Publications

Understanding people’s interest in using modern contraception is critical to ensuring programs align with people’s preferences and needs. Current measures of demand for contraception are misinterpreted. More direct measures of intention to use (ITU) contraception do exist but remain underexplored. This systematic review examines the relationship between intention to use and actual use of contraception.

Syria has experienced over a decade of armed conflict, characterized by targeted violence against healthcare. The impacts of these attacks have resulted in both direct and indirect attacks on health and reverberating effects on local communities. This study aims to explore the perspectives of health workers based in northern Syria who have experienced such attacks on health to understand the impacts on the health system as well as communities served. In-depth interviews were conducted with health workers in the northern regions of Syria where attacks on health have been frequent. Participants were identified using purposive and snowball sampling. Interviews were coded and analyzed using the Framework Method. Our inductive and deductive codes aligned closely with the WHO Health System Building Blocks framework, and we therefore integrated this framing into the presentation of findings. We actively sought to include female and non-physician health workers as both groups have been under-represented in previous research in northern Syria. A total of 40 health workers (32.5% female, 77.5% non-physicians) who experienced attacks in northern Syria between 2013 and 2020 participated in interviews in 2020–2021. Participants characterized attacks on health as frequent, persistent over years, and strategically targeted. The attacks had both direct and indirect impacts on the health system and consequently the wider health of the community. For the health system, participants noted compounded impacts on the delivery of care, health system governance, and challenges to financing, workforce, and infrastructure. Reconstructing health facilities or planning services in the aftermath of attacks on health was challenging due to poor health system governance and resource challenges. These impacts had ripple effects on the health of the community, particularly the most vulnerable. The impacts of attacks on health in Syria are multiple, with both short- and long-term consequences for the health system(s) across Syria as well as the health of communities in these respective areas. Though such attacks against healthcare are illegal under international humanitarian law, this and other legal frameworks have led to little accountability in the face of such attacks both in Syria and elsewhere. Characterizing their impacts is essential to improving our understanding of the consequences of attacks as a public health issue and supporting protection and advocacy efforts.

Syria has experienced over a decade of armed conflict, characterized by targeted violence against healthcare. The impacts of these attacks have resulted in both direct and indirect attacks on health and reverberating effects on local communities. This study aims to explore the perspectives of health workers based in northern Syria who have experienced such attacks on health to understand the impacts on the health system as well as communities served. In-depth interviews were conducted with health workers in the northern regions of Syria where attacks on health have been frequent. Participants were identified using purposive and snowball sampling. Interviews were coded and analyzed using the Framework Method. Our inductive and deductive codes aligned closely with the WHO Health System Building Blocks framework, and we therefore integrated this framing into the presentation of findings. We actively sought to include female and non-physician health workers as both groups have been under-represented in previous research in northern Syria. A total of 40 health workers (32.5% female, 77.5% non-physicians) who experienced attacks in northern Syria between 2013 and 2020 participated in interviews in 2020–2021. Participants characterized attacks on health as frequent, persistent over years, and strategically targeted. The attacks had both direct and indirect impacts on the health system and consequently the wider health of the community. For the health system, participants noted compounded impacts on the delivery of care, health system governance, and challenges to financing, workforce, and infrastructure. Reconstructing health facilities or planning services in the aftermath of attacks on health was challenging due to poor health system governance and resource challenges. These impacts had ripple effects on the health of the community, particularly the most vulnerable. The impacts of attacks on health in Syria are multiple, with both short- and long-term consequences for the health system(s) across Syria as well as the health of communities in these respective areas. Though such attacks against healthcare are illegal under international humanitarian law, this and other legal frameworks have led to little accountability in the face of such attacks both in Syria and elsewhere. Characterizing their impacts is essential to improving our understanding of the consequences of attacks as a public health issue and supporting protection and advocacy efforts.

Challenges in delivering evidence-based programming in humanitarian crises require new strategies to enhance implementation science for better decision-making. A recent scoping review highlights the scarcity of peer-reviewed studies on implementation in conflict zones. In this commentary, we build on this scoping review and make five recommendations for advancing implementation science for humanitarian settings. These include (1) expanding existing frameworks and tailoring them to humanitarian dynamics, (2) utilizing hybrid study designs for effectiveness-implementation studies, (3) testing implementation strategies, (4) leveraging recent methodological advancements in social and data science, and (5) enhancing training and community engagement. These approaches aim to address gaps in understanding intervention effectiveness, scale, sustainability, and equity in humanitarian settings. Integrating implementation science into humanitarian research is essential for informed decision-making and improving outcomes for affected populations.

Protecting the health of migrants and refugees during the pandemic was a significant challenge in the Latin American region. We aimed to describe and contrast the response of the health systems of Mexico, Colombia and Perú to migrants' and refugees’ health needs during the COVID-19 pandemic, and to situate the response in the context of the migration and health policies of each country.

Meeting the health needs of crisis-affected populations is a growing challenge, with 339 million people globally in need of humanitarian assistance in 2023. Given one in four people living in humanitarian contexts are women and girls of reproductive age, sexual and reproductive health care is considered as essential health service and minimum standard for humanitarian response. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on appropriate methods and analytical frameworks is limited.

Cholera outbreaks are on the rise globally, with conflict-affected settings particularly at risk. Case-area targeted interventions (CATIs), a strategy whereby teams provide a package of interventions to case and neighboring households within a predefined "ring," are increasingly employed in cholera responses. However, evidence on their ability to attenuate incidence is limited.

Although the evidence about coronavirus disease 2019 (COVID-19) has increased exponentially since the beginning of the pandemic, less is known about the direct and indirect effects of the pandemic in humanitarian settings. In the Democratic Republic of the Congo (DRC), most studies occurred in Kinshasa and other cities. Limited research was conducted in remote conflict-affected settings. We investigated the COVID-19 epidemiology, health service utilisation, and health care-seeking behaviour during the first year of the pandemic (March 2020–March 2021) in the Mweso health zone, North Kivu, DRC.

Despite a long history of political discourse around refugee integration, it wasn’t until 2016 that this issue emerged as a global political priority. Limited research has examined the evolution of policies of global actors around health service provision to refugees and how refugee integration into health systems came onto the global agenda. This study seeks to fill this gap.

International humanitarian law is routinely being broken with impunity in conflicts globally. Populism tinged with anti-refugee discourse has led to a weakening of asylum and refugee law in many countries.  While special protection of hospitals and ambulances was previously largely respected by warring parties under the Geneva Conventions, attacks on health care have become the norm. With conflict-related deaths at a 26-year record high and more than 110 million people forcibly displaced worldwide at the end of June, 2023, the humanitarian system is overwhelmed, despite increases in humanitarian support from public and private donors.  As one of us (PBS) wrote in The Lancet in 2017: “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.”  

Abstract

Introduction

Equitable access to vaccines for migrants and refugees is necessary to ensure their right to health and to achieve public health goals of reducing vaccine-preventable illness. Public health policies require regulatory frameworks and communication to effect uptake of effective vaccines among the target population. In Colombia, the National COVID-19 Vaccination Plan implicitly included Venezuelan refugees and migrants; however, initial communication of the policy indicated that vaccine availability was restricted to people with regular migration status. We estimated the impact of a public announcement, which clarified access for refugees and migrants, on vaccination coverage among Venezuelans living in Colombia.

Methods 

Between 30 July 2021 and 5 February 2022, 6221 adult Venezuelans participated in a cross-sectional, population-based health survey. We used a comparative cross-sectional time-series analysis to estimate the effect of the October 2021 announcement on the average biweekly change in COVID-19 vaccine coverage of Venezuelans with regular and irregular migration status.

Results 

71% of Venezuelans had an irregular status. The baseline (preannouncement) vaccine coverage was lower among people with an irregular status but increased at similar rates as those with a regular status. After the announcement, there was a level change of 14.49% (95% CI: 1.57 to 27.42, p=0.03) in vaccination rates among individuals with irregular migration status with a 4.61% increase in vaccination rate per biweekly period (95% CI: 1.71 to 7.51, p=0.004). By February 2022, there was a 26.2% relative increase in vaccinations among individuals with irregular migration status compared with what was expected without the announcement.

Conclusion

 While there was no policy change, communication clarifying the policy drastically reduced vaccination inequalities across migration status. Lessons can be translated from the COVID-19 pandemic into more effective global, regional and local public health emergency preparedness and response to displacement.

In today's modern warfare, there is a growing risk of chemical and biological weapons use. Despite the widespread adoption of the United Nations Biological and Toxin Weapons Convention1 in 1975 and the Chemical Weapons Convention2 in 1997, we have seen notable examples of state-sponsored use of agents on vulnerable populations, as well as the use by individuals and nonstate actors.3-7 With the rise in acts of terrorism and conflict, there is an increased likelihood of exposure to chemical or biological agents by women and young children, who often represent the most vulnerable among the population. Children aged 0 to 5 years carry the most significant burden of conflict-related deaths of all age groups.8 Women of reproductive age who live in conflict zones have 3 times higher mortality than women who live in predominantly conflict-free settings.9

Despite the stark evidence of severe short- and long-term impacts of conflict on women and young children, this population has historically been overlooked when it comes to setting policy or providing holistic or human-centered guidance in conflict settings.10 There are abundant guidelines and research available on chemical and biological threats and how the general population could be impacted, as well as references to the treatment of breastfeeding women when discussing antidotes, vaccines, and drug treatments. However, there is very little guidance on whether women can safely continue to breastfeed after specific chemical and biological events and at what point breastfeeding can be safely resumed. Current information about breastfeeding safety in this scenario is disparate and hard to find.

Abstract

In today's modern warfare, there is a growing risk of chemical and biological weapons use. Despite the widespread adoption of the United Nations Biological and Toxin Weapons Convention in 1975 and the Chemical Weapons Convention in 1997, we have seen notable examples of state-sponsored use of agents on vulnerable populations, as well as the use by individuals and nonstate actors. With the rise in acts of terrorism and conflict, there is an increased likelihood of exposure to chemical or biological agents by women and young children, who often represent the most vulnerable among the population. Children aged 0 to 5 years carry the most significant burden of conflict-related deaths of all age groups. Women of reproductive age who live in conflict zones have 3 times higher mortality than women who live in predominantly conflict-free settings.

Despite the stark evidence of severe short- and long-term impacts of conflict on women and young children, this population has historically been overlooked when it comes to setting policy or providing holistic or human-centered guidance in conflict settings. There are abundant guidelines and research available on chemical and biological threats and how the general population could be impacted, as well as references to the treatment of breastfeeding women when discussing antidotes, vaccines, and drug treatments. However, there is very little guidance on whether women can safely continue to breastfeed after specific chemical and biological events and at what point breastfeeding can be safely resumed. Current information about breastfeeding safety in this scenario is disparate and hard to find.

Abstract

The humanitarian situation in the Gaza Strip is untenable. An estimated 1·7 million people—over 75% of the population—have been displaced across Gaza as of Jan 30, 2024, often multiple times. Families have been forced to move multiple times in search of safety. According to local authorities, as of Jan 7, 2024, at least 26 901 Palestinians have been killed, 65 949 have been injured, and 7780 are missing, mostly under the rubble. Access to life-saving health services has been severely affected. Electricity, fuel, water, and medicines are either in very short supply or non-existent.  

Throughout this war—and before it, amid years of blockade—the UN Relief and Works Agency (UNRWA) has been a lifeline for people in Gaza. As of Jan 31, 2024, nearly 1·7 million displaced people are now sheltering in emergency shelters (both UNRWA and public shelters), informal sites, or in close vicinity to UNRWA shelters and distribution sites within host communities.

As part of COVID-19 mitigation strategies, emergency nutrition program adaptations were implemented, but evidence of the effects is limited. Compared to the standard protocol, the full adapted protocol included adapted admissions criteria, simplified dosing, and reduced visit frequency; partially adapted protocols consisting of only some of these modifications were also implemented. To enable evidence-based nutrition program modifications as the context evolved, this study was conducted to characterize how protocol adaptations in South Sudan affected Outpatient Therapeutic Feeding Program outcomes.

To respond to the COVID-19 pandemic, countries introduced public health and social measures that had indirect societal, economic consequences. Concerns during epidemics include continuity of routine health services. We investigate how healthcare utilisation and healthcare seeking behaviour changed during the first year of the COVID-19 pandemic among host communities in Cox’s Bazar, Bangladesh. This mixed-methods study combines quantitative analyses of routine health data and population-based findings about healthcare seeking behaviours. Trends in consultations changed according to facility level (higher-level facilities included Upazila Health Complexes and District Hospitals; lower-level facilities included Community Clinics and Union Health and Family Welfare Centers). At the pandemic’s beginning, drops were seen at higher-level health facilities for outpatient department (OPD) consultations, respiratory infections, and antenatal care. Minor reductions or increases were seen at lower-level facilities for the same services. Half of the subdistricts reported a cumulative increase in OPD and respiratory tract infection consultations. Most subdistricts reported a cumulative decrease in antenatal care. Child vaccinations dropped in all subdistricts, half of which did not catch-up, resulting in a cumulative decrease of delivered doses. Fear of contracting COVID-19 and financial constraints were the main reasons for decreased access. Drivers of healthcare seeking behaviours should be better understood to guide preparedness and service delivery modalities at primary and secondary levels.

Population-based estimates of syphilis prevalence are critical to informing public health response. We aimed to measure syphilis prevalence among Venezuelan refugees and migrants in Colombia to inform public health programming.

The ongoing war in Gaza has led to unprecedented death and destruction.  Hostilities continue to have a dire effect on the 2·2 million people living in Gaza, with particular and acute effects on the estimated 52 000 women who are currently pregnant.  At the time of writing, around 1·93 million people in Gaza (85% of the population) have been displaced and over 18 205 lives have been lost; of these lives lost, 5153 were women and 7729 were children, constituting 70% of the fatalities. Indirect causes of excess mortality, including from unmanaged obstetric complications, are expected to increasingly contribute to death.

In 2020, 149.2 million children worldwide under 5 years suffered from stunting, and 45.4 million experienced wasting. Many infants are born already stunted, while others are at high risk for growth faltering early after birth. Growth faltering is linked to transgenerational impacts of poverty and marginalization. Few interventions address growth faltering in infants under 6 months, despite a likely increasing prevalence due to the negative global economic impacts of the COVID-19 pandemic. Breastfeeding is a critical intervention to alleviate malnutrition and improve child health outcomes, but rarely receives adequate attention in growth faltering interventions. A systematic review and meta-analysis were undertaken to identify and evaluate interventions addressing growth faltering among infants under 6 months that employed supplemental milks. The review was carried out following guidelines from the USA National Academy of Medicine. A total of 10,405 references were identified, and after deduplication 7390 studies were screened for eligibility. Of these, 227 were assessed for full text eligibility and relevance. Two randomized controlled trials were ultimately included, which differed in inclusion criteria and methodology and had few shared outcomes. Both studies had small sample sizes, high attrition and high risk of bias. A Bangladeshi study (n = 153) found significantly higher rates of weight gain for F-100 and diluted F-100 (DF-100) compared with infant formula (IF), while a DRC trial (n = 146) did not find statistically significant differences in rate of weight gain for DF-100 compared with IF offered in the context of broader lactation and relactation support. The meta-analysis of rate of weight gain showed no statistical difference and some evidence of moderate heterogeneity. Few interventions address growth faltering among infants under 6 months. These studies have limited generalizability and have not comprehensively supported lactation. Greater investment is necessary to accelerate research that addresses growth faltering following a new research framework that calls for comprehensive lactation support.