Global Health Science Research Articles

Effects of Blood Lead Levels

Lead exposures among school-age children are a major public health issue. Although the harmful effects of lead exposure during the first years of life are well known, there is not as much understanding of the effects of low levels of lead exposure during later childhood. To review the effects of blood lead levels (BLLs) <10 µg/dL in school-age children and adolescents. We searched Medline, Embase, Global health, CINAHL, Scopus, and Environmental Science Collection databases between January 1, 2000, and May 11, 2023. We included peer-reviewed English-language articles that presented data on the effects of BLLs <10 µg/dL in individuals ages 5 through 18 years. Data on country, population, analytic design, sample size, age, BLLs, outcomes, covariates, and results were extracted. Overall, 115 of 3180 screened articles met the inclusion criteria. The reported mean or median BLL was <5 µg/dL in 98 articles (85%). Of the included articles, 89 (77%) presented some evidence of an association between BLLs <10 µg/dL during school age and detrimental outcomes in a wide range of categories. The strongest evidence of an association was for the outcomes of intelligence quotient and attention-deficit/hyperactivity disorder diagnoses or behaviors. Few articles controlled for BLLs at age <5 years, limiting conclusions about the relation between later BLLs and outcomes. BLLs <10 µg/dL in school-age children and adolescents may be associated with negative outcomes. This review highlights areas that could benefit from additional investigation.

Nothing But Nets: A Biography of Global Health Science and Its Objects by Kirsten Moore-Sheeley (review)

Nothing But Nets: A Biography of Global Health Science and Its Objects by Kirsten Moore-Sheeley (review)

Is detection of enteropathogens and human or animal faecal markers in the environment associated with subsequent child enteric infections and growth: an individual participant data meta-analysis

Quantifying contributions of environmental faecal contamination to child diarrhoea and growth faltering can illuminate causal mechanisms behind modest health benefits in recent water, sanitation, and hygiene (WASH) trials. We aimed to assess associations between environmental detection of enteropathogens and human or animal microbial source tracking markers (MSTM) and subsequent child health outcomes. In this individual participant data meta-analysis we searched we searched PubMed, Embase, CAB Direct Global Health, Agricultural and Environmental Science Database, Web of Science, and Scopus for WASH intervention studies with a prospective design and concurrent control that measured enteropathogens or MSTM in environmental samples, or both, and subsequently measured enteric infections, diarrhoea, or height-for-age Z-scores (HAZ) in children younger than 5 years. We excluded studies that only measured faecal indicator bacteria. The initial search was done on Jan 19, 2021, and updated on March 22, 2023. One reviewer (AM) screened abstracts, and two independent reviewers (AM and RT) examined the full texts of short-listed articles. All included studies include at least one author that also contributed as an author to the present Article. Our primary outcomes were the 7-day prevalence of caregiver-reported diarrhoea and HAZ in children. For specific enteropathogens in the environment, primary outcomes also included subsequent child infection with the same pathogen ascertained by stool testing. We estimated associations using covariate-adjusted regressions and pooled estimates across studies. Data from nine published reports from five interventions studies, which included 8603 children (4302 girls and 4301 boys), were included in the meta-analysis. Environmental pathogen detection was associated with increased infection prevalence with the same pathogen and lower HAZ (ΔHAZ -0·09 [95% CI -0·17 to -0·01]) but not diarrhoea (prevalence ratio 1·22 [95% CI 0·95 to 1·58]), except during wet seasons. Detection of MSTM was not associated with diarrhoea (no pooled estimate) or HAZ (ΔHAZ -0·01 [-0·13 to 0·11] for human markers and ΔHAZ -0·02 [-0·24 to 0·21] for animal markers). Soil, children's hands, and stored drinking water were major transmission pathways. Our findings support a causal chain from pathogens in the environment to infection to growth faltering, indicating that the lack of WASH intervention effects on child growth might stem from insufficient reductions in environmental pathogen prevalence. Studies measuring enteropathogens in the environment should subsequently measure the same pathogens in stool to further examine theories of change between WASH, faecal contamination, and health. Given that environmental pathogen detection was predictive of infection, programmes targeting specific pathogens (eg, vaccinations and elimination efforts) can environmentally monitor the pathogens of interest for population-level surveillance instead of collecting individual biospecimens. The Bill & Melinda Gates Foundation and the UK Foreign and Commonwealth Development Office.

Budgets and biologicals: The bio-economization of HIV governance

Changing global responses to HIV/AIDS entail shifting biological loci of surveillance which are believed to constitute HIV risk. Meanwhile, various local institutions and organizations are mobilized to play a key role in HIV service delivery and surveillance. Drawing on a socio-material approach to the body and the economy, this study theorizes the emergence of three ‘HIV service bio-economies’ devised to provide HIV services while controlling HIV transmission in Taiwan. Instead of presuming a divide between the social and the biological, it analyzes how different bodies are produced through differing modes of HIV surveillance and economization, buttressed by global health sciences, state budgets and quantitative metrics. The analysis of multiple ontologies of HIV underscores the political nature of risk-framing in a transnational context, but also how certain bodies incapable of being enrolled in these economies could be further marginalized – a process which might be understood as an ontological politics of HIV.

Looking ahead: ethical and social challenges of somatic gene therapy for sickle cell disease in Africa.

Somatic gene therapy will be one of the most exciting practices of genetic medicine in Africa and is primed to offer a "new life" for persons living with sickle cell disease (SCD). Recently, successful gene therapy trials for SCD in the USA have sparked a ray of hope within the SCD community in Africa. However, the high cost, estimated to exceed 1.5 million USD, continues to be a major concern for many stakeholders. While affordability is a key global health equity consideration, it is equally important to reflect on other ethical, legal and social issues (ELSIs) that may impact the responsible implementation of gene therapy for SCD in Africa. These include informed consent comprehension, risk of therapeutic misestimation and optimistic bias; priorities for SCD therapy trials; dearth of ethical and regulatory oversight for gene therapy in many African countries; identifying a favourable risk-benefit ratio; criteria for the selection of trial participants; decisional conflict in consent; standards of care; bounded justice; and genetic tourism. Given these ELSIs, we suggest that researchers, pharma, funders, global health agencies, ethics committees, science councils and SCD patient support/advocacy groups shouldwork together to co-develop: (1) patient-centric governance for gene therapy in Africa, (2) public engagement and education materials, and (3) decision making toolkits for trial participants. It is also critical to establish harmonised ethicaland regulatory frameworks for gene therapy in Africa, and for global health agencies to accelerate access to basic care for SCD in Africa, while simultaneously strengthening capacity for gene therapy.

Author's Satisfaction in Publishing the Manual in the Journal of CV Global Health Science Group

The publication process that is felt by each individual has several obstacles or factors delaying the publication process both from the author and from the publication services. This study aims to determine the level of author satisfaction in publishing journal manuscripts at CV Global Health. In this study using quantitative methods. The sampling technique used purposive sampling of 104 respondents. The results of the study found that the majority of respondents said they were very satisfied with the services provided by CV Global Health as many as 60 respondents (57.7%).

Effects of water, sanitation, and hygiene interventions on detection of enteropathogens and host-specific faecal markers in the environment: a systematic review and individual participant data meta-analysis

Water, sanitation, and hygiene (WASH) improvements are promoted to reduce diarrhoea in low-income countries. However, trials from the past 5 years have found mixed effects of household-level and community-level WASH interventions on child health. Measuring pathogens and host-specific faecal markers in the environment can help investigate causal pathways between WASH and health by quantifying whether and by how much interventions reduce environmental exposure to enteric pathogens and faecal contamination from human and different animal sources. We aimed to assess the effects of WASH interventions on enteropathogens and microbial source tracking (MST) markers in environmental samples. We did a systematic review and individual participant data meta-analysis, which included searches from Jan 1, 2000, to Jan 5, 2023, from PubMed, Embase, CAB Direct Global Health, Agricultural and Environmental Science Database, Web of Science, and Scopus, of prospective studies with water, sanitation, or hygiene interventions and concurrent control group that measured pathogens or MST markers in environmental samples and measured child anthropometry, diarrhoea, or pathogen-specific infections. We used covariate-adjusted regression models with robust standard errors to estimate study-specific intervention effects and pooled effect estimates across studies using random-effects models. Few trials have measured the effect of sanitation interventions on pathogens and MST markers in the environment and they mostly focused on onsite sanitation. We extracted individual participant data on nine environmental assessments from five eligible trials. Environmental sampling included drinking water, hand rinses, soil, and flies. Interventions were consistently associated with reduced pathogen detection in the environment but effect estimates in most individual studies could not be distinguished from chance. Pooled across studies, we found a small reduction in the prevalence of any pathogen in any sample type (pooled prevalence ratio [PR] 0·94 [95% CI 0·90-0·99]). Interventions had no effect on the prevalence of MST markers from humans (pooled PR 1·00 [95% CI 0·88-1·13]) or animals (pooled PR 1·00 [95% CI 0·97-1·03]). The small effect of these sanitation interventions on pathogen detection and absence of effects on human or animal faecal markers are consistent with the small or null health effects previously reported in these trials. Our findings suggest that the basic sanitation interventions implemented in these studies did not contain human waste and did not adequately reduce exposure to enteropathogens in the environment. Bill and Melinda Gates Foundation and the UK Foreign and Commonwealth Development Office.

PP235 [Healthcare systems » Capacity building]: CAPACITY BUILDING IN NORTHERN LAOS: AN EVALUATION OF THE PEDIATRIC NURSING TRAINING PROGRAM AT LAO FRIENDS HOSPITAL FOR CHILDREN

1Institute of Global Health Sciences, School of Nursing, University Of California, San Francisco, San Francisco, USA 2Vanderbilt University School of Nursing, Nashville, Tennessee, USA 3Vanderbilt University School of Nursing, International Division of Emergency Medicine, Nashville, Tennessee, USA 4Lao Friends Hospital for Children, Luang Prabang, Laos

The impact of alternative fuel vehicles on health: a systematic review

Background and Aim: Despite the increasing adoption of alternative fuel vehicles such as electric, hybrid, and clean diesel cars, trucks and buses, the health impacts of these vehicles (e.g., through changes in air quality) is largely unexplored. We reviewed the published literature to assess the state of the evidence on use of alternative fuel vehicles and health. Methods: We conducted a systematic literature search of MEDLINE, Embase, Global Health, CINAHL, Scopus, and Environmental Science Collection databases for articles published January 1990 to November 2021. We included articles presenting observed or modeled data on the association between alternative fuel vehicles and health-related outcomes. We abstracted data, categorized studies based on the type of alternative fuel and health outcomes studied, and summarized the results. Results: In our preliminary findings, 23 of 631 screened articles met our inclusion criteria. The most common vehicle types examined were electric or hybrid electric (n=18, 78%), clean diesel (n=5, 22%), and compressed natural gas (n=3, 13%). Overall, 17 articles (74%) assessed death as an outcome and 8 articles (35%) monetized health benefits. Only one study collected longitudinal data to assess the health impact on a population; the other articles all modeled data. All 23 articles observed some evidence of a positive health impact of adopting alternative fuel vehicles, although magnitudes varied. There was a paucity of information on the environmental justice implications of vehicle transitions (e.g., changing of the spatial distribution of air pollution, emphasis on adoption equity). Conclusions: There is limited information, particularly real-world studies, on the health impact of adoption of alternative fuel vehicles. The current rapid transitioning of vehicle fleets to alternative fuels provides a unique opportunity to conduct natural experiments to quantify health impacts and assess environmental justice implications of alternative fuel adoptions. Keywords: alternative fuels, traffic, review

Examining Intersectoral Action as an Approach to Implementing Multistakeholder Collaborations to Achieve the Sustainable Development Goals.

Objectives: The Sustainable Development Goals (SDGs) re-orient action towards improving the social and ecological determinants of health and equity. SDG 17 calls for enhanced policy and institutional coherence and strong multi-stakeholder partnerships. Intersectoral action (IA) has a promising history in public health, including health promotion and global health. Some experts see IA as crucial to the SDGs. Yet less is known about how IA is conceptualized and what promising models exist with relevance to the SDGs. We sought to investigate how IA is understood conceptually and empirically. Methods: We conducted a narrative review of global public health and political science literatures and grey literature on the SDGs to identify theoretical models, case studies and reviews of IA research. Results: Multiple competing conceptualizations of IA exist. Research has focused on case studies in high-income countries. More conceptual clarity, analyses of applications in LMICs, and explorations of political and institutional factors affecting IA are needed, as is attention to power dynamics between sectors. Conclusion: IA is required to collaborate on the SDGs and address equity. New models for successful implementation merit exploration.

Global trends health science libraries: Part 3.

This is the last of three articles based on a series of articles published in the Health Information and Libraries Journal's Regular Feature (International Perspectives and Initiatives). Key trends from 12 countries in Europe, North America, Africa, and Asia were identified. In this issue, the last five trends are considered: (1) Participation in collaborations, networks, partnerships, social networks; (2) Repurposing library space; (3) Focus on user experience; (4) Impact of technology on the provision of services; and (5) Engaging with the public. Readers are challenged to compare these trends with their own experiences.

OUR FOOD: How we went wrong

All living beings share eco-biopsychosocial systems. Good health of any single element of the system is dependentuponwell-beingof allthe elementstogether.The primary source of ourfood isfrom plants. A healthy plant is not conceivable without a healthy soil in which itsrootsystem grows. Soil contains multifarious microorganisms, fungal networks, nematodes and arthropods etc. These all act in concert to contribute to the richness of the milieu through zillions of phytochemicals that they all produce and exchange. Plants participate in the trade through root exudatesin exchange fortheir own needs. Greater the biodiversity of the species, greater the opportunities and benefits for all. Also, quorum sensing prevails, and population balances are maintained. Thisis how life has evolved and flourished on planet earthoverthe lastfour billionyears. In higher animals, humans included, relationships similar to the plant-soil situation the soil prevail within the body, in the gastrointestinal system. Diversity of our food ingestion determines the health of our gut microbiome,hence ourhealth too.Hunter-gatherers perhaps had great health given their circumstances favouring better survival based on diverse foods. Human settlements necessitated food sources with longerstorage lives. This brought increasing dependence on grains to support growing populations. The high starch content of grains meant increasing glucose load for the body as the proportion of starch kept on creeping up in our diets. This is furthercompounded by the advent of refined grains and simple sugarsin most of our food. The situation today is that most ofthe humanity is not able tometabolise the sugarload safely. About 20% are overtly type II diabetic and atleast another 40% prediabetic. Their tissues have developed insulin resistance, a defensive mechanism against insulin attempting to push, undesirably, even more glucose into the cells. Glucose is not a mandatoryfuel for metabolising tissue cells. Protein and fat deficiencies are known to cause disorders. There is no disease produced by absence of glucose from diet. By any measure, sugar has been the most potent, and most prevalent,weaponofmassdestruction unleashedonto humanity.Most of the 'modern era' diseases have insulin resistance with consequent hyperinsulinaemia as their underlying pathogenic mechanism. This includes, in addition to the pathology of type II diabetes mellitus, hypertension, atherosclerotic vascular disease (underlying myocardial infarction and stroke), allergies, autoimmune diseases,many types of cancers, autismand dementia. The common denominator, in this burdenof noncommunicable diseases (NCDs), is the inflammation ushered in due to, and accompanying, hyper insulinaemia.Sugars and starches have addictive potential. The thriving industrial/commercial activity benefitting from this humanpredilectionhas continuedto pocket huge profits,particularly overthe last century.Natural, organically grown wholesome foods have receded as the corporate industrial and supply chain processes had out stripped them. All this despite scientific evidence mounting up in favour of such food. The industry thrived onmanaged perception through advertisement. There waslittle to guard the peoples' right to knowthe reality foritis crowdedout by thecorporate efficiencies andpropaganda.The costs of health care on account of all the NCDs, as stated above, keeps on soaring. Globally, NCDs kill 41 million people each year, accounting for 71% of all deaths.1Institute of Global Health Sciences at University of California San Francisco had estimated, in 2017, that the NCDs could cost global economy US $ 47 trillion by 2030.2Disease prevention and health promotion through correction of our diet, by replacing sugar and starch rich foods with diverse nutrient dense, organic, wholesome foods, is obviously necessary. However, it is not easy. Old habits die hard. Those who profit from this human suffering may not become the most compliant easily, either.After all, as Albert Einstein had remarked, 'it is easier to fool people than to convince them that they have been fooled”.

Global trends health science libraries: Part 2.

This is the second of three articles which explore trends in health science libraries. It is based on a series of articles called New Directions in Health Science Libraries published in a HILJ regular feature (International Perspectives and Initiatives) between June 2017 and March 2020. The series covered 12 countries: The United States, Canada, Australia, China, England, two countries in Africa (Uganda and Tanzania) and five in Europe (Sweden, Romania, Belgium, Germany, and Switzerland). The commissioning editor identified potential authors and invited them to write a short piece. They were given a briefing sheet which said: 'Your article should serve as a road map, describing the key changes in the field and explain the factors driving the changes'. A review of the 12 articles identified 11 trends. This is the article which explores the trends four trends, using examples provided by the authors. The trends covered are: Involvement in systematic reviews and data synthesis; Professional development for health science librarians; Providing education and training to students, researchers, and clinicians; Supporting the delivery of health literacy.

339. COVID-19 Mortality in a Private Hospital in Mexico City

BackgroundAccording to the Institute of Global Health Science (IGHS), mortality for Covid-19 patients treated in public hospitals in Mexico ranges between 30-50%, decreasing to 20% in private health care facilities. Our objective was to describe the mortality rate in a teaching private hospital in Mexico City.MethodsWe included all patients that were admitted to hospital Medica Sur, in the south part of Mexico City during year 2020. We analyzed the total mortality presented in all our patients with a follow up of two months, and relay that to age and gender.ResultsDuring year 2020, we admitted in our hospital 1,075 patients with confirmed diagnosis of COVID-19 through nasopharyngeal molecular test; 772 were male (71.8%) with more than 50% between 40 and 59 years, while females were more frequent between 40 and 69 years’ age. Seventy-four patients (6.88%) died during hospitalization; 59 (79.7%) males and 15 females. Mortality rate was clearly related to age (figure 1) with 30% mortality for males between 80-89 years and 19% for females.Mortality rate by gender and age ConclusionMortality in private hospitals was clearly lower than in public hospitals. In our hospital, mortality was lower than 10%, mostly related to their availability of unlimited intensive care without ECMO and despite the lack of some drugs like Remdesivir. As described, space limitations for intensive care as well as the lack of trained personal impacted significantly the mortality in public hospitals. Disclosures All Authors: No reported disclosures

A review of interventions for noncommunicable diseases in humanitarian emergencies in low- and middle-income countries.

Noncommunicable diseases (NCDs) are of increasing prevalence in low- and middle-income countries (LMICs), affected by disasters. Humanitarian actors are increasingly confronted with how to effectively manage NCDs, yet primary focus on this topic is lacking. We conducted a systematic review on the effects of disasters on NCDs in LMICs. Key interventions were identified, and their effects on populations in disaster settings were reviewed. We electronically searched Medline, PubMed, Global Health, and Social Science Citation Index. We followed standard systematic review methodology for the selection, data abstraction, and risk of bias assessment. Eligible articles incorporated core intervention components as defined by the United States Department of Health and Human Services. Key intervention components including target population, phase of crisis, and measured outcomes were extracted and synthesized using a thematic analysis approach. The full systematic review is registered at PROSPERO (CRD42018088769). Of the 4,430 identified citations, we identified seven eligible studies. Studies reported on the response (n = 4) and recovery (n = 3) phases of disaster, with no studies reporting on the mitigation or preparedness phases. Successful interventions conducted predeployment risk assessments, performed training and capacity building for healthcare workers, worked in close cooperation with local health services, evaluated individual needs of subpopulations, promoted task shifting between humanitarian and development actors, and adopted flexibility in guideline -implementation. This review highlights the limited quantity and quality of evidence on interventions designed to address NCDs in humanitarian emergencies, with a particular paucity of studies addressing the mitigation and preparedness phases of disaster. While several challenges to NCD management such as insecurity and fluid movement of refugees create inherent challenges to NCD management in disasters, the lack of knowledge and training in NCD management among healthcare providers and the absence of basic medications and supplies for NCD management highlighted in this review are amenable to further intervention.

Thinking outside the box: students positive about visionary elective curricula in medical school.

Objective: Space for personality development as well as for the development of critical, creative and interdisciplinary thinking is rarely found in medical curricula in Germany. To be prepared for the challenges of modern medicine, future physicians need a visionary mindset. The aim of this study is to determine the need for teaching such content among medical students in the context of visionary elective curricula and to examine these with regard to the desired topics and organizational structure.Methods: This is a cross-sectional study with 236 medical students from all semesters of the Ludwig-Maximilians-University Munich. The survey consists of 50 questions and includes single choice, multiple choice, matrix questions, open-ended questions and Likert scales. Responses were examined using descriptive statistics and compared parametrically in sub-aspects.Results: Three-quarters of respondents would like to see curricular content on interdisciplinary interfaces with other disciplines. A suitable framework for this is seen by 87% of the respondents in a visionary elective curriculum. Students would like to see a broad range of specific content such as global health, politics, business, and computer science. The majority of respondents would like to see 1 unit of instruction per week and would participate in an appropriate program. Such an offering would promote creative (53.6%), critical (63.7%), and interdisciplinary thinking (69.0%) and train to become better physicians (87%).Conclusion: Participants in this study are positive toward the introduction of visionary content in medical school. Faculties should build visionary elective curricula according to the graduate profile requirements of the new NKLM 2.0 to make medical education sustainable.

Global trends health science libraries: Part 1.

This is the first of three articles based on articles published in the Health Information and Libraries Journal's Regular Feature (International Perspectives and Initiatives). Key trends from 12 countries in Europe, North America, Africa and Asia were identified. In this issue, two trends are described: emergence of new roles and challenges for library staff; supporting researchers engaging in research data management and maintaining institutional repositories. Readers are challenged to compare these trends with their own experiences.J.M.

Research task shifting and youth as drivers of a more global mental health science

One fundamental challenge that underlies the paucity of effective mental health-care provision in low-income and middle-income countries (LMICs) is the scarcity of contextually relevant, evidence-based research investigating aetiology, epidemiology, and interventions of mental health problems.1,2 Across the field of global mental health, a wide gap exists in research between LMICs compared with high-income countries, fuelled by a lack of research capacity and funding.3 Policy makers in LMICs respond best to locally developed research where researchers engage early and continuously on research design, implementation, and dissemination, and any such research and interventions are also likely to be more effective with appropriate consideration of local contexts.

Epidemic confusions: On irony and decolonisation in global health

ABSTRACT The movement to decolonise global health is gathering pace. In its concern with the fundamental, distal causes of inequality and its call for social justice, the decolonisation movement forces us to question how global health works, for whom, where it is located, its funding practices, power asymmetries, cultures of collaboration and publication. This paper uses a new book by Harvard-based physician-anthropologist Eugene T. Richardson, Epidemic Illusions, as a point of departure for a broader analysis of the nature of global health knowledge, science, authorship, research and practice. Written in a ‘carnivalesque’ style, the book proceeds through a series of ‘ironic (re)descriptions’ to argue that global public health is an ‘apparatus of coloniality’. In so doing, the book is generative of four ironic turns that we explore through the themes of guilt, humility, privilege and ambiguity. In locating these ironic turns within the broader landscape of global health, we reflect on whether the means of such a book achieve the ends of decolonisation.

A review of Cyclospora cayetanensis in animals.

Cyclosporiasis is a global, emerging disease in humans caused by Cyclospora cayetanensis. The role of animals in the epidemiology of cyclosporiasis is not fully understood. We conducted a narrative review of the published literature on C. cayetanensis in animals. MEDLINE® (Web of Science™ ), Agricola (ProQuest), CABI Global Health (1979 to December 2020) and Food Science and Technology Abstracts (EBSCOhost) (1979 to February 2020) were searched. Studies of C. cayetanensis in or on any species of animal were eligible. Thirteen relevant studies were found. C. cayetanensis was found in wild and farmed Mediterranean mussels (Mytilus galloprovincialis), wild grooved carpet shell clams (Ruditapes decussatus) and in the faeces of dogs (domestic and street), wild chickens, wild rhesus macaques (Macaca mulatta), chimpanzees (Pan troglodytes) from a wildlife research centre, and Cynomolgus monkeys (Macaca fascicularis) from an experimental primate research centre. As the small intestines of the naturally exposed animals were not biopsied, existence of a natural animal reservoir of C. cayetanensis could not be confirmed. Animals shedding oocysts in their faeces may be paratenic hosts. Investigators were able to successfully infect the following animals with C. cayetanensis: oysters, Asian freshwater clams (Corbicula fluminea), Swiss albino mice and guinea pigs. Future non-laboratory studies of animals should use PCR coupled with DNA sequencing to confirm that the species found is C. cayetanensis. The potential role of animals in the transport of oocysts and contamination of food, water, and soil could be explored through future primary research.