Conflict and Health is an open access, peer-reviewed journal published by BioMed Central.


The library contains articles of Conflict and Health as of vol. 1(2007) to current.

Recent Submissions

  • Simple ideas to mitigate the impacts of the COVID-19 epidemic on refugees with chronic diseases

    Muhammad Fawad; Fatima Rawashdeh; Parveen K. Parmar; Ruwan Ratnayake (BMC, 2020-05-01)
  • Pathways towards scaling up Problem Management Plus in Turkey: a theory of change workshop

    Daniela C. Fuhr; Ceren Acarturk; Ersin Uygun; Michael McGrath; Zeynep Ilkkursun; Sadaf Kaykha; Egbert Sondorp; Marit Sijbrandij; Peter Ventevogel; Pim Cuijpers (BMC, 2020-05-01)
    Abstract Background A considerable evidence base has been produced in recent years highlighting the effectiveness of brief scalable psychological interventions for people living in communities exposed to adversity. However, practical guidance on how to scale up these interventions to wider populations does not exist. In this paper we report on the use of Theory of Change (ToC) to plan the scale up of the World Health Organization’s flagship low intensity psychological intervention “Problem Management Plus” (PM+) for Syrian refugees in Turkey. Methods We conducted a one-day ToC workshop in Istanbul. ToC is a participatory planning process used in the development, implementation and evaluation of projects. It is similar to driver diagrams or logic models in that it offers a tool to visually present the components needed to reach a desired long-term outcome or impact. The overall aim of ToC is to understand the change process of a complex intervention and to map out causal pathways through which an intervention or strategy has an effect. Results Twenty-four stakeholders (including governmental officials, mental health providers, officials from international/national non-governmental organisations, conflict and health researchers) participated in the ToC workshop. A ToC map was produced identifying three key elements of scaling up (the resource team; the innovation and the health system; and the user organisation) which are represented in three distinct causal pathways. Context-specific barriers related to the health system and the political environment were identified, and possible strategies for overcoming these challenges were suggested. Conclusion ToC is a valuable methodology to develop an integrated framework for scaling up. The results highlight that the scaling up of PM+ for Syrian refugees in Turkey needs careful planning and investment from different stakeholders at the national level. Our paper provides a theoretical foundation of the scaling up of PM+, and exemplifies for the first time the use of ToC in planning the scaling up of an evidence-based psychological intervention in global mental health.
  • Health status of rescued people by the NGO Open Arms in response to the refugee crisis in the Mediterranean Sea

    Guillermo Cañardo; Jesús Gálvez; Juanfe Jiménez; Núria Serre; Israel Molina; Cristina Bocanegra (BMC, 2020-05-01)
    Abstract Background The migration over the Mediterranean has become one of the deadliest sea voyages in last few years. The NGO Open Arms works in the area since 2015, with the objectives of protecting and reporting human rights at sea. This paper aims to give an overview on characteristics and health conditions of rescued people by the NGO in the Central Mediterranean. Methods A descriptive retrospective population study was conducted, including people who were rescued from distress at sea by the NGO Open Arms from 1st July 2016 to 31st December 2018. Results In this period of time 22,234 people were rescued from sea. Among them 2234 (22.7%) were minors, and 177 (0.8%) pregnant women. The most frequent countries of origin were Nigeria (1278–13.1%), Eritrea (1215–12.3%) and Bangladesh (981–9.9%). Among all people rescued, 4516 (20.3%) reported symptoms. Scabies was the most frequent pathology, being suspected in 1817 (8.2%) people. Other infectious diseases were diagnosed in 91 (0.4%). Thirty-five (0.16%) patients suffered some complication from their chronic diseases. Acute injuries due to trauma, burns, aggressions, and bullet or bladed weapon wound were reported in 135 (0.6%) cases. Seventy-four corpses were recovered. Conclusions Main diagnoses on board were directly related to the precarious living conditions through migratory route, violence and complications of chronic diseases due to lack of care. The large number of people rescued highlights the catastrophic effect on migrants’ health of European policies, which overlap the desire to restrict migratory movements on the humanitarian and health issues. An integrated information system and a coordinated response are basic to improve the situation in the area.
  • Serious psychological distress and disability among older persons living in conflict affected areas in eastern Ukraine: a cluster-randomized cross-sectional household survey

    Aimee Summers; Eva Leidman; Isabel Maria Pereira Figueira Periquito; Oleg O. Bilukha (BMC, 2019-05-01)
    Abstract Background Older persons are often unable to leave conflict areas; however, little is known about the mental and physical health among this population. Our objective was to determine the prevalence of and whether there was an association between psychological distress and disability among older persons affected by conflict in eastern Ukraine. Methods We conducted a cluster-randomized cross-sectional household survey of persons aged ≥60 years in government and non-government controlled areas (GCA and NGCA) of Donetsk and Luhansk regions in January–March 2016. Psychological distress and dependency (degree of disability) were measured using the Kessler K6 Psychological Distress Scale and Katz Index of Independence in Activities of Daily Living, respectively. Association between psychological distress and dependency was assessed using logistic regression adjusting for demographic and socioeconomic characteristics. Results Final sample included 758 and 418 persons in GCA and NGCA, respectively. Prevalence of serious psychological distress was 33.6% (95% Confidence Interval (CI), 28.0–39.7%) in GCA and 42.5% (95%CI, 36.1–49.2%) in NGCA. Overall, 32.2% (95%CI, 27.9–36.7%) of independent persons and 74.0% (95%CI, 65.2–81.2%) of moderately/severely dependent persons reported serious psychological distress (P < .0001). Being dependent, a woman, and having a chronic disease were all significantly associated with psychological distress in a logistic regression model. Conclusions Prevalence of serious psychological distress was very high compared with rates reported from developed countries and was highly associated with disability. Health services for the disabled, including psychological as well as physical support, could help in reducing the proportion of people needing mental health services not normally identified.
  • “Emerging Technologies and Medical Countermeasures to Chemical, Biological, Radiological, and Nuclear (CBRN) Agents in East Ukraine”

    Sonny S. Patel; Robert M. Grace; Patrick Chellew; Mykola Prodanchuk; Olha Romaniuk; Yuriy Skrebets; Sergii A. Ryzhenko; Timothy B. Erickson (BMC, 2020-05-01)
    Abstract Since 2014, Ukraine has been beset by an armed conflict with international and internal dimensions. The nature of this conflict is multidimensional, and disaster preparedness and response in this context must be as well. Health experts from Ukraine, the United States of America, United Kingdom, Czech Republic, and Norway convened for an educational event in Dnipro, East Ukraine on November 11-15, 2019. At the event, “Emerging Technologies and Countermeasures to CBRN Agents: Advanced Training Response to Conflict and Security Challenges in East Ukraine,” over 1,000 participants participated in panel discussions, didactic lectures, and an advanced training on various dimensions of disaster response. This report provides an overview of the key discussions and outcomes of the event.
  • Deaths, injuries and detentions during civil demonstrations in Sudan: a secondary data analysis

    Maysoon Dahab; Nada Abdelmagid; Ahmed Kodouda; Francesco Checchi (BMC, 2019-05-01)
    Abstract Background Since December 2018, the latest wave of anti-government protests in Sudan has led to deaths, injuries and detentions. We estimated the number of people killed and described patterns of deaths, injuries and detentions up to 9 April 2019. Methods We tabulated data from three publicly available lists maintained by Sudanese civil society sources (the Independent Movement, the Sudan Doctors’ Union and the “Lest We Forget” project), and applied to these a capture-recapture statistical technique that models the overlap among lists to estimate the number of deaths not on any list. Results We estimated that about 117 civilians were killed in demonstrations during the above period, a considerably larger number than hitherto reported. Most decedents and injury victims were shot. Conclusions This analysis demonstrates the importance of real-time data on political violence collected by civil society initiatives. The de facto Sudanese government should immediately cease attacks against peaceful civilian protesters and put in place guarantees for their safety.
  • Health policy mapping and system gaps impeding the implementation of reproductive, maternal, neonatal, child, and adolescent health programs in South Sudan: a scoping review

    Loubna Belaid; Pontius Bayo; Lynette Kamau; Eva Nakimuli; Elijo Omoro; Robert Lobor; Baba Samson; Alexander Dimiti (BMC, 2020-04-01)
    Abstract Background Pregnant women, neonates, children, and adolescents are at higher risk of dying in fragile and conflict-affected settings. Strengthening the healthcare system is a key strategy for the implementation of effective policies and ultimately the improvement of health outcomes. South Sudan is a fragile country that faces challenges in implementing its reproductive, maternal, neonatal, child, and adolescent health (RMNCAH) policies. In this paper, we map the key RMNCAH policies and describe the current status of the WHO health system building blocks that impede the implementation of RMNCAH policies in South Sudan. Methods We conducted a scoping review (39 documents) and individual interviews (n = 8) with staff from the national Ministry of Health (MoH) and implementing partners. We organized a workshop to discuss and validate the findings with the MoH and implementing partner staff. We synthesized and analyzed the data according to the WHO health system building blocks. Results The significant number of policies and healthcare strategic plans focused on pregnant women, neonates, children, and adolescents evidence the political will of the MoH to improve the health of members of these categories of the population. The gap in the implementation of policies is mainly due to the weaknesses identified in different health system building blocks. A critical shortage of human resources across the blocks and levels of the health system, a lack of medicines and supplies, and low national funding are the main identified bottlenecks. The upstream factors explaining these bottlenecks are the 2012 suspension of oil production, ongoing conflict, weak governance, a lack of accountability, and a low human resource capacity. The combined effects of all these factors have led to poor-quality provision and thus a low use of RMNCAH services. Conclusion The implementation of RMNCAH policies should be accomplished through innovative and challenging approaches to building the capacities of the MoH, establishing governance and accountability mechanisms, and increasing the health budget of the national government.
  • Accountability strategies for sexual and reproductive health and reproductive rights in humanitarian settings: a scoping review

    Marta Schaaf; Victoria Boydell; Mallory C. Sheff; Christina Kay; Fatemeh Torabi; Rajat Khosla (BMC, 2020-04-01)
    Abstract Background Many of the 35 million women and girls aged 15–49 requiring humanitarian assistance have inadequate access to the sexual and reproductive health (SRH) services to which they are entitled. Ensuring accountability is critical to realizing their SRH and reproductive rights (RR). Objectives This scoping review examines the extent and nature of existing evidence on accountability strategies for SRH in humanitarian settings in different geographical scopes/contexts, and contextualizes these findings in the larger thematic literature. This review seeks to answer the following questions: What accountability strategies are employed to address the availability, accessibility, acceptability, and quality of SRH in humanitarian settings? What do we know about the successes and challenges of the given strategies? What are the implications for practice? Methods We consulted public health, social science, and legal databases including SCOPUS, PubMed, ProQuest, and LexisNexis for peer-reviewed articles, as well as Google Advanced search for grey literature; the search was conducted in March 2019. We searched for relevant articles and documents relating to accountability, humanitarian, and SRH and/or RR. To identify key challenges not reflected in the literature and additional grey literature, 18 key informants from international NGOs, local government bodies, academia, and donor agencies were interviewed from March–June 2019. Results A total of 209 papers and documents were identified via our literature searches and interviews for review. We identified three categories of approaches to accountability in our background reading, and we then applied these to the papers reviewed a priori. We created a fourth category based on our findings. The categories include: (1) humanitarian principles, codes of conduct, and legal instruments; (2) technical, performance, and impact standards; (3) efforts to solicit and address the rights and needs of the affected populations, or “listening and responding,” and, (4) accountability demands made by affected populations themselves. Almost all papers identified referred to challenges to realizing accountability in humanitarian contexts. There are promising accountability approaches – some specific to SRH and some not - such as open-ended feedback from affected populations, quality improvement, and practical application of standards. Reflecting a largely top down orientation, papers concentrate on accountability mechanisms within humanitarian work, with much less focus on supporting affected populations to deepen their understanding of structural causes of their position, understand their entitlements, or access justice. Conclusion In the last 20 years, there has been increasing standard and guideline development and program experiences related to accountability in humanitarian settings. Yet, the emphasis is on tools or mechanisms for accountability with less attention to changing norms regarding SRH and RR within affected communities, and to a lesser extent, among implementers of humanitarian programs or to institutionalizing community participation.
  • Mental health and psychosocial support for families of missing persons in Sri Lanka: A retrospective cohort study

    Ida Andersen; Bhava Poudyal; Arundathi Abeypala; Carla Uriarte; Rodolfo Rossi (BMC, 2020-04-01)
    Abstract Background The International Committee of the Red Cross (ICRC) has developed its ‘Accompaniment model’ to address the multi-faceted needs of relatives of people who go missing during armed conflict. In Sri Lanka an Accompaniment Programme was launched in 2015 for the relatives of the more than 16,000 missing persons who remain unaccounted for. Method One thousand seven hundred eighty-three relatives who took part in the mental health and psychosocial support (MHPSS) component of the ICRC’s Accompaniment Programme in Sri Lanka between April 2016 and August 2017 were offered eight peer-support group sessions, individual home visits, referrals to local services, and commemoration events to pay tribute to their missing relatives. Symptoms of anxiety and depression (using the HADS scale), somatic difficulties (using the BSI scale) and daily functioning (ICRC scale) were assessed before and after the MHPSS intervention. Results Prior to receiving support, Tamil and Muslim ethnicity, ≥60 years of age and civilian status were predictors of severe symptoms of anxiety; Tamil ethnicity, ≥50 years of age and being the mother of a missing person were predictors of severe symptoms of depression; and ≥ 50 years of age and severe symptoms of anxiety and depression were predictors of severe somatic difficulties. After receiving support, the vast majority of the relatives of missing persons showed reduced levels of anxiety (81%), depression (79%) and somatic pain (77%), as well as increased functioning (75%). Predictors of improvement following support were severe levels of distress at baseline and Tamil and Muslim ethnicity. In addition, attending at least three group sessions was a predictor of decreased anxiety, age group 51–60 was a predictor of decreased depression, female gender was a predictor of decreased somatic difficulties, and referrals were a predictor of increased functioning. Conclusion The MHPSS component of the ICRC’s Accompaniment Programme is a relevant approach to helping families to cope with not knowing the fate and whereabouts of their missing relatives, to reduce distress, to break their social isolation and to resume more functional lives. However, further research is needed, possibly through a controlled trial, to better establish the effectiveness of this approach.
  • Sexual violence against women and girls in South Sudan

    Dilshad Jaff (BMC, 2020-04-01)
    Abstract This Letter to the Editor is in reference to the article by Murphy M, Ellsberg M and Contreras-Urbina M, “Nowhere to go: disclosure and help-seeking behaviors for survivors of violence against women and girls in South Sudan,” published on 12 February 2020. The authors have to be lauded to study this important topic in South Sudan where data are scarce and the problem is less understood. In such a context, actions by various actors to address sexual violence, a major public health concern and a serious international humanitarian law and human rights violation, must be well thought of to avoid causing more harm and compound the suffering of survivors.
  • Displacement-related factors influencing marital practices and associated intimate partner violence risk among Somali refugees in Dollo Ado, Ethiopia: a qualitative study

    Vandana Sharma; Adaugo Amobi; Samuel Tewolde; Negussie Deyessa; Jennifer Scott (BMC, 2020-04-01)
    Abstract Background Child and forced marriage have negative health consequences including increased risk of intimate partner violence (IPV) for women and girls. War and humanitarian crises may impact decision-making around marriage and risks of IPV for displaced populations. A qualitative study was conducted among Somali refugees in Dollo Ado, Ethiopia to understand the interplay of factors that contribute to IPV and to inform an intervention. This secondary analysis aims to explore the influence of displacement on marital practices and associated IPV risk. Methods Interviews and focus group discussions were conducted in 2016 in Dollo Ado, Ethiopia, among Somali women and men living in Bokolmayo refugee camp, host community members, non-governmental staff and service providers, stakeholders, and community and religious leaders (N = 110). Data were transcribed, translated to English, and coded and analyzed thematically using Dedoose software and a codebook developed a priori. Results Findings reveal numerous displacement-related factors that led to perceived shifts in marital practices among refugees, including reductions in child and forced marriages. NGO awareness-raising programs and Ethiopian laws prohibiting child marriage as well as increased access to education for girls were reported to have contributed to these changes, despite continued economic hardship and high perceived risk of non-partner sexual violence within the camp and host community. Polygamy was also perceived to have decreased, primarily due to worsening economic conditions. Forced marriage, polygamy and dowry were reported to contribute to physical IPV, and sexual IPV was reported as common in all types of marital unions. However, there was no evidence that changes in these marital practices contributed to any perceived declines in IPV within this context. Conclusion Safe access to education for girls should be prioritized in humanitarian settings. Interventions to address child and forced marriage should address gender and social norms. Intimate partner violence prevention programming should include specialized content taking into account marital practices including child and forced marriage and polygamy. Laws recognizing sexual IPV within marital relationships are needed to reduce sexual IPV.
  • Episodes of violence suffered by migrants transiting through Libya: a cross-sectional study in “Médecins du Monde’s” reception and healthcare centre in Seine-Saint-Denis, France

    L. Reques; E. Aranda-Fernandez; C. Rolland; A. Grippon; N. Fallet; C. Reboul; N. Godard; N. Luhmann (BMC, 2020-02-01)
    Abstract Introduction The Central Mediterranean Route, passing through Libya, is one of the most dangerous for migrants. Episodes of violence have been documented but have not been accurately quantified. The objective of the study was to estimate the prevalence of episodes of violence suffered in Libya by migrants consulting the Médecins du Monde reception and healthcare centre in Seine-Saint-Denis (Ile-de-France). Methodology A monocentric cross-sectional study was conducted from February to May 2019 including migrants over the age of 18 years who had passed through Libya and arrived in Europe from 2017. The presence of emotional distress was considered as exclusion criterion. The proportion, frequency and factors associated to physical, deprivation and sexual violence in Libya were estimated through a bespoke questionnaire, as well as healthcare access in Libya and psychosocial support needs. Results Ninety eight people were recruited and 72 were interviewed (17 refused to participate and 9 were excluded). 76.4% were men, with a mean age of 31.9 years, 76.4% had low educational level, 66.7% came from Ivory Coast and 59.7% had left their country for security reasons. The median length of stay in Libya was 180 days. The overall proportion of participants having suffered from violence was 96.4% among men and 88.2% among women. The prevalence of physical, deprivation and sexual violence for men and women were 94.2, 81.7 and 18% and 80.0, 86.7 and 53.3%, respectively. Access to healthcare in Libya was 2.8 and 63.9% of participants were oriented to psychosocial support after the interview. Conclusions The vast majority of migrants reported having been victims of violence during their transit through Libya. Women were at particular risk of sexual violence. Access to health care in Libya was almost non-existent. Psychosocial support for this population is urgent.
  • Male and LGBT survivors of sexual violence in conflict situations: a realist review of health interventions in low-and middle-income countries

    Ligia Kiss; Meaghen Quinlan-Davidson; Laura Pasquero; Patricia Ollé Tejero; Charu Hogg; Joachim Theis; Andrew Park; Cathy Zimmerman; Mazeda Hossain (BMC, 2020-02-01)
    Abstract Conflict-related sexual violence (CRSV) against women and girls has been the subject of increasing research and scholarship. Less is known about the health of men, boys and lesbian, gay, bisexual, transgender (LGBT) and other gender non-binary persons who survive CRSV. This paper is the first systematic realist review on medical, mental health and psychosocial support (MHPSS) interventions that focusses on male and LGBT survivors of CRSV. The review explores the gender differences in context, mechanisms and outcomes that underpin interventions addressing the health and psychosocial wellbeing of male and LGBT survivors. The aim is to contribute to the design and delivery of gender-sensitive and, when needed, gender-specific approaches for interventions that respond to specific needs of different groups of all survivors. We conducted a systematic search of academic and grey literature to identify medical and MHPSS interventions that included men, boys and LGBT survivors. We identified interventions specifically targeting women and girls that we used as comparators. We then purposively sampled studies from the fields of gender and health, and sexual abuse against men and LGBT people for theory building and testing. We identified 26 evaluations of interventions for survivors of CRSV. Nine studies included male survivors, twelve studies focussed exclusively on female survivors and one study targeted children and adolescents. No intervention evaluation focussed on LGBT survivors of CRSV. The interventions that included male survivors did not describe specific components for this population. Results of intervention evaluations that included male survivors were not disaggregated by gender, and some studies did not report the gender composition. Although some mental health and psychosocial consequences of sexual violence against men and boys may be similar among male and female survivors, the way each process trauma, display symptoms, seek help, adhere to treatment and improve their mental health differ by gender. Initiatives targeting male and LGBT survivors of CRSV need to be designed to actively address specific gender differences in access, adherence and response to MHPSS interventions. Models of care that are gender-sensitive and integrated to local resources are promising avenues to promote the health of male and LGBT survivors of CRSV.
  • Correction to: Injury-related deaths before and during the Islamic State insurgency – Baghdad, Iraq, 2010–2015

    Matthew Goers; Eva Leidman; Abdul-Salam Saleh Sultan; Ahmed Hassan; Oleg Bilukha (BMC, 2020-03-01)
    The original publication of this article [1] contained an incorrect author name.
  • Obituary for Dr. Peter Salama

    Paul Spiegel (BMC, 2020-03-01)
  • A validation study of the Zanmi Lasante Depression Symptom Inventory (ZLDSI) in a school-based study population of transitional age youth in Haiti

    Rupinder K. Legha; Margaret E. Gerbasi; Mary C. Smith Fawzi; Eddy Eustache; Tatiana Therosme; J. Reginald Fils-Aime; Giuseppe J. Raviola; Emmeline Affricot; Ermaze Louis Pierre; Yoldie Alcindor (BMC, 2020-02-01)
    Abstract Background The Zanmi Lasante Depression Symptom Inventory (ZLDSI) is a screening tool for major depression used in 12 primary care clinics in Haiti’s Central Plateau. Although previously validated in a clinic-based sample, the present study is the first to evaluate the validity and clinical utility of the ZLDSI for depression screening in a school-based population in central Haiti. Methods We assessed depressive symptoms in a school-based sample of transitional age youth (18–22 years; n = 120) with the ZLDSI. Other mental health-related assessments included a modified Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID) for current Major Depressive Episode, the Center for Epidemiologic Studies Depression Scale, and selected items adapted from the Global School-Based Health Survey mental health module. Diagnostic assignments of major depressive episode (MDE) were based on modified SCID interviews. Results The ZLDSI demonstrated good overall accuracy in identifying current MDE (Area under the Curve = .92, 95% CI = .86, .98, p < .001). We ascertained ≥12 as the optimal cut-off point to screen for depression with a sensitivity of 100% and a specificity of 73.9%. In addition, the ZLDSI was associated with other measures of depressive symptoms, suggesting that it demonstrates construct validity. Conclusions Study findings support that the ZLDSI has clinical utility for screening for depression among school-going transitional age youth.
  • Injury-related deaths before and during the Islamic State insurgency – Baghdad, Iraq, 2010–2015

    Matthew Goers; Eva Leidman; Abdul-Salam Saleh Sultran; Ahmed Hassan; Oleg Bilukha (BMC, 2020-02-01)
    Abstract Background Following a period of low intensity conflict during 2009–2012, the emergence of the Islamic State of Iraq and Levant (or Islamic State) in 2013 was associated with a resurgence of violence in Baghdad, Iraq’s capital and largest city. We evaluated trends in injury-related deaths in Baghdad before and during the Islamic State insurgency. Methods Iraqi National Injury Mortality Surveillance System prospectively collects information on fatal injuries from governorate coroner offices using standardized reporting forms. Trained coroner clerks collect information on victim demographics, intention of injury and mechanism of injury during medical examinations using reports from police and families. We analyzed data on all deaths reported by the Baghdad Forensic Institute from January 1, 2010 to December 31, 2015. Results There were 17,555 injury-related deaths with documented intent and mechanism (range 2385–3347 per year): 6241 from gunfire (36%), 1381 explosions (8%), 1348 non-gunfire assaults (8%), 3435 traffic accidents (20%), and 5150 other unintentional injuries (29%). Rates of gunfire (23.45 per 100,000) and explosion (5.90 per 100,000) deaths were significantly higher in 2014 than in all other years during the review period (p < 0.001 and p = 0.03, respectively). During the same period from 2010 to 2015, traffic accident deaths declined significantly from 13.29 to 6.35 (p = 0.002), with declines observed primarily among pedestrians. Trends in the rate of non-gunfire-assault and unintentional deaths, comparing 2010 and 2015, were not significant (p = 0.12 and p = 0.63, respectively). Unintentional deaths were mostly attributed to burns (46%) and electricity-related injuries (31%). The proportion of both females and children was highest in unintentional injury deaths. Conclusions During the study period, deaths from both gunfire and explosions in Baghdad peaked in 2014, corresponding with emergence of the Islamic State. Trends suggest a potential impact of insurgency-related activity on other injuries as evidenced by a decrease in the death rate from traffic accidents. The decreased traffic-related death rate could be from decreased vehicle and pedestrian activity during times of violence. Monitoring trends in injury mortality during conflict allows Iraq to identify priority injury causes to inform public health interventions.
  • Addressing noncommunicable diseases among urban refugees in the Middle East and North Africa - a scoping review

    Zahirah Z. McNatt (BMC, 2020-02-01)
    Abstract Background More than 5.5 million Syrian refugees have fled violence and settled in mostly urban environments in neighboring countries. The Middle East and North Africa (MENA) region accounts for 6% of the global population but 25% of the population are ‘of concern’ to the UN Refugee Agency. In addition to large amounts of forced migration, the region is also undergoing an epidemiologic transition towards a heavier burden of noncommunicable diseases (NCDs), which in 2018 accounted for 74% of all deaths in the region. To address NCD needs globally, a myriad of policies and interventions have been implemented in low-income stable country settings. However, little is known about which policies and interventions are currently being implemented or are best suited for refugee hosting countries across the Middle East and North Africa. Methods A scoping review of peer-reviewed literature was conducted to identify policies and interventions implemented in the Middle East and North Africa to address the needs of urban refugees with noncommunicable diseases. Results This scoping review identified 11 studies from Jordan, Lebanon, Iran, West Bank, Gaza and Syria. These studies addressed three foci of extant work, (1) innovative financing for expensive treatments, (2) improvements to access and quality of treatment and, (3) efforts to prevent new diagnoses and secondary complications. All interventions targeted refugee populations including Palestinians, Sudanese, Syrians, Afghans and Iraqis. Discussion The scoping review highlighted five key findings. First, very few studies focused on the prevention of noncommunicable diseases among displaced populations. Second, several interventions made use of health information technologies, including electronic medical records and mHealth applications for patients. Third, the vast majority of publications were solely focused on tackling NCDs through primary care efforts. Fourth, the literature was very sparse in regard to national policy development, and instead favored interventions by NGOs and UN agencies. Last, the perspectives of refugees were notably absent. Conclusion Opportunities exist to prioritize prevention efforts, scale up eHealth interventions, expand access to secondary and tertiary services, address the scarcity of research on national policy, and incorporate the perspectives of affected persons in the broader discourse.
  • Nowhere to go: disclosure and help-seeking behaviors for survivors of violence against women and girls in South Sudan

    Maureen Murphy; Mary Ellsberg; Manuel Contreras-Urbina (BMC, 2020-02-01)
    Abstract Background Despite high rates of violence against women and girls (VAWG) in conflict and humanitarian contexts, many survivors do not tell anyone about their experience or seek help from support r services (e.g. health, legal, psychosocial support, police). Methods This paper examines disclosure and help seeking behaviours of survivors of non-partner sexual violence (NPSV) and intimate partner violence (IPV) among women and girls aged 15–64 from three sites in South Sudan. It seeks to understand how exposure to armed conflict is associated with disclosure and help seeking practices. Results For NPSV, respondents for whom an incident of sexual violence occurred during conflict had twice the odds of telling someone about their experience (aOR: 2.2; 95%CI: 1.3–3.7; p < 0.01) and three times the odds of seeking help (aOR: 3.1; 95%CI: 1.7–5.9, p < .001), compared to respondents for whom the incident of violence did not occur during conflict. Age, the identity of the perpetrator, working status of the woman, poverty and location also affected disclosure and help seeking behaviours for survivors of NPSV. For IPV, exposure to conflict increased the odds a respondent would tell someone about her experience (aOR 1.7; 95%CI 1.2–2.5; p < .01), but was not associated with seeking support services. The severity of IPV affected both disclosure and help seeking behaviours, with the odds of disclosing IPV increasing if the respondent experienced both physical and sexual IPV (compared to only sexual violence), had been injured, thought their well-being was affected, was afraid of their partner, or was controlled by their partner. However, not all these factors were subsequently associated with help seeking behaviours for survivors of IPV and respondents who reported they were sometimes afraid of their partner had reduced odds of seeking help, compared to those who were never afraid of their partners. Conclusions These findings are important as, prior to this analysis, it was unclear how experiencing conflict-related VAWG would influence disclosure and help seeking. Given the findings of this paper, it is important that the international community consider how to reduce barriers to reporting and help seeking for non-conflict-related forms of violence in these settings.

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