Publications

Building upon the successes of Countdown to 2015, Countdown to 2030 aims to support the monitoring and measurement of women's, children's, and adolescents' health in the 81 countries that account for 95% of maternal and 90% of all child deaths worldwide. To achieve the Sustainable Development Goals by 2030, the rate of decline in prevalence of maternal and child mortality, stillbirths, and stunting among children younger than 5 years of age needs to accelerate considerably compared with progress since 2000. Such accelerations are only possible with a rapid scale-up of effective interventions to all population groups within countries (particularly in countries with the highest mortality and in those affected by conflict), supported by improvements in underlying socioeconomic conditions, including women's empowerment. Three main conclusions emerge from our analysis of intervention coverage, equity, and drivers of reproductive, maternal, newborn, and child health (RMNCH) in the 81 Countdown countries. First, even though strong progress was made in the coverage of many essential RMNCH interventions during the past decade, many countries are still a long way from universal coverage for most essential interventions. Furthermore, a growing body of evidence suggests that available services in many countries are of poor quality, limiting the potential effect on RMNCH outcomes. Second, within-country inequalities in intervention coverage are reducing in most countries (and are now almost non-existent in a few countries), but the pace is too slow. Third, health-sector (eg, weak country health systems) and non-health-sector drivers (eg, conflict settings) are major impediments to delivering high-quality services to all populations. Although more data for RMNCH interventions are available now, major data gaps still preclude the use of evidence to drive decision making and accountability. Countdown to 2030 is investing in improvements in measurement in several areas, such as quality of care and effective coverage, nutrition programmes, adolescent health, early childhood development, and evidence for conflict settings, and is prioritising its regional networks to enhance local analytic capacity and evidence for RMNCH.

Monitoring and evaluation of mental health and psychosocial support (MHPSS) programs is critical to facilitating learning and providing accountability to stakeholders. As part of an inter-agency effort to develop recommendations on MHPSS monitoring and evaluation, this scoping review aimed to identify the terminology and focus of monitoring and evaluation frameworks in this field.

BACKGROUND: The burden of uncontrolled hypertension in Low-and-Middle Income Countries (LMICs) is high, with an increased risk of cardiovascular diseases and chronic renal failure in these settings.

OBJECTIVE: To assess the factors associated with uncontrolled blood pressure control in a cross-section of Ghanaian hypertensive subjects involved in an on-going multicenter epidemiological study aimed at improving access to hypertension treatment.

METHODS: A cross-sectional study involving 2,870 participants with hypertension with or without diabetes who were enrolled at 5 hospitals in Ghana (2 tertiary, 2 district and 1 rural hospital). Data on demographics, medical history, lifestyle factors, anti-hypertensive medications and treatment adherence were collected. The 14-item version of the Hill-Bone compliance to high blood pressure therapy scale was used to assess adherence to treatment in 3 domains namely adherence to medications, salt intake and clinic appointments. Questionnaires on knowledge, attitudes and practices on hypertension, sources of antihypertensive medications and challenges with accessing these medications were also administered. Blood pressure, weight and height were measured for each subject at enrollment. Factors associated with uncontrolled blood pressure (>140/90mmHg) were assessed using a multivariate logistic regression model.

RESULTS: The mean ± SD age of study participants was 58.9 ± 16.6 years, with a female preponderance (76.8%). Among study participants, 1,213 (42.3%) study participants had blood pressure measurements under control. Factors that remained significantly associated with uncontrolled blood pressure with adjusted OR (95% CI) included receiving therapy at a tertiary level of care: 2.47 (1.57-3.87), longer duration of hypertension diagnosis: 1.01 (1.00-1.03), poor adherence to therapy: 1.21 (1.09-1.35) for each 5 points higher score on the Hill-Bone scale, reported difficulties in obtaining antihypertensive medications: 1.24 (1.02-1.49) and number of antihypertensive medications prescribed: 1.32 (1.21-1.44).

CONCLUSION:  We have found high rates of uncontrolled blood pressure among Ghanaian patients with hypertension accessing healthcare in public institutions. The system-level and individual-level factors associated with poor blood pressure control should be addressed to improve hypertension management among Ghanaians.

Since Feb 4, 2018, Syrian forces with Russian support have bombarded Eastern Ghouta, an enclave out of government control near Damascus. This military action has killed hundreds of civilians and injured more than 1550 people as of Feb 21, 2018, in an area where about 390 000 people, most of whom are civilians, have lived under siege since October, 2013. The recent escalation is reportedly part of a Syrian Government offensive supported by its Russian and Iranian allies to retake Ghouta. In just 1 day, on Feb 20, 2018, PAX, an international peace movement, documented 110 civilians killed and hundreds injured in 131 air strikes, 44 barrel bombs, 28 surface-to-surface “elephant” missiles, five cluster bombs, and countless other artillery and rocket fire. Amnesty International sees this as continuing “war crimes on an epic scale”.

There is a severe shortage of specialist mental healthcare providers in low-income and middle-income countries (LMICs) affected by humanitarian crises. In these settings, talking therapies may be delivered by non-specialists, including lay workers with no tertiary education or formal certification in mental health. This systematic review will synthesise the literature on the implementation and effectiveness of talking therapies delivered by lay workers in LMICs affected by humanitarian crises, in order to develop a Theory of Change (ToC).

Five years of conflict in Syria have led to 13.5 million people in need of humanitarian assistance and 6.6 million internally displaced people. Humanitarian needs are ever-increasing as an inability to maintain humanitarian corridors and ceasefires continue. In light of the protracted nature of the conflict, immense needs, and dearth of large-scale data, we undertook this assessment to inform humanitarian response.

Sexual violence is associated with a multitude of poor physical, emotional, and social outcomes. Despite reports of stigma by sexual violence survivors, limited evidence exists on effective strategies to reduce stigma, particularly in conflict-affected settings. We sought to assess the effect of group Cognitive Processing Therapy (CPT) on stigma and the extent to which stigma might moderate the effectiveness of CPT in treating mental health problems among survivors of sexual violence in the Democratic Republic of Congo.

BACKGROUND: Limited knowledge exists to inform the selection and introduction of locally relevant, feasible, and effective mental health interventions in diverse socio-cultural contexts and health systems. We examined stakeholders' perspectives on mental health-related priorities, help-seeking behaviors, and existing resources to guide the development of a maternal mental health component for integration into non-specialized care in Soroti, eastern Uganda.

METHODS: We employed rapid ethnographic methods (free listing and ranking; semi-structured interviews; key informant interviews and pile sorting) with community health workers (n = 24), primary health workers (n = 26), perinatal women (n = 24), traditional and religious healers (n = 10), and mental health specialists (n = 9). Interviews were conducted by trained Ateso-speaking interviewers. Two independent teams conducted analyses of interview transcripts following an inductive and thematic approach. Smith's Salience Index was used for analysis of free listing data.

RESULTS: When asked about common reasons for visiting health clinics, the most salient responses were malaria, general postnatal care, and husbands being absent. Amongst the free listed items that were identified as mental health problems, the three highest ranked concerns were adeka na aomisio (sickness of thoughts); ipum (epilepsy), and emalaria (malaria). The terms epilepsy and malaria were used in ways that reflected both biomedical and cultural concepts of distress. Sickness of thoughts appeared to overlap substantially with major depression as described in international classification, and was perceived to be caused by unsupportive husbands, intimate partner violence, chronic poverty, and physical illnesses. Reported help-seeking for sickness of thoughts included turning to family and community members for support and consultation, followed by traditional or religious healers and health centers if the problem persisted.

CONCLUSION: Our findings add to existing literature that describes 'thinking too much' idioms as cultural concepts of distress with roots in social adversity. In addition to making feasible and effective treatment available, our findings indicate the importance of prevention strategies that address the social determinants of psychological distress for perinatal women in post-conflict low-resource contexts.

Social desirability bias and underreporting of HIV risk behaviors are significant challenges to the accurate evaluation of HIV prevention programs for orphans and vulnerable children (OVC) in sub-Saharan Africa. Valid and reliable HIV risk behavior instruments are critical to address these challenges. We assessed the psychometric properties of two risk behavior measures, the World Aids Foundation Survey (WAF) and the Peer HIV Risk Behavior Screener (PHRBS), administered to 210 OVC in Zambia using Audio Computer Assisted Self-Interviewing. All WAF subscales exhibited good internal reliability (α > .80); only the Sexual Behavior Practices subscale strongly distinguished (P < .01) adolescents who engaged in HIV risk behaviors ("cases") from those who did not ("non-cases"). An 8-item version of the PHRBS, refined using exploratory factor analysis, demonstrated good internal reliability (α = 87), differentiated "cases" from "non-cases" (P < .01), and correlated strongly with the Sexual Behavior Practices subcale (r = .34, P < .01). Results suggest that report of peers' sexual behaviors can serve as a proxy for OVCs' own behavior in contexts where social desirability bias affects reporting.

The UN Convention against Torture defines torture as “any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person” by someone acting in an official capacity for purposes such as obtaining a confession or punishing or intimidating that person.1 It is unethical for healthcare professionals to participate in torture, including any use of medical knowledge or skill to facilitate torture or allow it to continue, or to be present during torture.234567 Yet medical participation in torture has taken place throughout the world and was a prominent feature of the US interrogation practice in military and Central Intelligence Agency (CIA) detention facilities in the years after the attacks of 11 September 2001.891011 Little attention has been paid, however, to how a regime of torture affects the ability of health professionals to meet their obligations regarding routine clinical care for detainees.

Access to reliable energy has been identified as a global priority and codified within United Nations Sustainable Goal 7 and the Electrify Africa Act of 2015. Reliable hospital access to electricity is necessary to provide safe surgical care. The current state of electrical availability in hospitals in low- and middle-income countries (LMICs) throughout the world is not well known. This study aimed to review the surgical capacity literature and document the availability of electricity and generators.

Hepatitis E virus (HEV) is one of the leading global causes of acute viral hepatitis (Labrique et al., 1999; Emerson and Purcell, 2003). HEV infections result in serious morbidity and mortality, particularly among pregnant women (Tsega et al., 1992; Hamid et al., 1996), and have significant economic costs. Epidemics of hepatitis E are particularly problematic in areas of South Asia where seasonal floods lead to frequent contamination of drinking water supplies with HEV (Labrique et al., 2010; Ippagunta et al., 2007). Whereas case-fatality rates in the general population can vary from 0.1%–3.0% in South Asia, elevated mortality (10%–40%) in pregnant women infected with HEV genotype 1 has been demonstrated consistently. HEV infection during pregnancy frequently leads to miscarriage, preterm delivery and poor neonatal survival, stillbirth and neonatal death. Given its well-documented epidemic potential, with tens of thousands of hepatitis E cases reported annually, rapid, reliable diagnostic testing for hepatitis E is important. Rapid and reliable hepatitis E testing during outbreaks and epidemics could trigger preventive interventions (e.g., provision of safe drinking water, vaccination) to reduce the duration and severity of disease (Labrique et al., 2012; Krain et al., 2014).

One of the greatest public health challenges of our time is to assist countries affected by the dual problems of extreme poverty and exposure to mass conflict to achieve sustainable peace and economic advancement [1]. The pivotal role of women in achieving these goals has been emphasized, but their capacity to participate fully in development is compromised by a range of risk factors affecting their health and well-being, including exposure to intimate partner violence (IPV) [2]. Evidence is conclusive that IPV represents a pervasive risk factor for adverse physical and mental health outcomes amongst women in low income, conflict-affected countries [3]. The scale of harm caused to women has elevated IPV to a central focus in the Sustainable Development Goals (SDGs). Several factors are known to converge in contributing to the high rates of IPV in lowincome countries including gender inequality, societal tolerance and supportive attitudes of violence against women, poverty, male underemployment, low education in women, childhood exposure to abuse, and male alcohol and drug use. [4, 5] Yet, given the pervasive nature of these risk factors, major questions remain as to why some men resort to violence whereas others do not.

Purpose The influx of Syrian refugees into Jordan and Lebanon over the last 5 years presents an immense burden to national healthsystems. This study was undertaken to assess utilization of maternal health services among Syrian refugees in both countries. Description A cross-sectional survey of Syrian refugees living in urban and rural (non-camp) settings was conducted using a two-stage cluster survey design with probability proportional to size sampling in 2014-2015. Eighty-six percent of surveyed households in Lebanon and 88% of surveyed households in Jordan included women with a live birth in the last year. Information from women in this sub-set of households was analyzed to understand antenatal and intrapartum health service utilization. Assessment A majority of respondents reported seeking antenatal care, 82% and 89% in Jordan and Lebanon, respectively. Women had an average of at least six antenatal care visits. Nearly all births (98% in Jordan and 94% in Lebanon) took place in a health facility. Cesarean rates were similar in both countries; approximately one-third of all births were cesarean deliveries. A substantial proportion of women incurred costs for intrapartum care; 33% of Syrian women in Jordan and 94% of Syrian women in Lebanon reported paying out of pocket for their deliveries. The proportion of women incurring costs for intrapartum care was higher in Jordan both countries for women with cesarean deliveries compared to those with vaginal deliveries; however, this difference was not statistically significant in either country (Jordan p-value = 0.203; Lebanon p-value = 0.099). Conclusion Syrian refugeesliving in Jordan and Lebanon had similar levels of utilization of maternal health services, despite different health systems and humanitarian assistance provisions. As expected, a substantial proportion of households incurred out-of-pocket costs for essential maternal and newborn health services, making cost a major factor in care-seeking decisions and locations. As health financing policies shift to account for the continued burden of refugee hosting on the health system, sustained attention to the availability and quality of essential maternal and newborn health services is needed to protect both refugee and host populations women's rights to health and health care during pregnancy, childbirth, and the postpartum period.

An unprecedented number of humanitarian emergencies of large magnitude and duration is causing the largest number of people in a generation to be forcibly displaced. Yet the existing humanitarian system was created for a different time and is no longer fit for purpose. On the basis of lessons learned from recent crises, particularly the Syrian conflict and the Ebola epidemic, I recommend four sets of actions that would make the humanitarian system relevant for future public health responses: (1) operationalise the concept of centrality of protection; (2) integrate affected persons into national health systems by addressing the humanitarian–development nexus; (3) remake, do not simply revise, leadership and coordination; and (4) make interventions efficient, effective, and sustainable. For these recommendations to be implemented, governments, UN agencies, multilateral organisations, and international non-governmental organisations will need to put aside differences and relinquish authority, influence, and funding.

Stunting and micronutrient malnutrition are persistent public health problems in refugee populations. UNHCR and its partner organisations implement blanket supplementary feeding programmes using a range of special nutritional products as one approach to address these issues. The evidence base for the efficacy and effectiveness of a small quantity lipid-based nutrient supplement, Nutributter®, in reducing stunting and anaemia is limited. Secondary data analysis was used to assess the effectiveness of Nutributter® distribution on anaemia and stunting in children aged 6–23 months (programme target group) and 6–59 months (the standard age group sampled in routine nutrition surveys). Analysis was conducted using routine pre and post-intervention cross-sectional nutrition survey data collected between 2008–2011 in five refugee camps in Kenya and Djibouti. Changes in total anaemia (Haemoglobin<110g/L), anaemia categories (mild, moderate and severe), and stunting (height-for-age z-score <-2) were explored using available data on the Nutributter® programme and contextual factors. A significant reduction in the prevalence of anaemia in children aged 6–23 months and 6–59 months was seen in four of five, and in all five camps, respectively (p<0.05). Reductions ranged from 12.4 to 23.0, and 18.3 to 29.3 percentage points in each age group. Improvements were largely due to reductions in moderate and severe anaemia and occurred where the prevalence of acute malnutrition was stable or increasing. No change in stunting was observed in four of five camps. The replicability of findings across five sites strongly suggests that Nutributter®distribution was associated with a reduction in anaemia, but not stunting, among refugee children in the Horn of Africa. Benefits were not restricted to the 6–23 month target group targeted by the nutrition programme. However, even following this intervention anaemia remained a serious public health problem and additional work to define and evaluate an effective intervention package is warranted.

Objectives: To identify unmet needs and assistance priorities of displaced and female-headed households in government-controlled areas of Syria.

Methods: In mid-2016, we undertook a survey of accessible areas, largely urban and government-controlled, to identify unmet needs and assistance priorities. We used a cluster design with probability sampling to attain a final sample of 2405 households from 10 of 14 governorates; 31 of 65 (47.7%) districts were included that are home to 38.1% of people in need.

Results: Displaced and female-headed households were more vulnerable than nondisplaced and male-headed households in numerous sectors. Despite approximately half of surveyed households reporting receipt of humanitarian assistance in the preceding month and apparently effective targeting of assistance by vulnerability, unmet needs were nearly ubiquitous.

Conclusions: The humanitarian situation in inaccessible areas of Syria is likely to be considerably worse; thus, findings presented here likely underestimate humanitarian needs. Efforts to expand support to Syria’s most vulnerable households are desperately needed as are innovative targeting and modalities that enable more efficient and effective assistance.

In 2016, attacks on—or interference with—health care occurred in 23 countries in conflict or experiencing political unrest around the world. The sheer number of countries and the intensity of attacks on health facilities, health workers, ambulances, and patients are staggering. International law requires hospitals, clinics, and ambulances to be places of safety, yet health facilities are too often among the most dangerous places in communities. Moreover, health workers, who are bound by ethical codes to provide care to all who need it, were arrested, punished, and even killed for fulfilling their duty of impartial care.

Background: Armed conflict increasingly involves civilian populations, and health care needs may be immense. We hypothesized that sex disparities may exist among persons receiving operative care in conflict zones and sought to describe predictors of disparity.

Methods: We performed a retrospective analysis of operative interventions performed between 2008 and 2014 at Médecins Sans Frontières Operation Center Brussels conflict projects. A Médecins Sans Frontières Operation Center Brussels conflict project was defined as a program established in response to human conflict, war, or social unrest. Intervention- and country-level variables were evaluated. For multivariate analysis, multilevel mixed-effects logistic regression was used with random-effect modeling to account for clustering and population differences in conflict zones.

Results: Between 2008 and 2014, 49,715 interventions were performed in conflict zones by Médecins Sans Frontières Operation Center Brussels. Median patient age was 24 years (range: 1-105 years), and 34,436 (69%) were men. Patient-level variables associated with decreased interventions on women included: American Society of Anesthesiologists score (P = .003), degree of urgency (P = .02), mechanism (P < .0001), and a country's predominant religion (P = .006). Men were 1.7 times more likely to have an operative intervention in a predominantly Muslim country (P = .006).

Conclusion: Conflict is an unfortunate consequence of humanity in a world with limited resources. For most operative interventions performed in conflict zones, men were more commonly represented. Predominant religion was the greatest predictor of increased disparity between sexes, irrespective of the number of patients presenting as a result of traumatic injury. It is critical to understand what factors may underlie this disparity to ensure equitable and appropriate care for all patients in an already tragic situation.