At-risk Households Research Articles

Identifying Jurisdictions at Risk of Containing Housing Units With Deteriorated Paint: Results and Targeting Implications for the US Department of Housing and Urban Development.

The US Department of Housing and Urban Development provides millions in annual funding to make low-income housing lead safe, but funds are limited relative to need. To adequately target efforts, local program administrators must identify neighborhoods that are the most "at risk" of residential lead exposure; however, no federal agency currently provides a public data set for this use. To examine pre-1980 households with large areas of deteriorated paint, a significant and common predictor of lead dust, and identify high-risk jurisdictions. To highlight the potential use of a newly available data set for strategic lead poisoning prevention and targeting. Microdata from the 2011 American Housing Survey and the 2009-2013 American Community Survey were used to develop a household-level predicted risk metric that identifies housing units at risk of containing large areas of deteriorated paint. Predicted risk, defined as the mean predicted percentage of occupied housing units at risk of containing deteriorated paint within a given jurisdiction, was summarized by state, county, and tract. National, all occupied housing units. Occupied housing units summarized by household (n = 9 363 000), census tract (n = 72 235), county (n = 3143), and state (n = 51). Housing units built prior to 1980 with a large area of deteriorated paint. New York, Rhode Island, New Jersey, Massachusetts, and Pennsylvania had the highest predicted percentage of at-risk households (range: 2.52%-2.90%). County-level and tract-level estimates are the most useful when examining a predefined jurisdiction; New York state was presented as a case study. County-level quartile risk scores revealed Albany as an at-risk jurisdiction. Tract-level quartile risk scores further identified at-risk neighborhoods in northeastern Albany. Findings can help housing and health policy makers identify and target geographic areas with a high probability of households at risk of potential exposure to deteriorated lead-based paint.

Preferences for improved early warning services among coastal communities at risk in cyclone prone south-west region of Bangladesh

Cyclone early warning systems are the primary sources of information that enable people to develop a preparedness strategy to mitigate the hazards of cyclones to lives and livelihoods. In Bangladesh, cyclone early warnings have significantly decreased the number of cyclone related fatalities over the last two decades. Nevertheless, several challenges remain for existing early warning services (EWS), urging for both technical and non-technical improvements in the said services. Given limited financial resources, the economic efficiency assessment of the improvement is highly important. Therefore, this study aims to estimate the willingness to pay (WTP) for improved warning services by considering the at-risk households' trade-off between proposed improved EWS and existing EWS in coastal Bangladesh. Applying systematic random sampling, 490 respondent households were selected from Khulna, Satkhira, and Barguna districts, with whom a choice experiment (CE) was performed. The CE was designed by incorporating impact-based scenarios for improved EWS. As analytical tools, Conditional and Mixed-Logistic regression models were used that derived the WTP for improved EWS attributes. Empirical results show that the WTP of an at-risk household for improved EWS was estimated at Bangladeshi Taka BDT 468 (≈ US$ 5.57) per year, implying respondents were ready to pay for the improvement of the warning attributes, including precise information of the cyclones landfall time with possible impacts, more frequent radio forecasts, and voice messages in the local dialects over mobile phones. A revenue stream for improved EWS was developed, implying investments in EWS would be a no-regrets approach. This study concludes with four policy recommendations on mitigating the existing challenges for improving EWS in Bangladesh.

PROTOCOL: The effects of empowerment-based nutrition interventions on the nutritional status of adolescent girls in low- and middle-income countries.

PROTOCOL: The effects of empowerment-based nutrition interventions on the nutritional status of adolescent girls in low- and middle-income countries.

Protocol for the Development of a Food Stress Index to Identify Households Most at Risk of Food Insecurity in Western Australia.

Food stress, a similar concept to housing stress, occurs when a household needs to spend more than 25% of their disposable income on food. Households at risk of food stress are vulnerable to food insecurity as a result of inadequate income. A Food Stress Index (FSI) identifies at-risk households, in a particular geographic area, using a range of variables to create a single indicator. Candidate variables were identified using a multi-dimensional framework consisting of household demographics, household income, household expenses, financial stress indicators, food security, food affordability and food availability. The candidate variables were expressed as proportions, of either persons or households, in a geographic area. Principal Component Analysis was used to determine the final variables which resulted in a final set of weighted raw scores. These scores were then scaled to produce the index scores for the Food Stress Index for Western Australia. The results were compared with the Australian Bureau of Statistics’ Socio-Economic Indexes for Areas to determine suitability. The Food Stress Index was found to be a suitable indicator of the relative risk of food stress in Western Australian households. The FSI adds specificity to indices of relative disadvantage specifically related to food insecurity and provides a useful tool for prioritising policy and other responses to this important public health issue.

Shared Reading Quality and Brain Activation during Story Listening in Preschool-Age Children

To explore the relationship between maternal shared reading quality (verbal interactivity and engagement) and brain function during story listening in at-risk, preschool-age children, in the context of behavioral evidence and American Academy of Pediatrics, recommendations. In this cross-sectional study, 22 healthy, 4-year-old girls from low socioeconomic status households completed functional magnetic resonance imaging using an established story listening task, followed by videotaped observation of uncoached mother-daughter reading of the same, age-appropriate picture book. Shared reading quality was independently scored applying dialogic reading and other evidence-based criteria reflecting interactivity and engagement, and applied as a predictor of neural activation during the functional magnetic resonance imaging task, controlling for income and maternal education. Shared reading quality scores were generally low and negatively correlated with maternal distraction by smartphones (P < .05). Scores were positively correlated with activation in left-sided brain areas supporting expressive and complex language, social-emotional integration, and working memory (P <.05, false discovery rate corrected). Maternal shared reading quality is positively correlated with brain activation supporting complex language, executive function, and social-emotional processing in at-risk, preschool-age children. These findings represent novel neural biomarkers of how this modifiable aspect of home reading environment may influence foundational emergent literacy skills, reinforce behavioral evidence and American Academy of Pediatrics, recommendations, and underscore the potential of dialogic reading interventions to promote healthy brain development, especially in at-risk households.

Can Strategies to Cope with Hazard Shocks be Explained by At-Risk Households\u2019 Socioeconomic Asset Profile? Evidence from Tropical Cyclone-Prone Coastal Bangladesh

This article documents the results of an empirical investigation on the complex interplay between diverse coping mechanisms and the socioeconomic asset profiles of coastal households at risk. Focusing on household-level perceptions and responses to cyclone hazards, a case study was carried out in a poor area in Bangladesh that is prone to natural hazards. We developed and tested our own analytical models based on the asset approach. We conducted a face-to-face household survey in southwestern coastal Bangladesh, in the Koyra sub-district, in late 2009. We asked 360 households affected by the May 2009 tropical Cyclone Aila about their hazard perceptions, preparedness, coping practices, and socioeconomic assets. The results suggest that the majority of households at risk perceive an increasing trend of different climate hazards, with a distinct dominance of tropical cyclones, storm surges, and flash floods in the study area, which resulted in a yearly average economic damage of USD 144 for each household in the first year after Aila. However, such damage is significantly and inversely correlated with the number of adopted coping practices. Significant and systematic differences exist between upstream and downstream households in the study area with respect to hazard perception, hazard induced damages, asset accessibility, and adopted diversified coping practices. The empirical findings suggest that the degree of adoption of coping practices depends primarily on elements of socioeconomic asset profile and the duration of the consequences of cyclone hazards. Disaster preparedness training seems to improve at-risk households’ degree of information access and eventually leads them to adopt more coping practices to reduce adverse impacts of climate hazards. Area-specific practical modules on coping practices should be incorporated in curricula of disaster preparedness training to make people at risk more resilient to hazard shocks.

A Burgeoning Crisis? A Nationwide Assessment of the Geography of Water Affordability in the United States.

While basic access to clean water is critical, another important issue is the affordability of water access for people around the globe. Prior international work has highlighted that a large proportion of consumers could not afford water if priced at full cost recovery levels. Given growing concern about affordability issues due to rising water rates, and a comparative lack of work on affordability in the developed world, as compared to the developing world, more work is needed in developed countries to understand the extent of this issue in terms of the number of households and persons impacted. To address this need, this paper assesses potential affordability issues for households in the United States using the U.S. EPA’s 4.5% affordability criteria for combined water and wastewater services. Analytical results from this paper highlight high-risk and at-risk households for water poverty or unaffordable water services. Many of these households are clustered in pockets of water poverty within counties, which is a concern for individual utility providers servicing a large proportion of customers with a financial inability to pay for water services. Results also highlight that while water rates remain comparatively affordable for many U.S. households, this trend will not continue in the future. If water rates rise at projected amounts over the next five years, conservative projections estimate that the percentage of U.S. households who will find water bills unaffordable could triple from 11.9% to 35.6%. This is a concern due to the cascading economic impacts associated with widespread affordability issues; these issues mean that utility providers could have fewer customers over which to spread the large fixed costs of water service. Unaffordable water bills also impact customers for whom water services are affordable via higher water rates to recover the costs of services that go unpaid by lower income households.

The Effect of Introducing a Minimum Price on the Distribution of Alcohol Purchase: A Counterfactual Analysis.

We use counterfactual analysis techniques to evaluate the impact of a $2 minimum unit price (MUP) on the distribution of Australian (Victorian) household off-trade alcohol purchases. Our estimates suggest that a $2 MUP significantly reduces the purchases of at-risk households by up to -0.92 [90% CI: -1.55, -0.28] standard drinks at the highest quantiles and has substantially less effect on households purchasing at light and moderate levels. A $2 MUP may reduce the proportions of male and female shoppers purchasing at the public health threshold of more than two standard drinks per household member per day by -3.03 [90% CI: -4.83, -1.22] percentage points (relative variation: -17%); and -1.85 [90% CI: -2.60, -1.10] percentage points (relative variation:-22%), respectively. Implementing an MUP on alcohol thus promises significant positive impacts on public health. Copyright © 2016 John Wiley & Sons, Ltd.

Food Acquisition in Poughkeepsie, NY:

This article provides and examines empirical evidence in order to evaluate scholarly, professional and activist perspectives that view food insecurity as a function of the stratification of food consciousness. This concept highlights causal models of food insecurity that emphasize micro-level and idealist factors to explain why stratified groups hold distinct attitudes and preferences regarding food provisioning and consumption. An empirical model is developed for the household activity of food acquisition, and the hypothesized preferences of food-insecure and other at-risk urban households are investigated for foods and stores that promote unhealthy eating. The data come from a community food assessment survey in the city of Poughkeepsie, New York, administered to a probabilistic sample of 355 city households. Evidence is found that disproves the stratification of food consciousness model for food acquisition, and debates and research are directed toward more significant factors and contexts of food insecurity.

The distributional consequences of future flood risk management in England and Wales

Much flood risk management (FRM) research has examined the predicted increased burden of risk from future climate change. In contrast, this paper examines the changing funding regime for FRM and arrangements for flood insurance in the UK today. These changes, after the 1998–2013 period of severe and repeated flooding, may considerably increase the burden for at-risk households, but affect different groups differently, raising the question as to how to manage the risk and who should pay for this risk management. We explore this through scenarios incorporating modelled changes both to government investment to reduce risk and to flood insurance. The key findings are that moving towards a more risk-based approach could move the burden hugely, particularly onto financially deprived at-risk households, such that both investment and insurance could be unaffordable or unavailable. As insurance becomes more risk based, deprived households are less likely to purchase cover, but higher costs might incentivise those at risk to adapt to the risk they face. In the end, society has to decide whether to promote more substantial incentives discouraging occupation of the floodplain, with the likely adverse consequences for those there who are financially deprived, or retain the current discouragement of self-help.

The distributional consequences of future flood risk management in England and Wales

Much flood risk management (FRM) research has examined the predicted increased burden of risk from future climate change. In contrast, this paper examines the changing funding regime for FRM and arrangements for flood insurance in the UK today. These changes, after the 1998–2013 period of severe and repeated flooding, may considerably increase the burden for at-risk households, but affect different groups differently, raising the question as to how to manage the risk and who should pay for this risk management. We explore this through scenarios incorporating modelled changes both to government investment to reduce risk and to flood insurance. The key findings are that moving towards a more risk-based approach could move the burden hugely, particularly onto financially deprived at-risk households, such that both investment and insurance could be unaffordable or unavailable. As insurance becomes more risk based, deprived households are less likely to purchase cover, but higher costs might incentivise those at risk to adapt to the risk they face. In the end, society has to decide whether to promote more substantial incentives discouraging occupation of the floodplain, with the likely adverse consequences for those there who are financially deprived, or retain the current discouragement of self-help.

Conceptual framework and quantification of population vulnerability for effective emergency response planning.

The study focused on the methodological advancement and analytical approach of using multilevel data to define population vulnerability and risk in bioemergency disaster planning. The authors considered two types of vulnerabilities, transportation vulnerability that stems from lack of access to transportation (public or private) and communication vulnerability that stems from unavailability of needed language-specific communication resources. The authors used Transit Authority general transit feed data and the American Community Survey 5-year estimate data (2006-2010 summary files) to quantify these vulnerabilities. These data were integrated with Topologically Integrated Geographic Encoding and Referencing (TIGER) data for spatial analysis. A response plan was generated for Tarrant County, TX, and deemed feasible before consideration of vulnerable populations. The results point to the importance of integrating geographical and population demographic features that represent potential barriers to the optimum distribution and utilization of resources into the analysis of response plans. An examination of transportation vulnerabilities indicate that, of those vulnerable in Tarrant County, nearly 23,000 individuals will be at-risk of not being able to reach the Point Of Dispensing (POD) to obtain services as they are beyond walking distance to the POD and lack access to transportation resources. The analysis of language vulnerability depicts an uneven distribution resulting in nonuniform demand at PODs for translation resources. There are more than 11,000 at-risk households in the South East region of Tarrant County alone that are truly in need of translation services. The authors demonstrated that multiple vulnerabilities at each POD can be quantified by aggregating the vulnerability at the available granularity (ie, all blocks or block groups) in a given service area. The quantification of vulnerability at each service area facilitates a POD-based at-risk analysis for the response plan. Disparities stemming from social, behavioral, cultural, economic, and health characteristics of diverse subpopulations could induce the need for additional targeted resources to support emergency response efforts.

Rising Food Insecurity and Conservative Policy in the US: Impact on the Elderly

&lt;em&gt;Food insecurity, a critical problem in the developing world, has recently received increased attention among wealthy nations. Food insecurity, broadly defined, is when a lack of resources prevents household members from having enough food. In the US, food insecurity has been rising while social safety net programs to ameliorate hunger among at-risk households have been targeted for cuts by conservatives. Our main objective was to assess the prevalence and impact of food insecurity among the elderly. In a survey of 500 older, homebound meal clients in New York City, we found that nearly one in five (17%) is food insecure, 89% endure chronic health problems, 14% live with severe functional impairments, 38% are in declining health, and 10% experience unmet needs for services. New York City’s oldest community residents have serious health problems, multiple unmet social service needs, and often suffer from food insecurity. Understanding the relationship between these issues is critical if community organizations and government agencies at all levels—even in wealthy countries—are to be more effective in assuring the well being of their oldest residents.&lt;/em&gt;

Estimating the number of vulnerable people in the United States exposed to residential wood smoke: Rogalsky et al. Respond.

We appreciate the thoughtful comments by Noonan et al. and consider them an important contribution to the dialogue surrounding the public health issue of residential wood smoke. Their comments accurately reflect and deal fairly with the issues raised in our recent article, “Estimating the Number of Low-Income Americans Exposed to Household Air Pollution from Burning Solid Fuels” (Rogalsky et al. 2014). Absent the availability of new data on household exposure to residential wood smoke in the United States, we agree that it is challenging to develop an accurate estimate of the potential risk. It is true that we were purposefully conservative in our assumptions in order to estimate the household air pollution (HAP) burden among the most vulnerable Americans. We appreciate the alternate estimate that Noonan et al. have offered, although we would argue that their estimate likely includes a significant number of individuals with only intermittent exposure to high levels of HAP. Our estimate began with the 2.8 million households that use wood, coal, or coke as the primary means of household heating, but we also recognize that an additional 8.8 million homes use wood as a secondary heating source. Nearly 5 million households from these two groups use a wood-burning stove, whereas the remainder typically use fireplaces. We believe that it is reasonable to assume that primary users heat their homes daily with wood during the heating season, but this assumption does not hold for secondary users. An unknown but significant number of these households may heat their homes with wood only on rare occasions, resulting in less frequent HAP exposure. Noonan et al. excluded homes with wood-burning fireplaces in their estimate because the frequency of use in this group is unknown, but they did include secondary users of wood stoves for whom there are also no data. Combining all secondary users of a wood stove into the same group as primary users likely includes many homes with infrequent or episodic HAP exposure. Noonan et al. also note that we were conservative in our estimate by limiting the at-risk households to those below the federal poverty level. Children and the elderly residing in homes that burn wood may certainly reflect an at-risk population regardless of socioeconomic status, and this notion does merit consideration. However, by not focusing on poverty, Noonan et al. bring into their estimate all wood stove users, including the most affluent users most likely to have clean-burning stoves with regular maintenance. This is an important point for discussion and further research because—as is clear from previous work on this topic, much of it done by Noonan, Ward, and colleagues—even in communities with a relatively high proportion of the population below the federal poverty level, only 53–65% of homes exceed the World Health Organization standard for particulate matter of < 2.5 µm/24 hr (Noonan et al. 2012; World Health Organization 2005). It is unclear, given the current published data on the subject, whether this proportion of homes would be different in more affluent communities, but it seems likely, given the data from international sources that strongly link poverty and HAP from burning solid fuels (World Bank 2011). Noonan et al. are correct in pointing out the limitations inherent in our estimates. Our estimates did not account for the regional and neighborhood effects of wood smoke. This is relevant because communities with a high proportion of wood-burning homes experience significant infiltration of outdoor air pollution. Unfortunately, from an estimation standpoint, these issues are extremely variable by region and weather patterns and are not easily incorporated into national estimates such as ours. However, it bears repeating that the negative health effects of HAP have been demonstrated most consistently in those with daily, chronic exposure to high concentrations of particulate matter; therefore, it seems likely that frequent direct exposure would correlate most closely with the negative health impacts (World Bank 2011). Ultimately, in our research, we and Noonan et al. struggle with a lack of available data on exposure to HAP in U.S.-based households. Going forward, we recommend that future studies include measures such as household, personal, and ambient air monitoring to determine whether levels are consistent with impairment of human health and how frequently these levels are attained in such households. We also recommend that the U.S. Census Bureau should, in the next installment of the American Community Survey, ask respondents to quantify how frequently they use their wood-burning appliances or fireplaces to heat their homes as either a primary or secondary source of heating. This information would allow researchers to better understand the overall number of Americans potentially at risk. HAP is an environmental justice issue of clear public health importance, both globally and in its disproportionate impact on mostly rural Americans. We wholeheartedly join Noonan et al. in advocating for those affected.

Household saving in Australia

AbstractThis paper investigates household saving behavior in Australia, as well as the drivers behind the recent rise in the aggregate household saving ratio. Our results explaining differences in saving behavior across households are consistent with theory and previous findings. As might be expected, households’ saving ratios tend to increase with income, but decrease with wealth and gearing. More at-risk households such as single-parent and migrant households tend to save more than other households, all else being equal. While saving differs substantially across age groups we find that, at least in part, this reflects differing circumstances. Our results suggest that the rise in household saving between 2003/2004 and 2009/2010 was driven by changes in behavior rather than changes in population characteristics: in particular, more educated households, as well as households with high debt and/or wealth increased their propensity to save. Our interpretation of these results is that a reduction in future income growth expectations for more highly educated households after the financial crisis, and an associated effort to rebuild wealth and repay debt, drove to the aggregate rise in household saving.

The role of wild foods in food security: the example of Timor-Leste

Many rural households in the developing world are subject to chronic seasonal food insecurity. Often cited among coping strategies is foraging for wild foods. This study was to understand the role of wild food in household food security in Timor-Leste. Information on wild food use comes from three sources: a) a longitudinal study of food consumption among 14 subsistence farmer households across four districts in 2006–2007; b) a survey in 2011 of 1,800 farmer households across all 13 districts in Timor-Leste; and c) a survey of 64 households from eight community seed groups in three districts in 2013. The consumption of wild food fluctuated widely across the year with consumption much reduced in the wet season (December – April) compared to the dry season (May – November). Wild food use in a normal year – 2006–2007 and a food-deficit year – 2011, characterized by a severe hungry season, were compared. In the normal year the maize grain store was exhausted in 50 % of households (expressed as cumulative percentage of ‘at risk’ households) during the month of August and the percent of households consuming wild food was 9.2 %. By contrast in the food deficit year, maize grain stores were typically exhausted 2 months earlier than in a normal year, and 50 % of all interviewed households were foraging for wild food by May in four districts. Clearly in the food deficit season wild food foraging was dramatically increased compared to a normal year, particularly by poor at-risk households. The early depletion of grains store stocks under food insecurity resulted in greater coincidence of the period of wild food foraging with the hungry season than in a normal year. In two surveys there were clear differences between districts in the extent of wild food foraging. The most widely eaten wild plant foods in Timor-Leste are lesser yam (Dioscorea esculenta considered wild in Timor-Leste) followed by elephant’s foot yam (Amorphophallus paeoniifolius) and bitter bean (Phaseolus lunatus). Looking to the future in Timor-Leste, the wild food resource will continue to provide an important food buffer in deficit years especially to poor at-risk households, increasing their resilience and reducing their vulnerability.

Savings and prize-linked savings accounts

Many households have insufficient savings to handle moderate and routine consumption shocks. Many of these financially fragile households also have the highest lottery expenditures as a proportion of income. This combination suggests that prize-linked savings (PLS) accounts, combining security of principal with lottery-type jackpots, can increase savings among these at-risk households. Results from an online experiment show that the introduction of PLS accounts increase total savings and reduce lottery expenditures significantly, especially among individuals with the lowest levels of savings and income. The results imply that PLS accounts offer a plausible market-based solution to encourage individuals to increase savings.

Household malaria knowledge and its association with bednet ownership in settings without large-scale distribution programs: Evidence from rural Madagascar.

BackgroundInsecticide–treated bednets are effective at preventing malaria. This study focuses on household–level factors that are associated with bednet ownership in a rural area of Madagascar which had not been a recipient of large–scale ITN distribution.MethodsData were gathered on individual and household characteristics, malaria knowledge, household assets and bednet ownership. Principal components analysis was used to construct both a wealth index based on household assets and a malaria knowledge index based on responses to questions about malaria. Bivariate and multivariate regressions were used to determine predictors of household bednet ownership and malaria knowledge.ResultsForty–seven of 560 households (8.4%) owned a bednet. In multivariate analysis, higher level of malaria knowledge among household members was the only variable significantly associated with bednet ownership (odds ratio 3.72, P < 0.001). Among respondents, predictors of higher malaria knowledge included higher education levels, female sex and reporting fever as the most frequent or dangerous illness in the community. Household wealth was not a significant predictor of bednet ownership or respondent malaria knowledge.ConclusionIn this setting of limited supply of affordable bednets, malaria knowledge was associated with an increased probability of household bednet ownership. Further studies should determine how such malaria knowledge evolves and if malaria–specific education programs could help overcome the barriers to bednet ownership among at–risk households living outside the reach of large–scale bednet distribution programs.

Rationale and design of the Primary pREvention strategies at the community level to Promote Adherence of treatments to pREvent cardiovascular diseases trial number (CTRI/2012/09/002981)

Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality in low-income countries including India. There is a need for effective, low-cost methods to prevent CVDs in rural India. One strategy is to identify and implement interventions at high-risk individuals using community health workers (CHWs). There is a paucity of CHW-based CVD intervention trials from low-income countries. We designed a multicenter, household-level, cluster-randomized trial with 1:1 allocation to intervention and control arms. The CHWs undertook a door-to-door survey and screened 5,699 households in 28 villages from 3 rural regions in India to identify at-risk households. The households were defined as those with ≥1 individual aged ≥35 years and at moderate or high risk for CVD based on the non-laboratory-based National Health and Nutrition Examination Survey score. All at-risk individuals were invited to attend a physician-led village clinic that provided a CVD risk reduction prescription and education about target risk factor levels for CVD control. All households in which at least 1 member at moderate to high risk for CVD had received a risk reduction prescription were eligible for randomization. Households randomized to the CHW-based intervention will receive 1 household visit by a CHW every 2 months, for 12 months. During these visits, CHWs will measure blood pressure, ascertain and reinforce adherence to prescribed therapies, and modify therapy to meet targets. Households randomized to the control arm do not receive CHW visits. At 12 months after randomization, we will evaluate 2 primary outcomes of systolic blood pressure and adherence to antihypertensive drugs and secondary outcomes of INTERHEART risk score, body mass index, and waist-to-hip ratios. At 18 to 24 months after randomization and 6 to 12 months after the last intervention, we will record these outcomes to evaluate sustainability of intervention. Community health workers screened a total of 5,033 households that included 9,248 individuals and identified 2,571 households with 3,784 at-risk individuals. We randomized 2,438 households (1,219 to intervention and 1,219 to control groups). Our large trial of CHWs in rural India will provide important information regarding a promising approach to primary prevention of CVDs.

Editorial: Why is community action needed for disaster risk reduction and climate change adaptation?

When disasters happen, the speed and effectiveness of response depends very heavily on local organizations that represent the needs of those most impacted and most vulnerable. As the paper by Jorgelina Hardoy, Gustavo Pandiella and Luz Stella Velasquez Barrero notes, it is at the local or neighbourhood level that disasters happen, lives and livelihoods are lost, houses and infrastructure damaged or destroyed, and health and education compromised. It is also at the local level that many of the disaster risks can be addressed before disasters occur. Much of the responsibility for disaster risk reduction falls to local governments and much of the death and destruction from disasters shows up the failings of local government. The success of post-disaster actions is also to a large extent determined by pre-disaster planning and awareness and readiness within local government and civil society organizations. In this way, community action and partnerships with local government are central not just to minimizing risk but also in responding to impact and shaping recovery in ways that can strengthen local livelihoods and quality of life. The papers in this issue bring to our attention the importance of community action – for disaster risk reduction, for post-disaster rebuilding and for climate change adaptation. The paper by Diane Archer and Somsook Boonyabancha highlights the energy and creativity of disaster-affected communities as they rebuild their homes and livelihoods far more effectively and far more cheaply than external agencies. The paper by Norberto Carcellar, Jason Christopher Rayos Co and Zarina O Hipolito describes the support programme developed by the Homeless People’s Federation of the Philippines for disaster-affected communities and for disaster risk reduction, and the benefits this brings to low-income disaster-affected or atrisk households. The paper by Cassidy Johnson reviews the roles of local civil society groups in Turkey after the 1999 earthquakes. And the paper by Mark Pelling considers the roles of community organizations in urban disaster risk reduction in Haiti, Guyana and the Dominican Republic. Other papers in this issue show the importance of community organizations in developing responses to disaster risk or in post-disaster rebuilding and in trying to get government support to do so. Furthermore, some papers have already been accepted for the April 2012 issue of Environment and Urbanization on the capacities of community organizations to map disaster risk and vulnerability and develop measures to address them. But is this focus on community organization appropriate for urban contexts? And what are the limits? Community organizations cannot design and build the citywide infrastructure that is so important for resilience to storms and heavy rainfall – for instance, storm and surface drains and road and bridge networks that can cope with sudden and much increased volumes of water. The paper by Mark Pelling describes how working with community organizations on risk mapping and awareness raising can lead to small works and provide a focus for group activities (e.g. building small bridges across drainage canals,