster-Randomized Controlled Trial.

BACKGROUND: Smallholder farmers receive educational interventions on safe pesticide handling by governmental agencies, industries, or nongovernmental organizations to reduce exposure risks. However, existing educational interventions have limited effects on changing behaviors. Targeting psychosocial determinants of behavior change in educational interventions through theory- and evidence-based approaches may enhance their effectiveness. OBJECTIVE: We aim at describing the intervention development and study design of a 3-arm cluster-randomized controlled trial to assess the effects in improving safe pesticide handling and reducing pesticide exposure of (1) an existing educational intervention and (2) a newly developed SMS text messaging intervention based on the Risks, Attitudes, Norms, Abilities, and Self-regulation (RANAS) behavior change approach. METHODS: We enrolled 539 Ugandan smallholder farmers in 12 clusters (subcounties). The clusters, each with 45 farmers, were randomly allocated to one of the three arms: (1) educational intervention, (2) educational intervention+RANAS-based SMS text messages, or (3) control group. The educational intervention comprised a 2-day workshop that targeted multiple aspects of safe pesticide handling, whereas the SMS text messages targeted the use of personal protective equipment (PPE) and were based on the RANAS approach. For intervention development in this study, this approach includes identifying psychosocial determinants of PPE use at baseline and selecting behavior change techniques to target them in SMS text messages. The primary outcomes of the study are (1) pesticide knowledge, attitude, and practice scores indicating performance throughout the educational intervention; and (2) frequency of PPE use. Secondary outcomes are the RANAS-based behavioral determinants of PPE use, the frequency of glove use, algorithm-based pesticide exposure intensity scores, and signs and symptoms of pesticide poisoning. The outcomes were assessed in structured interviews before the intervention (baseline) and at the 12-month follow-up. The effect of the interventions among the arms will be analyzed using the intervention arms and baseline measures as predictors and the follow-up measures as outcomes in linear multivariable mixed models including the clusters as random effects. The mediating psychosocial determinants of the interventions will be assessed in multiple mediation models. RESULTS: The study was conducted from 2020 to 2021-baseline interviews were conducted in October 2020, and the educational intervention was delivered in November 2020. The RANAS-based SMS text messages were developed based on the baseline data for relevant behavioral determinants of PPE use and sent between February 2021 and September 2021. Follow-up interviews were conducted in October 2021. Overall, 539 farmers were enrolled in the study at baseline; 8.3% (45/539) were lost to follow-up by the end of the study. CONCLUSIONS: This study will contribute to a better understanding of the effectiveness and behavior change mechanisms of educational interventions by using an experimental, cluster-randomized study design to improve pesticide handling among smallholder farmers. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number (ISRCTN) 18237656; https://doi.org/10.1186/ISRCTN18237656. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55238.

Environmental management cycles for chemicals and climate change, EMC4 : A new conceptual framework contextualizing climate and chemical risk assessment and management.

The environmental management cycles for chemicals and climate change (EMC4 ) is a suggested conceptual framework for integrating climate change aspects into chemical risk management. The interaction of climate change and chemical risk brings together complex systems that are imperfectly understood by science. Making management decisions in this context is therefore difficult and often exacerbated by a lack of data. The consequences of poor decision-making can be significant for both environmental and human health. This article reflects on the ways in which existing chemicals management systems consider climate change and proposes the EMC4 conceptual framework, which is a tool for decision-makers operating at different spatial scales. Also presented are key questions raised by the tool to help the decision-maker identify chemical risks from climate change, management options, and, importantly, the different types of actors that are instrumental in managing that risk. Case studies showing decision-making at different spatial scales are also presented highlighting the conceptual framework's applicability to multiple scales. The United Nations Environment Programme's development of an intergovernmental Science Policy Panel on Chemicals and Waste has presented an opportunity to promote and generate research highlighting the impacts of chemicals and climate change interlinkages. Integr Environ Assess Manag 2024;20:433-453. © 2023 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

Child and adolescent mortality associated with pesticide toxicity in Cape Town, South Africa, 2010-2019: a retrospective case review.

BACKGROUND: Poisoning of children after exposure to pesticides is a major public health concern, particularly in countries with poorer urban populations, such as South Africa. This may stem from the illegal distribution and domestic use of street pesticides, which are highly hazardous agricultural pesticides. The aim of this study was to profile paediatric deaths due to acute pesticide poisoning in the west-metropole of Cape Town, South Africa; to identify whether the active ingredients were highly hazardous pesticides according to the FAO and WHO; and to inform policy and public health interventions to prevent future exposures and mortality. METHODS: A retrospective and descriptive analysis of forensic post-mortem records (2010 to 2019) was conducted to identify cases of paediatric deaths (< 18 years old) in the west metropole of Cape Town, involving pesticide poisoning admitted to the Salt River mortuary (one out of 16 mortuaries in the Western Cape province). Demographic, circumstantial, autopsy, and toxicological information was captured. Descriptive statistics, together with chi-square tests, Fisher's probability tests, and Mann-Whitney U tests were used to analyse the data. RESULTS: In total, 54 paediatric pesticide deaths were identified, including 22 (40.7%) males and 32 (59.3%) females, out of 5,181 paediatric unnatural deaths admitted over the 10-year period. The median age of the decedents was 8.3 years (range: 1 day to 17.9 years), with the majority under five years (42.6%) or between 15 and 18 years old (40.7%). All incidents occurred in peri-urban areas of Cape Town, with most individuals being admitted to hospital (88.9%) for a median survival time of 4.8 h. Toxicological analysis was requested in 50 cases (92.6%) with the organophosphate pesticides terbufos (n = 29), methamidophos (n = 2) and diazinon (n = 2) detected most frequently. Adolescent (15-18 years) suicides (29.6%) and accidental child deaths (< 4 years) (18.5%) were common. CONCLUSIONS: Terbufos and methamidophos are highly hazardous pesticide (HHP) active ingredients registered in South Africa for agricultural uses, yet commonly sold as street pesticides for domestic use in lower socioeconomic areas. Reducing access and availability of toxic pesticides, especially through the illegal selling of street pesticides, and providing low toxic alternatives to poorer communities, may support mortality reduction initiatives. Mortality and toxicology data provide important, often overlooked, surveillance tools for informing policy and public health interventions to reduce toxic pesticide harm in local communities.

Current pesticide suicide surveillance methods used across the African continent: a scoping review protocol.

INTRODUCTION: Every year, more than 800 000 people die from suicides of which an estimated 20% are from pesticide ingestion. Multiple studies have estimated that around 77%-80% of these pesticide suicides occur in low/middle-income countries. The full burden of pesticide suicides in African countries remains poorly documented, one reason being the lack of systematic data collection. It is essential to know the number of pesticide suicide cases to guide prevention of further cases occurring. This can be done by informing policy and legislation, and the implementation of targeted bans, as well as raising community awareness around the use of these pesticides, training of healthcare personnel, and influencing the type and level of clinical facility investments into this area of healthcare. The scoping review aims to investigate how pesticide suicide deaths in Africa are recorded by exploring the various surveillance systems in place, as well as highlighting key limitations and data collection barriers. METHODS AND ANALYSIS: A scoping review will be carried out with the five-stage methodological frameworks set out by Arksey and O'Malley and the Joanna Briggs Institute. Studies in English that looked at pesticide suicide in African countries will be extracted and screened independently by two reviewers against the inclusion and exclusion criteria of this review. Studies' data will be extracted, and a descriptive synthesis developed of their main findings, as guided by the approach of Levac and colleagues. ETHICS AND DISSEMINATION: Ethics approval is not required for this review as no human participants will be involved. The study findings will be distributed in a peer-reviewed publication. REGISTRATION DETAILS: This protocol has been submitted for publication to BMJ Open.

Interventions to Reduce Pesticide Exposure from the Agricultural Sector in Africa: A Workshop Report.

Despite the fact that several cases of unsafe pesticide use among farmers in different parts of Africa have been documented, there is limited evidence regarding which specific interventions are effective in reducing pesticide exposure and associated risks to human health and ecology. The overall goal of the African Pesticide Intervention Project (APsent) study is to better understand ongoing research and public health activities related to interventions in Africa through the implementation of suitable target-specific situations or use contexts. A systematic review of the scientific literature on pesticide intervention studies with a focus on Africa was conducted. This was followed by a qualitative survey among stakeholders involved in pesticide research or management in the African region to learn about barriers to and promoters of successful interventions. The project was concluded with an international workshop in November 2021, where a broad range of topics relevant to occupational and environmental health risks were discussed such as acute poisoning, street pesticides, switching to alternatives, or disposal of empty pesticide containers. Key areas of improvement identified were training on pesticide usage techniques, research on the effectiveness of interventions targeted at exposure reduction and/or behavioral changes, awareness raising, implementation of adequate policies, and enforcement of regulations and processes.

Whose Jurisdiction Is Home Contamination? Para-Occupational 'Take-Home' Herbicide Residue Exposure Risks among Forestry Workers' Families in South Africa.

Para-occupational "take-home" exposure risks among forestry workers and their families in low-and middle-income countries (LMICs) have not been well characterized. This is a concern because research shows an association between chronic low-dose herbicide exposure and adverse health effects. This study explored take-home herbicide residue exposure risks among forestry workers in the Western Cape, South Africa, through the community-based participatory research approach of photovoice. A key finding of the study was the absence of provisions related to take-home exposure in the national legislation and workplace policies, which largely contributed to poor adherence to risk reduction practices at worksites, in addition to workers transporting residues to their homes. This study demonstrated evidence of the key omissions regarding take-home exposure at the policy level (e.g., recommendations for employers to reduce take-home risks among employees, and training of workers and their families on take-home exposure) and take-home herbicide residue exposure among worker's families, including children.

Pesticide Research on Environmental and Human Exposure and Risks in Sub-Saharan Africa: A Systematic Literature Review.

On the African continent, ongoing agriculture intensification is accompanied by the increasing use of pesticides, associated with environmental and public health concerns. Using a systematic literature review, we aimed to map current geographical research hotspots and gaps around environmental and public health risks research of agriculture pesticides in Sub-Saharan Africa (SSA). Studies were included that collected primary data on past and current-used agricultural pesticides and assessed their environmental occurrence, related knowledge, attitude and practice, human exposure, and environmental or public health risks between 2006 and 2021. We identified 391 articles covering 469 study sites in 37 countries in SSA. Five geographical research hotspots were identified: two in South Africa, two in East Africa, and one in West Africa. Despite its ban for agricultural use, organochlorine was the most studied pesticide group (60%; 86% of studies included DDT). Current-used pesticides in agriculture were studied in 54% of the study sites (including insecticides (92%), herbicides (44%), and fungicides (35%)). Environmental samples were collected in 67% of the studies (e.g., water, aquatic species, sediment, agricultural produce, and air). In 38% of the studies, human subjects were investigated. Only few studies had a longitudinal design or assessed pesticide's environmental risks; human biomarkers; dose-response in human subjects, including children and women; and interventions to reduce pesticide exposure. We established a research database that can help stakeholders to address research gaps, foster research collaboration between environmental and health dimensions, and work towards sustainable and safe agriculture systems in SSA.

Climate Change, Pesticides and Health: Considering the Risks and Opportunities of Adaptation for Zimbabwean Smallholder Cotton Growers.

There is potential for increased pesticide-related adverse health outcomes in the agricultural sector linked to adaptive increases in pesticide use necessitated, in part, by climate change-related increases in pest populations. To understand the role of adaptation practices in pesticide use and health risks, this study assessed Zimbabwean smallholder cotton farmers' adaptive responses linked to their climate change perceptions. In depth interviews were conducted with 50 farmers who had been growing cotton for at least 30 years. The study identified farmers' adaptation practices that increased their pesticide use, as well as those that presented opportunities for reducing pesticide use through non-pesticide-dependent adaptation pathways. The findings show that due to perceived climate change impacts, such as a shorter growing season, farmers were adopting a range of adaptive practices. These included changes in pest management practices, such as increasing pesticide spraying frequencies due to keeping ratoon crops, which were increasing farmers' overall pesticide use. Such incremental adaptive practices are potentially maladaptive, as they may increase farmers' pesticide-related health risks. Other practices, however, such as reducing cotton acreage and diversifying crops, resulting in transformational adaptation, suggest the existence of opportunities for decreasing overall pesticide use or totally eliminating pesticides from the farming system.

Controlling and preventing climate-sensitive noncommunicable diseases in urban sub-Saharan Africa.

Research continues to highlight the link between climate change and health outcomes. There is, however, limited evidence in research, policies and in the Sustainable Development Goals (SDGs) about the impact of environmental factors on noncommunicable diseases (NCDs) for people living in urban areas of sub-Saharan Africa (SSA). Important is that 80% of NCDs are taking place in low- and middle-income countries (LMICs) and linked to a third of the deaths in SSA. The question is, what would these statistics look like if environmental risk factors (e.g., pollution, chemicals) for NCDs, linked to climate change, were prevented and controlled. This article presents a framework for understanding climatic pathways' impacts on climate-sensitive NCDs and achieving the SDGs. It further explains how current global mitigation interventions in high income urban settings, with implied health co-benefits for NCD reduction (i.e., promoting use of less polluting vehicles, bicycles, walking, public transport, green spaces), experience major implementation challenges in SSA cities (i.e., too costly, lack of availability, poor road conditions, gender and cultural norms, security problems). Recommendations are made for applying this framework to control climate change impacts on NCDs and achieving the SDGs in SSA cities. These include, support for more research on the climate - NCD nexus, ensuring health professional training includes sustainable health education, and including a focus on climate change and health in primary and secondary school curricula. Further recommendations for addressing climate-sensitive NCDs and urban environmental health towards achieving and sustaining the SDGs, are linked to promoting climate-sensitive and health policies and governance, as well as controlling the influence of advertising. Lastly, improving communication of research findings for policy makers and the public in a manner for informed policy making, and how to comprehend this information to promote the reduction and prevention of NCDs in urban SSA, is key.

Evaluating a South African mobile application for healthcare professionals to improve diagnosis and notification of pesticide poisonings.

BACKGROUND: Mobile health is a fast-developing field. The use of mobile health applications by healthcare professionals (HCPs) globally has increased considerably. While several studies in high income countries have investigated the use of mobile applications by HCPs in clinical practice, few have been conducted in low- and middle-income countries. The University of Cape Town developed a pesticide notification guideline which has been adapted and embedded into a South African Essential Medical Guidance mobile application. This study evaluated the usefulness of the guideline within a mobile application for improving the ability of HCPs to diagnose and notify on acute pesticide poisonings (APPs). METHODS: A descriptive online questionnaire, with 15 open- and 20 closed-ended questions, was completed by 50 South African emergency medicine physicians and registrars (i.e. medical doctors training as specialists) between December 2015 to February 2016. Descriptive statistics were used to calculate response frequencies and percentages using SPSS version 23. Texts from the open-ended questions were thematically analysed. Fisher's exact test was applied to determine associations. RESULTS: A significant association was found between participants' knowledge that APP is a notifiable condition, and ever reporting the poisoning to the National Department of Health (p = 0.005). Thirty four percent of the participants were aware of the guideline within the Essential Medical Guidance application despite only seven participants having used it. Those who used the guideline found it provided useful information for the identification of unlabelled pesticides products and promoted reporting these cases to the National Department of Health for surveillance purposes. In addition, it appeared to facilitate the prompt diagnosis and treatment of APP cases, and most intended to continue using it for training and educational purposes. CONCLUSIONS: Mobile health applications appear to support overburdened medical education programmes and promote better patient care. However, since most participants were not aware of the existence of the pesticide guideline within the studied essential medicine application, there is potential for the use of healthcare applications to play a more central role in healthcare systems and medical training. Furthermore, the field of medical informatics could support HCPs through mobile applications in improving reporting of APP.

Part of the solution - an engaged scholarship approach for the sustainable reduction of street pesticides and poisonings.

In low-income townships, pests are rife, a nuisance and are vectors of disease. Although alternatives are available, chemical means of pest control is often the first resort due to lack of knowledge of other methods, convenience and presumed efficacy. The demand for chemical pest control has created a unique business opportunity for informal vendors in South Africa servicing predominately low socio-economic communities. That is the selling of 'street pesticides', which are either containing agricultural pesticides too toxic for domestic use or illegally imported products. Poisonings from street pesticide exposures, particularly in children, are increasingly common and, along with pest-related diseases, creates a double burden of disease. Solutions are needed to decrease these incidences and to develop pest control strategies that are low- or non-toxic. It is imperative that, for sustainable problem-solving, all stakeholders, including vendors, be part of the solution in tackling this public health issue. This manuscript outlines an engaged scholarship approach for developing a sustainable resolution for reducing street pesticide use. This cyclical and iterative approach encompasses: the establishment of relationships, co-creation of solutions, co-implementation, co-monitoring, co-evaluation, co-reflection and co-re-design. The significance of the research and proposed engagement are discussed, as are anticipated challenges.

Priority focus areas for a sub-national response to climate change and health: A South African provincial case study.

INTRODUCTION: The intersection of health and climate change is often absent or under-represented in sub-national government strategies. This analysis of the literature, using a new methodological framework, highlights priority focus areas for a sub-national government response to health and climate change, using the Western Cape (WC) province of South Africa as a case study. METHODS: A methodological framework was created to conduct a review of priority focus areas relevant for sub-national governments. The framework encompassed the establishment of a Project Steering Group consisting of relevant, sub-national stakeholders (e.g. provincial officials, public and environmental health specialists and academics); an analysis of local climatic projections as well as an analysis of global, national and sub-national health risk factors and impacts. RESULTS: Globally, the discussion of health and climate change adaptation strategies in sub-national, or provincial government is often limited. For the case study presented, multiple health risk factors were identified. WC climatic projections include a warmer and potentially drier future with an increased frequency and intensity of extreme weather events. WC government priority focus areas requiring further research on health risk factors include: population migration and environmental refugees, land use change, violence and human conflict and vulnerable groups. WC government priority focus areas for further research on health impacts include: mental ill-health, non-communicable diseases, injuries, poisonings (e.g. pesticides), food and nutrition insecurity-related diseases, water- and food-borne diseases and reproductive health. These areas are currently under-addressed, or not addressed at all, in the current provincial climate change strategy. CONCLUSIONS: Sub-national government adaptation strategies often display limited discussion on the health and climate change intersect. The methodological framework presented in this case study can be globally utilized by other sub-national governments for decision-making and development of climate change and health adaptation strategies. Additionally, due to the broad range of sectoral issues identified, a primary recommendation from this study is that sub-national governments internationally should consider a "health and climate change in all policies" approach when developing adaptation and mitigation strategies to address climate change.

Toxic layering through three disciplinary lenses: childhood poisoning and street pesticide use in Cape Town, South Africa.

This article focuses on the devastating hidden perils of agricultural pesticides repurposed by informal sellers in urban South African townships to kill rats and other unwanted pests. Drawing on collaborative research techniques, we investigate the causal relationship between child poisoning episodes and the household use of illegal street pesticides. Such pesticides are used to safeguard homes from pests in an attempt to protect children from the harmful consequences of rodent bites and vectorborne diseases. Here, we consider the social injustice and economic inequality of episodes of child pesticide poisoning in the Western Cape from three disciplinary perspectives: public health, medical anthropology and fine art. We ultimately seek to demonstrate the complex relationship between the political economy of sanitation, waste removal and insecure housing, and the proliferation of rodents and other pests in urban townships. As a contribution to the medical humanities, the paper leans into different disciplines to highlight the toxic layering at play in a child pesticide poisoning event. The public health perspective focuses on the circulation of illegal street pesticides, the anthropologists focus on the experiences of the children and caregivers who are victims of poisoning, and the fine artist centres the rat within a broader environmental context. While non-toxic methods to eliminate rats and household pests are critical, longer term structural changes, through environmental and human rights activism, are necessary to ameliorate the suffering caused by poisoning. The medical and health humanities is well poised to highlight creative ways to draw public attention to these challenges, as well as to bridge the divide between science and the humanities through collaborative research efforts. With this paper we set the stage for discussing and balancing perspectives when addressing pest control in poor urban communities.

Climate variability, perceptions and political ecology: Factors influencing changes in pesticide use over 30 years by Zimbabwean smallholder cotton producers.

Pesticides represent a potential public health hazard of note in farming communities. Accumulating evidence indicates that some pesticides used in agriculture act as hormone disrupters, with the potential to result in chronic health effects. Despite such a growing evidence base, pesticides remain the preferred method of pest control in agriculture worldwide. In many parts of Sub-Saharan Africa, usage is on the increase. This qualitative study assessed changes in the usage of pesticides by Zimbabwean smallholder cotton farmers in the past 30 years. Farmers reported an increase in the usage of pesticides, specifically insecticides, since the early 1980s. An increase in pest populations was also reported. The findings suggested a bi-directional causal relationship between the increase in pest population and the increase in pesticide use. Factors which emerged to have collectively impacted on the changes include climate variability, limited agency on the part of farmers, power dynamics involving the government and private cotton companies and farmers' perceptions and practices. An Integrated Pest Management Policy for Zimbabwe is recommended to facilitate integration of chemical controls with a broad range of other pest control tactics. Continuous farmer education and awareness raising is further recommended, since farmers' perceptions can influence their practices.

Demographic determinants of chemical safety information recall in workers and consumers in South Africa: A cross sectional study.

BACKGROUND: Chemical hazard communication is intended to alert users of the potential hazards of chemicals. Hazard information needs to be understood and recalled. Recall of hazard communication is critical when the written form of the information is not available at the time it is required. METHODS: A cross-sectional study investigating associations between recall of chemical safety information on labels amongst 402 participants including 315 workers and 87 consumers in two provinces of South Africa. RESULTS: Respondents were predominantly male (67.7%), the median age was 37 years (IQR: 30-46years) and less than half of the participants completed high school (47.5%). Multivariate analysis identified the following positive associations with the recall of all the label elements listing the strongest association: call appropriate services and industrial vs consumer sector (OR=2.4; 95% CI: 1.2; 4.6 ); call appropriate services and transport vs consumer sector (OR=4.4; 95% CI: 1.2; 16.0); flammable symbol and male vs female gender (OR=2.3; 95% CI: 1.0; 5.3); flammable symbol and home language English vs African languages (OR=6.6; 95% CI: 2.1; 21.2); any hazard statement and home language Afrikaans vs African languages (OR=14.0; 95% CI: 3.6; 54.2), any first aid statement and further education vs none (OR=3.3; 95% CI: 1.3; 8.0), correct chemical name and industry blue collar workers vs non-industry blue collar workers (OR=2.6; 95% CI: 1.1; 6.1), correct chemical name and non-industry white collar occupations vs non-industry blue collar workers (OR=2.7; 95% CI: 1.0; 7.1). CONCLUSION: The study found a number of potential positive associations which influence recall of label elements of which some (e.g., sector, gender, occupation) suggest further research. Relevant policies in South Africa should ensure that the safety information on chemical labels is clearly visible to read and understandable which aids recall and the reduction in harmful chemical exposures.

Building an environmentally accountable medical curriculum through international collaboration.

BACKGROUND: Global environmental change is associated with significant health threats. The medical profession can address this challenge through advocacy, health system adaptation and workforce preparedness. Stewardship of health systems with attention to their environmental impacts can contribute to mitigation of and adaptation to negative health impacts of environmental change. Medical schools have an integral role in training doctors who understand the interdependence of ecosystems and human health. Yet integrating environmental perspectives into busy medical curricula is not a simple task. CONTENT: At the 2016 Association for Medical Education in Europe conference, medical educators, students and clinicians from six continents discussed these challenges in a participatory workshop. Here we reflect on emerging themes from the workshop and how to plan for curricular change. Firstly, we outline recent developments in environmental health and associated medical education. Secondly, we reflect on our process and outcomes during this innovative approach to international collaboration. Thirdly, we present learning objectives which cover core content for environmentally accountable medical curricula, developed through a reflective process of international collaboration integrating current literature and the workshop outcomes. CONCLUSIONS: International collaboration can bring together diverse perspectives and provide critical insights for the inclusion of environmental health into basic education for medical practitioners.

A Qualitative study of language barriers between South African health care providers and cross-border migrants.

BACKGROUND: Communication with health care providers represents an essential part of access to health care for the over 230 million cross-border migrants around the world. In this article, we explore the complexity of health communication from the perspective of cross-border migrants seeking antenatal care in Cape Town, South Africa in order to highlight the importance of high quality medical interpretation. METHODS: As part of a broader study of migrant maternal and infant nutrition, we conducted a secondary data analysis of semi-structured in-depth interviews (N = 23) with Congolese (n = 7), Somali (n = 8) and Zimbabwean (n = 8) women living in Cape Town, as well as nine focus group discussions (including men: n = 3 and women: n = 6) were conducted with migrant Somalis, Congolese, and Zimbabweans (N = 48). We first used content analysis to gather all data related to language and communication. We then analysed this data thematically. RESULTS: Zimbabwean participants described how the inability to speak the local South African language (IsiXhosa) gave rise to labelling and stereotyping by healthcare staff. Congolese and Somali participants described medical procedures, including tubal ligation, which were performed without consent. Partners often tried to play the role of interpreter, which resulted in loss of income and non-professional medical interpretation. Participants' highlighted fears over unwanted procedures or being unable to access care. Challenges of communication without a common language (and without professional medical interpretation), rather than outright denial of care by healthcare professionals, mediated these encounters. CONCLUSION: Although there are several factors impeding cross-border migrants' access to health care, effective communication is a prerequisite for quality care. Free-to-patient professional medical interpretation would not only benefit migrant populations but would benefit the broader community where language and health literacy are barriers to accessing health care. Novel approaches to language access may include technology-enabled professional interpretation.