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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.

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  • Research ethics and refugee health: a review of reported considerations and applications in published refugee health literature, 2015-2018

    Emma E. Seagle; Amanda J. Dam; Priti P. Shah; Jessica L. Webster; Drue H. Barrett; Leonard W. Ortmann; Nicole J. Cohen; Nina N. Marano (BMC, 2020-06-01)
    Abstract Introduction Public health investigations, including research, in refugee populations are necessary to inform evidence-based interventions and care. The unique challenges refugees face (displacement, limited political protections, economic hardship) can make them especially vulnerable to harm, burden, or undue influence. Acute survival needs, fear of stigma or persecution, and history of trauma may present challenges to ensuring meaningful informed consent and establishing trust. We examined the recently published literature to understand the application of ethics principles in investigations involving refugees. Methods We conducted a preliminary review of refugee health literature (research and non-research data collections) published from 2015 through 2018 available in PubMed. Article inclusion criteria were: participants were refugees, topic was health-related, and methods used primary data collection. Information regarding type of investigation, methods, and reported ethics considerations was abstracted. Results We examined 288 articles. Results indicated 33% of investigations were conducted before resettlement, during the displacement period (68% of these were in refugee camps). Common topics included mental health (48%) and healthcare access (8%). The majority (87%) of investigations obtained consent. Incentives were provided less frequently (23%). Most authors discussed the ways in which community stakeholders were engaged (91%), yet few noted whether refugee representatives had an opportunity to review investigational protocols (8%). Cultural considerations were generally limited to gender and religious norms, and 13% mentioned providing some form of post-investigation support. Conclusions Our analysis is a preliminary assessment of the application of ethics principles reported within the recently published refugee health literature. From this analysis, we have proposed a list of best practices, which include stakeholder engagement, respect for cultural norms, and post-study support. Investigations conducted among refugees require additional diligence to ensure respect for and welfare of the participants. Development of a refugee-specific ethics framework with ethics and refugee health experts that addresses the need for stakeholder involvement, appropriate incentive use, protocol review, and considerations of cultural practices may help guide future investigations in this population.
  • Impact of conflict on maternal and child health service delivery: a country case study of Afghanistan

    Shafiq Mirzazada; Zahra Ali Padhani; Sultana Jabeen; Malika Fatima; Arjumand Rizvi; Uzair Ansari; Jai K. Das; Zulfiqar A. Bhutta (BMC, 2020-06-01)
    Abstract Introduction Since decades, the health system of Afghanistan has been in disarray due to ongoing conflict. We aimed to explore the direct effects of conflict on provision of reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH&N) services and describe the contextual factors influencing these services. Method We conducted a quantitative analysis of secondary data on RMNCAH&N indicators and undertook a supportive qualitative study to help understand processes and contextual factors. For quantitative analysis, we stratified the various provinces of Afghanistan into minimal-, moderate- and severe conflict categories based on battle-related deaths from Uppsala Conflict Data Program (UCDP) and through accessibility of health services using a Delphi methodology. The coverage of RMNCAH&N indicators across the continuum of care were extracted from the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Survey (MICS). The qualitative data was captured by conducting key informant interviews of multi-sectoral stakeholders working in government, NGOs and UN agencies. Results Comparison of various provinces based on the severity of conflict through Delphi process showed that the mean coverage of various RMNCAH&N indicators including antenatal care (OR: 0.42, 95%CI: 0.32–0.55), facility delivery (OR: 0.42, 95%CI: 0.32–0.56), skilled birth attendance (OR: 0.43, 95%CI: 0.33–0.57), DPT3 (OR: 0.26, 95% CI: 0.20–0.33) and oral rehydration therapy (OR: 0.37, 95% CI: 0.25–0.55) was significantly lower for severe conflict provinces when compared to minimal conflict provinces. The qualitative analysis identified various factors affecting decision making and service delivery including insecurity, cultural norms, unavailability of workforce, poor monitoring, lack of funds and inconsistent supplies. Other factors include weak stewardship, capacity gap at the central level and poor coordination at national, regional and district level. Conclusion RMNCAH&N service delivery has been significantly hampered by conflict in Afghanistan over the last several years. This has been further compromised by poor infrastructure, weak stewardship and poor capacity and collaboration at all levels. With the potential of peace and conflict resolution in Afghanistan, we would underscore the importance of continued oversight and integrated implementation of sustainable, grass root RMNCAH&N services with a focus on reaching the most marginalized.
  • Responding to health needs of women, children and adolescents within Syria during conflict: intervention coverage, challenges and adaptations

    Chaza Akik; Aline Semaan; Linda Shaker-Berbari; Zeina Jamaluddine; Ghada E. Saad; Katherine Lopes; Joanne Constantin; Abdulkarim Ekzayez; Neha S. Singh; Karl Blanchet (BMC, 2020-05-01)
    Abstract Background Women and children suffer disproportionately in armed-conflicts. Since 2011, the protracted Syrian crisis has fragmented the pre-existing healthcare system. Despite the massive health needs of women and children, the delivery of key reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH&N) interventions, and its underlying factors are not well-understood in Syria. Our objective was to document intervention coverage indicators and their implementation challenges inside Syria during conflict. Methods We conducted 1) a desk review to extract RMNCAH&N intervention coverage indicators inside Syria during the conflict; and 2) qualitative interviews with decision makers and health program implementers to explore reasons behind provision/non-provision of RMNCAH&N interventions, and the rationale informing decisions, priorities, collaborations and implementation. We attempt to validate findings by triangulating data from both sources. Results Key findings showed that humanitarian organisations operating in Syria adopted a complex multi-hub structure, and some resorted to remote management to improve accessibility to certain geographic areas. The emergency response prioritised trauma care and infectious disease control. Yet, with time, humanitarian organisations successfully advocated for prioritising maternal and child health and nutrition interventions given evident needs. The volatile security context had implications on populations’ healthcare seeking behaviors, such as women reportedly preferring home births, or requesting Caesarean-sections to reduce insecurity risks. Additional findings were glaring data gaps and geographic variations in the availability of data on RMNCAH&N indicators. Adaptations of the humanitarian response included task-shifting to overcome shortage in skilled healthcare workers following their exodus, outreach activities to enhance access to RMNCAH&N services, and operating in ‘underground’ facilities to avoid risk of attacks. Conclusion The case of Syria provides a unique perspective on creative ways of managing the humanitarian response and delivering RMNCAH&N interventions, mainly in the multi-hub structure and use of remote management, despite encountered challenges. The scarcity of RMNCAH&N data is a tremendous challenge for both researchers and implementing agencies, as it limits accountability and monitoring, thus hindering the evaluation of delivered interventions.
  • Impact of conflict on maternal and child health service delivery – how and how not: a country case study of conflict affected areas of Pakistan

    Jai K. Das; Zahra Ali Padhani; Sultana Jabeen; Arjumand Rizvi; Uzair Ansari; Malika Fatima; Ghulam Akbar; Wardah Ahmed; Zulfiqar A. Bhutta (BMC, 2020-05-01)
    Abstract Introduction In conflict affected countries, healthcare delivery remains a huge concern. Pakistan is one country engulfed with conflict spanning various areas and time spans. We aimed to explore the effect of conflict on provision of reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH&N) services and describe the contextual factors influencing the prioritization and implementation in conflict affected areas of Pakistan (Balochistan and FATA). Method We conducted a secondary quantitative and a primary qualitative analysis. For the quantitative analysis, we stratified the various districts/agencies of Balochistan and FATA into the conflict categories of minimal-, moderate- and severe based on accessibility to health services through a Delphi methodology with local stakeholders and implementing agencies and also based on battle-related deaths (BRD) information from Uppsala Conflict Data Program (UCDP). The coverage of RMNCAH&N indicators across the continuum of care were extracted from the demographic and health surveys (DHS) and district health information system (DHIS). We conducted a stratified descriptive analysis and multivariate analysis using STATA version 15. The qualitative data was captured by conducting key informant interviews of stakeholders working in government, NGOs, UN agencies and academia. All the interviews were audiotaped which were transcribed, translated, coded and analyzed on Nvivo software version 10. Results The comparison of the various districts based on the severity of conflict through Delphi process showed that the mean coverage of various RMNCAH&N indicators in Balochistan were significantly lower in severe- conflict districts when compared to minimal conflict districts, while there was no significant difference between moderate and severe conflict areas. There was no reliable quantitative data available for FATA. Key factors identified through qualitative analysis, which affected the prioritization and delivery of services included planning at the central level, lack of coordination amongst various hierarchies of the government and various stakeholders. Other factors included unavailability of health workforce especially female workers, poor quality of healthcare services, poor data keeping and monitoring, lack of funds and inconsistent supplies. Women and child health is set at a high priority but capacity gap at service delivery, resilience from health workers, insecurity and poor infrastructure severely hampers the delivery of quality healthcare services. Conclusion Conflict has severely hampered the delivery of health services and a wholesome effort is desired involving coordination amongst various stakeholders. The multiple barriers in conflict contexts cannot be fully mitigated, but efforts should be made to negate these as much as possible with good governance, planning, efficiency and transparency in utilization of available resources.
  • Health in conflict and post-conflict settings: reproductive, maternal and child health in Colombia

    Sara Milena Ramos Jaraba; Natalia Quiceno Toro; María Ochoa Sierra; Laura Ruiz Sánchez; Marlly Andrea García Jiménez; Mary Y. Salazar-Barrientos; Edison Bedoya Bedoya; Gladis Adriana Vélez Álvarez; Ana Langer; Jewel Gausman (BMC, 2020-05-01)
    Abstract Background In conflict-afflicted areas, pregnant women and newborns often have higher rates of adverse health outcomes. Objective To describe maternal and child health indicators and interventions between 1998 and 2016 comparing high and low conflict areas in Colombia. Methods Mixed study of convergent triangulation. In the quantitative component, 16 indicators were calculated using official, secondary data sources. The victimization rate resulting from armed conflict was calculated by municipality and grouped into quintiles. In the qualitative component, a comparative case study was carried out in two municipalities of Antioquia: one with high rates of armed conflict and another with low rates. A total of 41 interviews and 8 focus groups were held with local and national government officials, health professionals, community informants, UN agencies and NGOs. Results All of the indicators show improvement, however, four show statistically significant differences between municipalities with high victimization rates versus low ones. The maternal mortality ratio was higher in the municipalities with greater victimization in the periods 1998–2004, 2005–2011 and 2012–2016. The percentage of cesarean births and women who received four or more antenatal visits was lower among women who experienced the highest levels of victimization for the period 1998–2000, while the fertility rate for women between 15 and 19 years was higher in these municipalities between 2012 and 2016. In the context of the armed conflict in Colombia, maternal and child health was affected by the limited availability of interventions given the lack of human resources in health, supplies, geographical access difficulties and insecurity. The national government was the one that mostly provided the programs, with difficulties in continuity and quality. UN Agencies and NGOs accessed more easily remote and intense armed conflict areas. Few specific health interventions were identified in the post-conflict context. Conclusions In Colombia, maternal and child health indicators have improved since the conflict, however a pattern of inequality is observed in the municipalities most affected by the armed conflict.
  • C’est vraiment compliqué: a case study on the delivery of maternal and child health and nutrition interventions in the conflict-affected regions of Mali

    Anushka Ataullahjan; Michelle F. Gaffey; Moctar Tounkara; Samba Diarra; Seydou Doumbia; Zulfiqar A. Bhutta; Diego G. Bassani (BMC, 2020-05-01)
    Abstract Background Mali is currently in the midst of ongoing conflicts which involve jihadist groups, rebels, and the state. This conflict has primarily centered in the North of the country. Humanitarian actors delivering services in these geographies must navigate the complex environment created by conflict. This study aimed to understand how humanitarian actors make decisions around health service delivery within this context. Methods The current case-study utilized a mixed methods approach and focused on Mopti, Mali’s fifth administrative region and fourth largest in population. Latent content analysis was used to analyze interview transcripts guided by our research objectives and new concepts as they emerged. Indicators of coverage of health interventions in the area of maternal and child health and nutrition were compiled using Mali’s National Evaluation Platform and are presented for the conflict and non-conflict regions. Development assistance estimates for Mali by year were obtained from the Developmental Assistance for Health Database compiled by the Institute for Health Metrics and Evaluation. Administrative data was compiled from the annual reports of Mali’s Système Local d’Information Sanitaire (SLIS), Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS). Results Our data suggests that the reaction of the funding mechanisms to the conflict in Mali was a major barrier to timely delivery of health services to populations in need and the nature of the conflict is likely a key modifier of such reaction patterns. Concerns have been raised about the disconnect between the very high administrative capacity of large NGOs that control the work, and the consequent burden it puts on local NGOs. Population displacement and inaccurate estimates of needs made it difficult for organizations to plan program services. Moreover, actors delivering services to populations in need had to navigate an unpredictable context and numerous security threats. Conclusions Our study highlights the need for a more flexible funding and management mechanism that can better respond to concerns and issues arising at a local level. As the conflict in Mali continues to worsen, there is an urgent need to improve service delivery to conflict-affected populations.
  • Understanding the factors affecting the humanitarian health and nutrition response for women and children in Somalia since 2000: a case study

    Zahra Ahmed; Anushka Ataullahjan; Michelle F. Gaffey; Mohamed Osman; Chantal Umutoni; Zulfiqar A. Bhutta; Abdirisak A. Dalmar (BMC, 2020-05-01)
    Abstract Background Somalia has been ravaged by more than two decades of armed conflict causing immense damage to the country’s infrastructure and mass displacement and suffering among its people. An influx of humanitarian actors has sought to provide basic services, including health services for women and children, throughout the conflict. This study aimed to better understand the humanitarian health response for women and children in Somalia since 2000. Methods The study utilized a mixed-methods design. We collated intervention coverage data from publically available large-scale household surveys and we conducted 32 interviews with representatives from government, UN agencies, NGOs, and health facility staff. Qualitative data were analyzed using latent content analysis. Results The available quantitative data on intervention coverage in Somalia are extremely limited, making it difficult to discern patterns or trends over time or by region. Underlying sociocultural and other contextual factors most strongly affecting the humanitarian health response for women and children included clan dynamics and female disempowerment. The most salient operational influences included the assessment of population needs, donors’ priorities, and insufficient and inflexible funding. Key barriers to service delivery included chronic commodity and human resource shortages, poor infrastructure, and limited access to highly vulnerable populations, all against the backdrop of ongoing insecurity. Various strategies to mitigate these barriers were discussed. In-country coordination of humanitarian health actors and their activities has improved over time, with federal and state-level ministries of health playing increasingly active roles. Conclusions Emerging recommendations include further exploration of government partnerships with private-sector service providers to make services available throughout Somalia free of charge, with further research on innovative uses of technology to help reaches remote and inaccessible areas. To mitigate chronic skilled health worker shortages, more operational research is needed on the expanded use of community health workers. Persistent gaps in service provision across the continuum must be addressed, including for adolescents, for example. The is also a clear need for longer term development focus to enable the provision of health and nutrition services for women and children beyond those included in recurrent emergency response.
  • Maternal and child health service delivery in conflict-affected settings: a case study example from Upper Nile and Unity states, South Sudan

    Samira Sami; Augustino Mayai; Grace Sheehy; Nicole Lightman; Ties Boerma; Hannah Wild; Hannah Tappis; Wilfred Ochan; James Wanyama; Paul Spiegel (BMC, 2020-05-01)
    Abstract Background Decades of war left the Republic of South Sudan with a fragile health system that has remained deprived of resources since the country’s independence. We describe the coverage of interventions for women’s and children’s health in Upper Nile and Unity states, and explore factors that affected service provision during a protracted conflict. Methods We conducted a case study using a desk review of publicly available literature since 2013 and a secondary analysis of intervention coverage and conflict-related events from 2010 to 2017. During June through September 2018, we conducted 26 qualitative interviews with technical leads and 9 focus groups among health workers working in women and children’s health in Juba, Malakal, and Bentiu. Results Coverage for antenatal care, institutional delivery, and childhood vaccines were low prior to the escalation of conflict in 2013, and the limited data indicate that coverage remained low through 2017. Key factors that determined the delivery of services for women and children in our study sites were government leadership, coordination of development and humanitarian efforts, and human resource capacity. Participants felt that national and local health officials had a limited role in the delivery of services, and financial tracking data showed that funding stagnated or declined for humanitarian health and development programming during 2013–2014. Although health services were concentrated in camp settings, the availability of healthcare providers was negatively impacted by the protracted nature of the conflict and insecurity in the region. Conclusions Health care for women and children should be prioritized during acute and protracted periods of conflict by strengthening surveillance systems, coordinating short and long term activities among humanitarian and development organizations, and building the capacity of national and local government officials to ensure sustainability.
  • Investigating the delivery of health and nutrition interventions for women and children in conflict settings: a collection of case studies from the BRANCH Consortium

    Anushka Ataullahjan; Michelle F. Gaffey; Samira Sami; Neha S. Singh; Hannah Tappis; Robert E. Black; Karl Blanchet; Ties Boerma; Ana Langer; Paul B. Spiegel (BMC, 2020-05-01)
    Abstract Globally, the number of people affected by conflict is the highest in history, and continues to steadily increase. There is currently a pressing need to better understand how to deliver critical health interventions to women and children affected by conflict. The compendium of articles presented in this Conflict and Health Collection brings together a range of case studies recently undertaken by the BRANCH Consortium (Bridging Research & Action in Conflict Settings for the Health of Women and Children). These case studies describe how humanitarian actors navigate and negotiate the multiple obstacles and forces that challenge the delivery of health and nutrition interventions for women, children and adolescents in conflict-affected settings, and to ultimately provide some insight into how service delivery can be improved.
  • Health services for women, children and adolescents in conflict affected settings: experience from North and South Kivu, Democratic Republic of Congo

    Chiara Altare; Espoir Bwenge Malembaka; Maphie Tosha; Christopher Hook; Hamady Ba; Stéphane Muzindusi Bikoro; Thea Scognamiglio; Hannah Tappis; Jerome Pfaffmann; Ghislain Bisimwa Balaluka (BMC, 2020-05-01)
    Abstract Background Insecurity has characterized the Eastern regions of the Democratic Republic of Congo for decades. Providing health services to sustain women’s and children’s health during protracted conflict is challenging. This mixed-methods case study aimed to describe how reproductive, maternal, newborn, child, adolescent health and nutrition (RMNCAH+N) services have been offered in North and South Kivu since 2000 and how successful they were. Methods We conducted a case study using a desk review of publicly available literature, secondary analysis of survey and health information system data, and primary qualitative interviews. The qualitative component provides insights on factors shaping RMNCAH+N design and implementation. We conducted 49 interviews with government officials, humanitarian agency staff and facility-based healthcare providers, and focus group discussions with community health workers in four health zones (Minova, Walungu, Ruanguba, Mweso). We applied framework analysis to investigate key themes across informants. The quantitative component used secondary data from nationwide surveys and the national health facility information system to estimate coverage of RMNCAH+N interventions at provincial and sub-provincial level. The association between insecurity on service provision was examined with random effects generalized least square models using health facility data from South Kivu. Results Coverage of selected preventive RMNCAH+N interventions seems high in North and South Kivu, often higher than the national level. Health facility data show a small negative association of insecurity and preventive service coverage within provinces. However, health outcomes are poorer in conflict-affected territories than in stable ones. The main challenges to service provisions identified by study respondents are the availability and retention of skilled personnel, the lack of basic materials and equipment as well as the insufficient financial resources to ensure health workers’ regular payment, medicaments’ availability and facilities’ running costs. Insecurity exacerbates pre-existing challenges, but do not seem to represent the main barrier to service provision in North and South Kivu. Conclusions Provision of preventive schedulable RMNCAH+N services has continued during intermittent conflict in North and South Kivu. The prolonged effort by non-governmental organizations and UN agencies to respond to humanitarian needs was likely key in maintaining intervention coverage despite conflict. Health actors and communities appear to have adapted to changing levels and nature of insecurity and developed strategies to ensure preventive services are provided and accessed. However, emergency non-schedulable RMNCAH+N interventions do not appear to be readily accessible. Achieving the Sustainable Development Goals will require increased access to life-saving interventions, especially for newborn and pregnant women.
  • Child marriage practices among the Rohingya in Bangladesh

    Andrea J. Melnikas; Sigma Ainul; Iqbal Ehsan; Eashita Haque; Sajeda Amin (BMC, 2020-05-01)
    Abstract Background Previous research suggests that child marriage may be accelerated during times of crisis and insecurity as resources are scarce and child marriage may be a survival strategy for girls and their families. In 2017, the Rohingya experienced a mass displacement to Bangladesh in response to escalating violence in Myanmar. This displacement has resulted in an estimated population of nearly 1 million Rohingya living in Cox’s Bazar. Methods We conducted in-depth interviews (n = 48) and focus group discussions (n = 12) with Rohingya male and female adolescents and young adults (14–24 years), and program managers and service providers (n = 24) working in Cox’s Bazar to understand their experience of living or working in the camps, preferences for timing of marriage, and marriage practices in Myanmar and in the camps. We also interviewed Bangladeshis in the host community to complement our understanding of marriage in the camps and its influence in the broader community. Our primary objective was to describe how displacement influenced marriage timing and practices. Results We found that child marriage is a strong cultural phenomenon among the Rohingya, primarily rooted in socio-cultural and religious beliefs around readiness for marriage. Although child marriage was practiced by the Rohingya in Myanmar, specific state law and oppression by military forces prevented many from marrying before age 18. Now this preference is more easily practiced in the camps in Bangladesh where the displaced Rohingya experience less marriage regulation. Host community participants perceive the presence of the Rohingya as encouraging both polygamy and child marriage in their communities, leading to tension among the host community. Conclusions Our findings support evidence that conflict and displacement increase child marriage in populations already vulnerable to child marriage by exacerbating gender inequities. However, our findings also suggest group norms around religious and cultural preferences for age at marriage play a significant role in post-displacement behaviors surrounding marriage.
  • Reproductive, maternal, newborn and child health service delivery during conflict in Yemen: a case study

    Hannah Tappis; Sarah Elaraby; Shatha Elnakib; Nagiba A. Abdulghani AlShawafi; Huda BaSaleem; Iman Ahmed Saleh Al-Gawfi; Fouad Othman; Fouzia Shafique; Eman Al-Kubati; Nuzhat Rafique (BMC, 2020-05-01)
    Abstract Background Armed conflict, food insecurity, epidemic cholera, economic decline and deterioration of essential public services present overwhelming challenges to population health and well-being in Yemen. Although the majority of the population is in need of humanitarian assistance and civil servants in many areas have not received salaries since 2016, many healthcare providers continue to work, and families continue to need and seek care. Methods This case study examines how reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH+N) services have been delivered since 2015, and identifies factors influencing implementation of these services in three governorates of Yemen. Content analysis methods were used to analyze publicly available documents and datasets published since 2000 as well as 94 semi-structured individual and group interviews conducted with government officials, humanitarian agency staff and facility-based healthcare providers and six focus group discussions conducted with community health midwives and volunteers in September–October 2018. Results Humanitarian response efforts focus on maintaining basic services at functioning facilities, and deploying mobile clinics, outreach teams and community health volunteer networks to address urgent needs where access is possible. Attention to specific aspects of RMNCAH+N varies slightly by location, with differences driven by priorities of government authorities, levels of violence, humanitarian access and availability of qualified human resources. Health services for women and children are generally considered to be a priority; however, cholera control and treatment of acute malnutrition are given precedence over other services along the continuum of care. Although health workers display notable resilience working in difficult conditions, challenges resulting from insecurity, limited functionality of health facilities, and challenges in importation and distribution of supplies limit the availability and quality of services. Conclusions Challenges to providing quality RMNCAH+N services in Yemen are formidable, given the nature and scale of humanitarian needs, lack of access due to insecurity, politicization of aid, weak health system capacity, costs of care seeking, and an ongoing cholera epidemic. Greater attention to availability, quality and coordination of RMNCAH services, coupled with investments in health workforce development and supply management are needed to maintain access to life-saving services and mitigate longer term impacts on maternal and child health and development. Lessons learned from Yemen on how to address ongoing primary health care needs during massive epidemics in conflict settings, particularly for women and children, will be important to support other countries faced with similar crises in the future.
  • Improving pediatric TB diagnosis in North Kivu (DR Congo), focusing on a clinical algorithm including targeted Xpert MTB/RIF on gastric aspirates

    Daan Van Brusselen; Erica Simons; Tony Luendo; Delphine Habarugira; Jimmy Ngowa; Nadine Neema Mitutso; Zakari Moluh; Mieke Steenssens; Rachelle Seguin; Hilde Vochten (BMC, 2020-05-01)
    Abstract Background The incidence of tuberculosis (TB) in the Democratic Republic of the Congo (DRC) is 323/100,000. A context of civil conflict, internally displaced people and mining activities suggests a higher regional TB incidence in North Kivu. Médecins Sans Frontières (MSF) supports the General Reference Hospital of Masisi, North Kivu, covering a population of 520,000, with an elevated rate of pediatric malnutrition. In July 2017, an adapted MSF pediatric TB diagnostic algorithm, including Xpert MTB/RIF on gastric aspirates (GAs), was implemented. The aim of this study was to evaluate whether the introduction of this clinical pediatric TB diagnostic algorithm influenced the number of children started on TB treatment. Methods We performed a retrospective analysis of pediatric TB cases started on treatment in the inpatient therapeutic feeding centre (ITFC) and the pediatric ward. We compared data collected in the second half (July to December) of 2016 (before introduction of the new diagnostic algorithm) and the second half of 2017. For the outcome variables the difference between the two years was calculated by a Pearson Chi-square test. Results In 2017, 94 GAs were performed, compared to none in 2016. Twelve percent (11/94) of samples were Xpert MTB/RIF positive. Sixty-eight children (2.9% of total exits) aged between 3 months and 15 years started TB treatment in 2017, compared to 19 (1.4% of total exits) in 2016 (p 0.002). The largest increase in pediatric TB diagnoses in 2017 occurred in patients with a negative Xpert MTB/RIF result, but clinically highly suggestive of TB according to the newly introduced diagnostic algorithm. Fifty-two (3.1%) children under five years old started treatment in 2017, as compared to 14 (1.3%) in 2016 (p 0.004). The increase was less pronounced and not statistically significant in older patients: sixteen children (2.6%) above 5 years old started TB treatment in 2017 as compared to five (1.3%) in 2016 (p 0.17). Conclusion After the introduction of an adapted clinical pediatric TB diagnostic algorithm, including Xpert MTB/RIF on gastric aspirates, we observed a significant increase in the number of children – especially under 5 years old – started on TB treatment, mostly on clinical grounds. Increased ‘clinician awareness’ of pediatric TB likely played an important role.
  • Conducting operational research in humanitarian settings: is there a shared path for humanitarians, national public health authorities and academics?

    Enrica Leresche; Claudia Truppa; Christophe Martin; Ariana Marnicio; Rodolfo Rossi; Carla Zmeter; Hilda Harb; Randa Sami Hamadeh; Jennifer Leaning (BMC, 2020-05-01)
    Abstract In humanitarian contexts, it is a difficult and multi-faceted task to enlist academics, humanitarian actors and health authorities in a collaborative research effort. The lack of research in such settings has been widely described in the past decade, but few have analysed the challenges in building strong and balanced research partnerships. The major issues include considering operational priorities, ethical imperatives and power differentials. This paper analyses in two steps a collaborative empirical endeavour to assess health service utilization by Syrian refugee and Lebanese women undertaken by the International Committee of the Red Cross (ICRC), the Lebanese Ministry of Public Health (MoPH) and the Harvard François-Xavier Bagnoud (FXB) Center. First, based on challenges documented in the literature, we shed light on how we negotiated appropriate research questions, methodologies, bias analyses, resource availability, population specificities, security, logistics, funding, ethical issues and organizational cultures throughout the partnership. Second, we describe how the negotiations required each partner to go outside their comfort zones. For the academics, the drivers to engage included the intellectual value of the collaboration, the readiness of the operational partners to conduct an empirical investigation and the possibility that such work might lead to a better understanding in public health terms of how the response met population needs. For actors responding to the humanitarian crisis (the ICRC and the MOPH), participating in a technical collaboration permitted methodological issues to be worked through in the context of deliberations within the wider epistemic community. We find that when they collaborate, academics, humanitarian actors and health authorities deploy their respective complementarities to build a more comprehensive approach. Barriers such as the lack of uptake of research results or weak links to the existing literature were overcome by giving space to define research questions and develop a longer-term collaboration involving individual and institutional learning. There is the need ahead of time to create balanced decision-making mechanisms, allow for relative financial autonomy, and define organizational responsibilities. Ultimately, mutual respect, trust and the recognition of each other’s expertise formed the basis of an initiative that served to better understand populations affected by conflict and meet their needs.
  • A systematic literature review of the ethics of conducting research in the humanitarian setting

    William Bruno; Rohini J. Haar (BMC, 2020-05-01)
    Abstract Background Research around humanitarian crises, aid delivery, and the impact of these crises on health and well-being has expanded dramatically. Ethical issues around these topics have recently received more attention. We conducted a systematic literature review to synthesize the lessons learned regarding the ethics of research in humanitarian crises. Methods We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines to identify articles regarding the ethics of research in humanitarian contexts between January 1, 1997 and September 1, 2019. We analyzed the articles to extract key themes and develop an agenda for future research. Results We identified 52 articles that matched our inclusion criteria. We categorized the article data into five categories of analysis: 32 were expert statements, 18 were case studies, 11 contained original research, eight were literature reviews and three were book chapters. All included articles were published in English. Using a step-wise qualitative analysis, we identified 10 major themes that encompassed these concepts and points. These major themes were: ethics review process (21 articles, [40.38%]); community engagement (15 articles [28.85%]); the dual imperative, or necessity that research be both academically sound and policy driven, clinical trials in the humanitarian setting (13 articles for each, [25.0%)]; informed consent (10 articles [19.23%]); cultural considerations (6 articles, [11.54%]); risks to researchers (5 articles, [9.62%]); child participation (4 articles [7.69%]); and finally mental health, and data ownership (2 articles for each [3.85%]). Conclusions Interest in the ethics of studying humanitarian crises has been dramatically increasing in recent years. While key concepts within all research settings such as beneficence, justice and respect for persons are crucially relevant, there are considerations unique to the humanitarian context. The particular vulnerabilities of conflict-affected populations, the contextual challenges of working in humanitarian settings, and the need for ensuring strong community engagement at all levels make this area of research particularly challenging. Humanitarian crises are prevalent throughout the globe, and studying them with the utmost ethical forethought is critical to maintaining sound research principles and ethical standards.
  • 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.

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