Publications

Gender based violence (GBV) remains one of the most serious threats to the health and safety of women and girls worldwide. The problem is even more pronounced in refugee populations where women and girls are at increased risk of violence. In 2015, UNHCR reported the highest number of forcibly displaced people in recorded history. Despite growing need, there have been few rigorous evaluations of interventions aimed at primary GBV prevention and no systematic reviews of GBV prevention efforts specifically focused on refugee populations; reviews to date have primarily examined prevention of conflict related sexual violence, with very limited focus on other forms of GBV such as intimate partner violence Methods: This study reviewed the scientific literature addressing strategies for primary prevention of GBV and their effectiveness among refugee populations over the past ten years (2006 to 2015). Narrative content analysis methods were used to extract findings related to prevention activities/programs recommended by the global humanitarian community, such as sociocultural norms change, rebuilding family and community support structures, improving accountability systems, designing effective services and facilities, working with formal and traditional legal systems, monitoring and documenting GBV, and/or engaging men and boys in GBV prevention and response.

Introduction: The influx of Syrian refugees into Jordan presents an immense burden to the Jordanian health system, particularly in treating chronic health conditions. This study was undertaken to assess utilization of health services for chronic health conditions among Syrian refugees in non-camp settings.

Methods: A survey of Syrian refugees in Jordan was undertaken in June 2014 to characterize health seeking behaviors and issues related to accessing care for hypertension, diabetes, cardiovascular diseases, chronic respiratory diseases, and arthritis. A cluster design with probability proportional to size sampling was used to attain a nationally representative sample of 1550 non-camp Syrian refugee households.

Results: Of 1363 cases with a chronic health condition diagnosis, 84.7% had received care in Jordan. Public facilities faced a heavy burden serving over half (53.9%) of care-seekers; the remainder received care in the private (29.6%) and NGO/charity (16.6%) sectors. Individuals with non-communicable diseases (NCDs) in the central region of Jordan and with arthritis had the lowest rates of care-seeking when compared to other regions and conditions. Overall, 31.6% of care-seekers had an out-of-pocket payment for the most recent care-seeking event which averaged 18.8 USD (median = 0 USD), excluding cost of medications.

Discussion: Forced displacement presents major challenges to those with NCDs, which have the potential to seriously impact both the quality of life and life expectancy amongst refugees. NCD patterns among Syrian refugees indicate the importance of continuing support to public sector services in Jordan to adequately meet expanding needs and ensure appropriate prevention and control of priority NCDs.

Background: A cluster randomized trial of a pay-for-performance (P4P) scheme was implemented in Afghanistan to test whether P4P could improve maternal and child (MCH) services.

Methods: All 442 primary care facilities in 11 provinces were matched by type of facility and outpatient volume, and randomly assigned to the P4P or comparison arm. P4P facilities were given bonus payments based on the MCH services provided. An endline household sample survey was conducted in 72 randomly selected matched pair catchment areas (3421 P4P households; 3427 comparison).The quality of services was assessed in 81 randomly sampled matched pairs of facilities. Data collectors and households were blinded to the intervention assignment. MCH outcomes were assessed at the cluster level.

Results: There were no substantial differences in any of the five MCH coverage indicators (P4P vs comparison): modern contraception(10.7% vs 11.2% (P = 0.90); antenatal care: 56.2% vs 55.6% (P = 0.94); skilled birth attendance (33.9% vs 28.5%, P = 0.17); postnatal care (31.2% vs 30.3%, P = 0.98); and childhood pentavalent3 vaccination (49.6 vs 52.3%, P = 0.41), or in the equity measures. There were substantial increases in the quality of history and physical examinations index (P = 0.01); client counselling index (P = 0.01); and time spent with patients (P = 0.05). Health workers reported limited understanding about the bonuses.

Conclusions: The intervention had minimal effect, possibly due to difficulties communicating with health workers and inattention to demand-side factors. P4P interventions need to consider management and community demand issues.

Introduction: Afghanistan has a maternal mortality ratio of 400 per 100,000 live births. Hemorrhage is the leading cause of maternal death. Two-thirds of births occur at home. A pilot program conducted from 2005 to 2007 demonstrated the effectiveness of using community health workers for advance distribution of misoprostol to pregnant women for self-administration immediately following birth to prevent postpartum hemorrhage. The Ministry of Public Health requested an expansion of the pilot to study implementation on a larger scale before adopting the intervention as national policy. The purpose of this before-and-after study was to determine the effectiveness of advance distribution of misoprostol for self-administration across 20 districts in Afghanistan and identify any adverse events that occurred during expansion.

Methods: Cross-sectional household surveys were conducted pre- (n = 408) and postintervention (n = 408) to assess the effect of the program on uterotonic use among women who had recently given birth. Maternal death audits and verbal autopsies were conducted to investigate peripartum maternal deaths that occurred during implementation in the 20 districts.

Results: Uterotonic use among women in the sample increased from 50.3% preintervention to 74.3% postintervention. Because of a large-scale investment in Afghanistan in training and deployment of community midwives, it was assumed that all women who gave birth in facilities received a uterotonic. A significant difference in uterotonic use at home births was observed among women who lived farthest from a health facility (> 90 minutes self-reported travel time) compared to women who lived closer (88.5% vs 38.9%; P < .0001). All women who accepted misoprostol and gave birth at home used the drug. No maternal deaths were identified among those women who used misoprostol.

Discussion: The results of this study build on the findings of the pilot program and provide evidence on the effectiveness, primarily measured by uterotonic use, of an expansion of advance distribution of misoprostol for self-administration.

Background: Anesthesia is integral to improving surgical care in low-resource settings. Anesthesia providers who work in these areas should be familiar with the particularities associated with providing care in these settings, including the types and outcomes of commonly performed anesthetic procedures.

Methods: The authors conducted a retrospective analysis of anesthetic procedures performed at Médecins Sans Frontières facilities from July 2008 to June 2014. The authors collected data on patient demographics, procedural characteristics, and patient outcome. The factors associated with perioperative mortality were analyzed.

Results: Over the 6-yr period, 75,536 anesthetics were provided to adult patients. The most common anesthesia techniques were spinal anesthesia (45.56%) and general anesthesia without intubation (33.85%). Overall perioperative mortality was 0.25%. Emergent procedures (0.41%; adjusted odds ratio [AOR], 15.86; 95% CI, 2.14 to 115.58), specialized surgeries (2.74%; AOR, 3.82; 95% CI, 1.27 to 11.47), and surgical duration more than 6 h (9.76%; AOR, 4.02; 95% CI, 1.09 to 14.88) were associated with higher odds of mortality than elective surgeries, minor surgeries, and surgical duration less than 1 h, respectively. Compared with general anesthesia with intubation, spinal anesthesia, regional anesthesia, and general anesthesia without intubation were associated with lower perioperative mortality rates of 0.04% (AOR, 0.10; 95% CI, 0.05 to 0.18), 0.06% (AOR, 0.26; 95% CI, 0.08 to 0.92), and 0.14% (AOR, 0.29; 95% CI, 0.18 to 0.45), respectively.

Conclusions: A wide range of anesthetics can be carried out safely in resource-limited settings. Providers need to be aware of the potential risks and the outcomes associated with anesthesia administration in these settings.

Purpose: Rates of alcohol use may be increasing among Asian-American adolescents. Among youth from Asian-immigrant families, intergenerational cultural dissonance (ICD), a difference in acculturation between children and caregivers, is associated with adverse childhood outcomes. This study investigates the longitudinal association of ICD and alcohol use among youth from immigrant Vietnamese and Cambodian families in the United States.

Methods: Two waves of annual data, wave 4 (baseline for this study) and wave 5 (follow-up), were obtained from the Cross-Cultural Families Project, a longitudinal study of 327 Vietnamese and Cambodian immigrant families in Washington State. The Asian-American Family Conflicts Scale was used to measure ICD. Adolescent alcohol use was measured as any drinking in the past 30 days. A multiple logistic regression model was estimated with the outcome, alcohol use, measured at the follow-up visit and all predictors, including ICD, measured at baseline. Sex, nationality, nativity, and acculturation were tested as modifiers of the ICD-alcohol use relationship.

Results: Nine percent of adolescents (age range 13-18 years) reported alcohol use at baseline and this increased significantly (p < .0001) to 16% one year later. ICD was associated with increased odds of alcohol use at follow-up (odds ratio: 1.57; 95% confidence interval: 1.03-2.41; p = .04). None of the interactions were statistically significant.

Conclusions: ICD is a significant predictor of alcohol use among Vietnamese and Cambodian adolescents. Interventions that should be targeted toward reducing ICD through enhancing parent-child communication and teaching bicultural competence skills may help prevent alcohol use problems among youth from immigrant families.

In light of the recent Ebola epidemic, Francesco Checchi and colleagues argue that the World Health Organization’s response to health emergencies is not fit for purpose and put forward six proposals to reform WHO’s crisis response

Background: With over one million Syrian refugee children in the region, we undertook this study to characterize care-seeking behaviors and health service utilization for child refugees with the aim of informing humanitarian programming for non-camp settings in Jordan.

Methods: A survey of Syrian refugees living outside of camps in Jordan was conducted using a 125 × 12 cluster design with probability proportional to size sampling to obtain a representative sample. The questionnaire focused on access to health services, including a module on care seeking for children.

Results: Care seeking was high with 90.9% of households with a child less than 18 years seeking medical care the last time it was needed. Households most often sought care for children in the public sector (54.6%), followed by private (36.5%) and charity sectors (8.9%). Among child care seekers, 88.6% were prescribed medication during the most recent visit, 90.6% of which obtained the medication. Overall, 49.4% of households reported out-of-pocket expenditures for either the consultation or prescribed medications at the most recent visit (mean $US21.1 and median $US0).

Conclusions: Syrian refugees had good access to care for their sick children at the time of the survey; however, this has likely deteriorated since the survey because of the withdrawal of free access for refugees. The number of refugees in Jordan and relative accessibility of care has resulted in a large burden on the health system; the Jordanian government will require additional support if current levels of health access are to be maintained for Syrian refugees.

Stigma related to sexual violence (SV) is associated with many negative physical and social outcomes. We sought to create a contextually relevant measure of SV-related stigma for women in the Democratic Republic of Congo (DRC) and assess itspsychometrics and validity. Using baseline screening data from two randomized controlled trials of services for female SV survivors in Eastern DRC ( n = 1,184), we conducted exploratory and confirmatory factor analyses to test the measurement model. Cronbach's alphas and Kuder-Richardson 20 (KR-20) statistics were used to evaluate internal consistency. Logistic and linear regressions of the stigma measures with related constructs were used to assess construct validity. Two distinct but related scales were developed based on factor analyses: a four-item scale of discrimination-related stigma (i.e., enacted stigma) and an eight-item scale of combined perceived and internalized stigma (i.e., felt stigma). Both scales showed good internal consistency (KR-20 = .68; α = .86). A higher felt stigma score was associated with significant increases in combined depression and anxiety and trauma symptoms, as well as functional impairment ( p < .001). Having a child as a result of SV was associated with both significantly higher enacted and felt stigma ( p < .001). Neither SV stigma scale was associated with medical care seeking. To address harmful ramifications of stigma among SV survivors, locally relevant quantitative measures are necessary to understand the nature and severity of stigma they experience. Our process of scale creation and evaluation can serve as an example for developing locally relevant SV-related stigma measures.

The objectives are as follows: To identify, synthesise and evaluate the effects of health system and other interventions aimed at improving maternal, newborn and women's reproductive health in crisis settings.

Worldwide, humanitarian crises impact significantly on public health, health infrastructure and the delivery of health care (WHO 2012). A humanitarian crisis can be understood as '...a situation in which there is an exceptional and generalized threat to human life, health or subsistence. These crises usually appear within the context of an existing situation of a lack of protection where a series of pre‐existent factors (poverty, inequality, lack of access to basic services) exacerbated by a natural disaster or armed conflict, multiply the destructive effects' (Francesch 2010). Humanitarian crises are generally grouped into the following three categories: 

• natural disasters (e.g. earthquakes, floods, storms and volcanic eruptions);
• man‐made disasters (e.g. conflicts, plane and train crashes, fires and industrial accidents); and 
• complex emergencies (Humanitarian Coalition)

We assessed symptoms of psychological distress among a population-based sample of 9000-plus adults in Burundi during (1998) and after (2007) armed conflict. After exploratory and confirmatory factor analysis to an 8-item, self-report measure, we identified two domains of psychological distress “Depression/Anxiety” and “Functioning” with good fit to data. The questionnaire was invariant in males and females. Depression and Anxiety symptoms during conflict were more frequently reported than Functioning symptoms; all symptoms were more frequently reported by women. Psychological distress was found in 44 % of individuals during conflict and in 29 % 2 years after the conflict. Results call for further research in Burundi that can inform the development of mental health interventions.

The effectiveness of humanitarian programs normally is evaluated according to a limited number of pre-defined objectives. These objectives typically rep- resent only selected positive expected impacts of program interventions and as such, are inadequate benchmarks for understanding the overall effective- ness of aid. This is because programs also have unexpected impacts (both pos- itive and negative) as well as expected negative impacts and expected positive impacts beyond the program objectives. The authors contend that these other categories of program impacts also should be assessed, and suggest a method- ology for doing so that draws on input from the perspectives of beneficiaries. This paper includes examples of the use of this methodology in the field. Finally, the authors suggest future directions for improving this type of expanded assessment and advocate for its widespread use, both within and without the field of disaster response.

On Nov 1, 2023, the only cancer hospital in Gaza ceased functioning. The Turkish–Palestinian Friendship Hospital in Gaza had already been seriously damaged by Israeli airstrikes, but it was the shortage of fuel that forced its closure. The UN Office for the Coordination of Humanitarian Affairs warned that the lives of 70 patients were at risk. Reports subsequently emerged that four patients had died due to insufficient medical care. Médecins Sans Frontières (MSF), which supported the Turkish–Palestinian Friendship Hospital, published a social media post stating how the entry of fuel into Gaza, which is essential for powering hospitals, is being prevented by the Israeli authorities and that hospitals and health-care facilities continue to be attacked. There are grave concerns that insufficient fuel supplies will eventually mean incubators and oxygen machines will shut down, the water and sanitation system will collapse, and trucks carrying life-saving supplies will not reach their destination.

Objective

The US government detains hundreds of thousands of migrants across a network of facilities each year. This research aims to evaluate the completeness of standards across US detention agencies to protect the health and dignity of migrants.

Design

 Five documents from three US agencies were examined in a systematic review: Immigration and Customs Enforcement (ICE; 3), Customs and Border Protection (CBP; 1) and Office of Refugee Resettlement (ORR; 1). Standards within five public health categories (health, hygiene, shelter, food and nutrition, protection) were extracted from each document and coded by subcategory and area. Areas were classified as critical, essential or supportive. Standards were measured for specificity, measurability, attainability, relevancy and timeliness (SMART), resulting in a sufficiency score (0%–100%). Average sufficiency scores were calculated for areas and agencies.

Results

 711 standards were extracted within 5 categories, 12 subcategories and 56 areas. 284 standards of the 711 standards were included in multiple (2–7) areas, resulting in 1173 standards counted as many times as each was included. On average, 85.4% of standards were specific, 87.1% measurable, 96.6% attainable and 74.9% time-bound. All standards were considered relevant. CBP standards were the least sufficient across all other SMART components, when compared with ICE and ORR.

Background

Colombia hosts a large number of Venezuelan migrants and refugees who are uniquely vulnerable and have been markedly impacted by the COVID-19 pandemic. It is necessary to understand their experiences to inform future policy decisions both in Colombia and during disease outbreaks in other humanitarian contexts in the future. As part of a larger study focused on HIV among Venezuelans residing in Colombia, qualitative interviews were conducted to understand this population's experiences and access to healthcare.

Methods

Interviews were conducted with Venezuelan migrants and refugees as well as stakeholders such as care providers, humanitarian workers, and government officials. Interviews were recorded, transcribed, and coded using thematic content analysis. Select quotes were translated and edited for length and/or clarity.

Results

Venezuelan migrants and refugees reported high levels of housing instability, job instability, increased barriers to accessing healthcare, and complications in engaging in the HIV care continuum, among other impacts of the COVID-19 pandemic. Stakeholders reported complications in provision of care and obtaining medicines, difficulty maintaining contact with patients, increased discrimination and xenophobia targeting Venezuelan migrants and refugees, increased housing instability among Venezuelan migrants and refugees, and other impacts as a result of the COVID-19 pandemic.

Humanitarian crises pose a major threat to health and dignity worldwide. There is a need for evidence-based interventions in humanitarian settings to maximise the impact of efforts to respond to pressing needs. Our first Humanitarian Health Evidence Review (HHER1), led by a team from the London School of Hygiene & Tropical Medicine and published in 2015, was the first publication of its kind to provide a comprehensive assessment of the evidence base for humanitarian health interventions in low- and middle-income countries (LMICs).

As we approach a decade since the creation of our Research for Health in Humanitarian Crises (R2HC) programme, and in recognition of the persistent need for evidence-informed public health response in diverse and complex humanitarian settings, we have taken stock of humanitarian health research published since the first review was conducted. We are pleased to present here the second Humanitarian Health Evidence Review (HHER2), which reflects a collaboration between Elrha and the Johns Hopkins Center for Humanitarian Health, led by Shannon Doocy, Emily Lyles and Hannah Tappis.  

HHER2 provides a thorough mapping of the quantity and quality of evidence examining the effectiveness of health interventions in humanitarian settings in LMICs. It captures peer-reviewed evidence published since 2013 and offers an analysis of critical strengths and weaknesses in the evidence base across priority humanitarian health areas: communicable disease control; water, sanitation and hygiene; nutrition; sexual and reproductive health, and gender-based violence; mental health and psychosocial support; non-communicable diseases; injury and physical rehabilitation; health service delivery; and health systems.

Highly active antiretroviral therapy (HAART) strongly inhibits HIV replication. However, many patients show suboptimal immune recovery (SIR), as defined by virological suppression (i.e. low viral load) with a CD4+ T-cell count of ? 200 cells/mm3, after HAART initiation. Here, we performed a systematic evaluation of the SIR prevalence among HIV-infected patients in cohort studies. We searched PubMed, Cochrane Library, Embase, CNKI, Wanfang database, and Chinese Biomedicine Database for cohort studies about HIV-infected participants whose CD4+ T-cell count was ? 200 cells/mm3 but still had virological suppression after HAART initiation. The SIR prevalence from each of those cohort studies was pooled into a random-effect meta-analysis. We obtained two kinds of pooled post-HARRT initiation SIR prevalence: one among participants with virological suppression (11 cohort studies involving 18,672 participants), and the other among all HIV-infected participants (seven cohort studies involving 12,063 participants). The pooled SIR prevalence among HIV-infected patients with virological suppression after HAART initiation was 43% (95% confidence interval [CI], 34-51%) at 6 months post-HAART initiation and 10% (95% CI, 5-18%) at 36 months post-HAART initiation; among all HIV-infected patients after HAART initiation, it was 17% (95% CI, 0-55%) and 5% (95% CI, 2-10%) at 6 and 36 months post-HAART initiation, respectively. The SIR prevalence among HIV-infected patients is high at 6 months post-HAART initiation, but its prevalence gradually reduces over time under continuous HAART. Thus, it is important to follow-up on variations in the CD4+ T-cell count and viral load.

This study assesses differences mortality patterns and relative hazard due to fatal occupational injuries between native and immigrant workers in the US. Fatal occupational injury data from 2003 to 2010 were examined using survival analysis based on proportional hazards models controlling for categorical variables of race, gender, occupation, and industry. Workers are stratified based on whether they are native to the US (n = 31952) or born abroad (n = 7096). Foreign-born workers are further stratified into region of birth. Foreign-born workers had an adjusted hazard ratio of 1.148 (95 % CI 1.109:1.189) relative to native workers. Stratifying foreign-born workers into region of origin revealed significantly higher adjusted risk of work fatality relative to native workers for most foreign regions. Of fatally injured workers, foreign-born workers have shorter survival before succumbing to traumatic injury during their time of occupational ‘exposure’ in the workforce. Native-born workers tend to incur fatal injuries at older ages after longer ‘exposure’.