Publications

Active conflict settings present challenging operating environments for humanitarian health organizations and workers. An emerging feature of some conflicts is direct violence against health workers, facilities, and patients. Since the start of the war in 2011, Syria has endured extreme and deliberate violent attacks on health facilities and workers. This paper reports findings from a qualitative study that examined the lived experiences of Syrian humanitarian health workers facing extreme ethical challenges and coping with moral distress. In-depth interviews were carried out with 58 front-line health workers in northern and southern Syria. Participants described a number of ethical and operational challenges they experienced while providing services in extreme conditions, as well as strategies used to cope with them. The complex intersection of personal and organizational challenges is considered, and findings are linked to key ethical and humanitarian principles. Practical recommendations and action steps are provided to guide humanitarian health organizations. This article is protected by copyright. All rights reserved.

The worsening humanitarian catastrophe and conflict in Ukraine has led to the largest refugee crisis in Europe since World War 2. Millions of people are expected to flee Ukraine, with more than a million individuals having fled the country in the first week of the conflict alone. The consequences of war, trauma, and devastation must be tackled swiftly. The resultant mid-term and long-term needs must propel all sectors, including health, into rapid action. The UCL–Lancet Commission on Migration and Health report highlighted evidence-based approaches to address the health needs of forcibly displaced individuals.

Although the initial response of the EU agreeing to a uniform policy of settlement, work, and welfare rights for those forcibly displaced is welcomed, implementation of these policies, without restrictions, red tape, or xenophobia and racism is by no means assured. The COVID-19 pandemic illuminated the need to strengthen health systems and reduce disparities in access to and quality of care for migrant groups. As the crisis in Ukraine becomes protracted, access to health care could be at further risk because nations have varying levels of preparedness and reception, and variable health systems, particularly in neighbouring countries such as Poland, Slovakia, Bulgaria, and the Czech Republic (Czechia), which will be strained by the large numbers of people arriving from Ukraine. These countries will need increased support, including financial support, from other countries. The Ukrainian crisis will test political solidarity, health system planning and capacity, and the global community's ability to keep the commitment to universal health coverage.

Introduction 

Non-pharmaceutical interventions (NPIs) are a crucial suite of measures to prevent and control infectious disease outbreaks. They are particularly important for crisis-affected populations that typically reside in settings characterised by overcrowding, inadequate access to healthcare and resource limitations. To describe the landscape of research and identify evidence gaps concerning the acceptability, feasibility, and effectiveness of NPIs among crisis-affected populations and informal settings, we conducted a systematic scoping review of the published evidence.

Methods

We systematically reviewed peer-reviewed articles published between 1970 and 2020 to collate available evidence on the feasibility, acceptability, and effectiveness of NPIs in crisis-affected populations and informal settlements. We performed quality assessments of each study using a standardised questionnaire.

Results

 Our review included 158 studies published in 85 peer-reviewed articles. Most research used low quality study designs. The acceptability, feasibility, and effectiveness of NPIs was highly context dependent. In general, simple and cost-effective interventions such as community-level environmental cleaning and provision of water, sanitation and hygiene services, and distribution of items for personal protection such as insecticide-treated nets, were both highly feasible and acceptable. Logistical, financial, and human resource constraints affected both the implementation and sustainability of measures. Community engagement emerged as a strong factor contributing to the effectiveness of NPIs. Conversely, measures that involve potential restriction on personal liberty such as case isolation were found to be less acceptable to the community.

As of March 31, 2022, the World Health Organization’s Surveillance System for Attacks on Health Care (SSA) reported at least 82 attacks on health care in Ukraine, resulting in 72 deaths and 43 injuries. Most attacks involved the use of heavy weapons against health care facilities, personnel, patients, and medical supplies. In Mariupol, a direct Russian airstrike on a hospital complex reportedly injured at least 17 health workers and patients; an expectant mother later died. Russian forces reportedly took 100 patients and health workers and 400 civilians as hostages inside an intensive care hospital. These are part of a larger global pattern of attacks on health care in conflict zones. In the period 2016-2020, more than 4000 incidents of violence against health care in conflict areas were reported.

Background

Cholera is a major cause of mortality and morbidity in low-resource and humanitarian settings. It is transmitted by fecal-oral route, and the infection risk is higher to those living in and near cholera cases. Rapid identification of cholera cases and implementation of measures to prevent subsequent transmission around cases may be an efficient strategy to reduce the size and scale of cholera outbreaks.

Methodology/Principle findings

We investigated implementation of cholera case-area targeted interventions (CATIs) using systematic reviews and case studies. We identified 11 peer-reviewed and eight grey literature articles documenting CATIs and completed 30 key informant interviews in case studies in Democratic Republic of Congo, Haiti, Yemen, and Zimbabwe. We documented 15 outbreaks in 12 countries where CATIs were used. The team composition and the interventions varied, with water, sanitation, and hygiene interventions implemented more commonly than those of health. Alert systems triggering interventions were diverse ranging from suspected cholera cases to culture confirmed cases. Selection of high-risk households around the case household was inconsistent and ranged from only one case to approximately 100 surrounding households with different methods of selecting them. Coordination among actors and integration between sectors were consistently reported as challenging. Delays in sharing case information impeded rapid implementation of this approach, while evaluation of the effectiveness of interventions varied.

Background

Active screening of only pregnant and lactating mothers (PLMs) excludes other mothers of reproductive age susceptible  undernutrition. Our analysis evaluated if mothers presenting with wasted children were more likely to be undernourished themselves.

Methods

The observational study enrolled mother and child dyads presenting to an outpatient facility in Mogadishu, Somalia, between November 2019 and March 2020. Trained nurses recorded lower extremity oedema for children aged 6–59 months, parity and gestational status for women aged 19–50 years and age, access to care, height/length, mid-upper arm circumference (MUAC) and weight for both. Weight-for-height z-score (WHZ) for children and body mass index (BMI) for mothers were calculated using standard procedures. Wasting was defined as WHZ <−2, MUAC <12.5 cm and/or presence of oedema for children. Undernutrition was defined as MUAC <23 cm for PLMs and BMI <18.5 kg/m2 for neither pregnant nor lactating mothers (non-PLMs). Four multivariable linear regression models were fit to evaluate maternal anthropometric indicators (BMI or MUAC) given child anthropometric indicators (MUAC or WHZ), adjusting for maternal age, parity and gestational status.

The provinces of North and South Kivu in eastern Democratic Republic of the Congo (DRC) have experienced insecurity since the 1990s. Without any solution to the conflict in sight, health actors have adapted their interventions to maintain some level of health service provision. We reflect on the health system resilience in the Kivu provinces in response to chronic levels of insecurity. Using qualitative interviews of health care providers from local government, United Nations agencies, and international nongovernmental organizations, we identify the mediating factors through which insecurity affects both service quality and delivery and investigate the strategies adopted to sustain service provision.

Three main drivers linking insecurity and health service quality and delivery emerged: via violence, mobility restrictions, and resources availability. The effect of these drivers is mediated by several system or individual-level factors. Two factors were reported in each pathway: health care workforce availability and drug/equipment accessibility. Human resources were affected differently by each driver: in terms of willingness to be stationed in a certain area (violence), capacity to access the health facility (mobility), and sustainability and motivation of conducting duties (resources). Similarly, the presence of drugs/equipment varied in case of looting or damages (violence), delays in delivery (mobility), or delays in procurement (resources). While these mediators are not surprising, their identification allows the design of appropriate response strategies. The majority of the reported solutions attempt to address the lack of human resources and reflect absorptive capacity. Adaptive capacity characterizes the attempts to address lack of access (contingency plan, mobile clinics, maternity waiting homes, and security drugs). Finally, interventions to address insecurity can be classified as transformative. Health actors in eastern DRC have shown some capacity to adapt, adjust, and transform due to insecurity. Further research is needed to measure the effectiveness of such strategies to provide guidance to increasingly vulnerable health systems.

A shared understanding of key priorities and the path forward is critical to improving reproductive, maternal, newborn, and child health (RMNCH) in humanitarian emergencies. Stakeholders, including local governments, multilateral, United Nations (UN) agencies, and non-governmental organization (NGO) partners, must plan and implement coherent programs to reduce disease burden while working with available financial resources. However, tools to support evidence-based decision making in the challenging context of humanitarian crises are lacking; the paucity of research conducted in a complex humanitarian setting poses additional constraints [1]. The Humanitarian Lives Saved Tool approach (H-LiST) responds to this need, drawing upon humanitarian health, evaluation, costing and modeling principles and evidence about effectiveness of RMNCH interventions from the existing Lives Saved Tool (LiST) model. Here, we present the conceptual framework (Figure 1), experiences implementing with in-country partners, and strengths and limitations of the current H-LiST approach. We then discuss gaps and next steps for refining and improving this accessible technical resource.

Background

 For humanitarian organisations to respond effectively to complex crises, they require access to up-todate evidence-based guidance. The COVID-19 crisis has highlighted the importance of updating global guidance to context-specific and evolving needs in humanitarian settings. Our study aimed to understand the use of evidence-based guidance in humanitarian responses during COVID-19. Primary data collected during the rapidly evolving pandemic sheds new light on evidence-use processes in humanitarian response.

Methods

We collected and analysed COVID-19 guidance documents, and conducted semi-structured interviews remotely with a variety of humanitarian organisations responding and adapting to the COVID-19 pandemic. We used the COVID-19 Humanitarian platform, a website established by three universities in March 2020, to solicit, collate and document these experiences and knowledge.

Results

We analysed 131 guidance documents and conducted 80 interviews with humanitarian organisations, generating 61 published field experiences. Although COVID-19 guidance was quickly developed and disseminated in the initial phases of the crisis (from January to May 2020), updates or ongoing revision of the guidance has been limited. Interviews conducted between April and September 2020 showed that humanitarian organisations have responded to COVID-19 in innovative and context-specific ways, but have often had to adapt existing guidance to inform their operations in complex humanitarian settings.

Background

The COVID-19 pandemic has had wide-reaching direct and indirect impacts on population health. We describe one of the most critical of these secondary consequences, the decrease in the utilization of health services and the resulting consequences for mortality. In low- and middle-income countries, these disruptions can halt progress towards reducing maternal and child mortality.

Methods

Data on service utilization from January 2018 to June 2021 is extracted from health management information systems of 18 low- and lower-middle-income countries. Interrupted time series design is used to estimate percent change in the volumes of essential health services delivered during the pandemic compared to projected volumes based on pre-pandemic trends. The Lives Saved Tool mathematical model is used to estimate the impact of the service utilization disruptions on child and maternal mortality. In addition, the estimated monthly disruptions are also correlated to the COVID-19 burden, time since the start of the pandemic, and relative severity of mobility restrictions.

Background

The 2014-2015 Ebola epidemic in West Africa became a humanitarian crisis that exposed significant gaps in infection prevention and control (IPC) capacity in primary care facilities in Sierra Leone. Operational partners recognized the national gap and rapidly scaled-up an IPC training and infrastructure package. This prompted us to carry out a mixed-methods research study which aimed to evaluate adherence to IPC practices and understand how to improve IPC at the primary care level, where most cases of Ebola were initially presenting. The study was carried out during the national peak of the epidemic.

Discussion

We successfully carried out a rapid response research study that produced several expected and unexpected findings that were used to guide IPC measures during the epidemic. Although many research challenges were similar to those found when conducting research in low-resource settings, the presence of Ebola added risks to safety and security of data collectors, as well as a need to balance research activities with the imperative of response to a humanitarian crisis. A participatory approach that attempted to unify levels of the response from community upwards helped overcome the risk of lack of trust in an environment where Ebola had damaged relations between communities and the health system.

Conclusion

In the context of a national epidemic, research needs to be focused, appropriately resourced, and responsive to needs. The partnership between local academics and a humanitarian organization helped facilitate access to study sites and approvals that allowed the research to be carried out quickly and safely, and for findings to be shared in response forums with the best chance of being taken up in real-time.

In 2019 the United States signed Asylum Cooperative Agreements with the Northern Triangle countries of El Salvador, Guatemala, and Honduras, in Central America. In November 2019 the Trump administration announced that these agreements would be used to permit the expedited removal of asylum seekers from the US, claiming that these countries provided comprehensive legal procedures for adjudicating asylum claims and protection against further persecution. To assess the presence of dangerous conditions in the three countries, we examined forensic medical evaluations of asylum seekers from the Northern Triangle who are in the US and who presented to an academic medical center asylum clinic in Boston, Massachusetts, from 2017 to 2020. Northern Triangle asylum seekers reported high rates of exposure to trauma and violence, including gender-based violence and violence perpetrated by gangs, and they also exhibited a high prevalence of trauma-related psychiatric disorders. Asylum seekers also reported state actors in Northern Triangle countries as perpetrators of violence and described denial of protection from the state when it was solicited. These findings cast doubt on key tenets underpinning the legal basis for the Asylum Cooperative Agreements. The agreements should be formally terminated and investigations undertaken to determine the impact on people who were subject to removal from the US during preliminary implementation.

Background

Although there have been notable improvements in availability and utilization of maternal health care in Afghanistan over the last few decades, risk of maternal mortality remains very high. Previous studies have highlighted gaps in quality of emergency obstetric and newborn care practices, however, little is known about the quality of routine intrapartum care at health facilities in Afghanistan.

Methods

We analyzed a subset of data from the 2016 Afghanistan Maternal and Newborn Health Quality of Care Assessment that comprised of observations of labor, delivery and immediate post-partum care, as well as health facility assessments and provider interviews across all accessible public health facilities with an average of five or more births per day in the preceding year (N = 77). Using the Quality of the Process of Intrapartum and Immediate Postpartum Care index, we calculated a quality of care score for each observation. We conducted descriptive and bivariate analyses and built a multivariate linear regression model to identify facility-level factors associated with quality of care scores.

Results

Across 665 childbirth observations, low quality of care was observed such that no health facility type received an average quality score over 56%. The multivariate regression model indicated that availability of routine labor and delivery supplies, training in respectful maternity care, perceived gender equality for training opportunities, recent supervision, and observation during supervision have positive, statistically significant associations with quality of care.

The Syrian refugee influx in Lebanon challenges non-communicable disease (NCD) management, requiring evidence to adapt intervention to quality care demands. Baseline data from a longitudinal cohort study examines general practitioner (GP) and specialist care-seeking by Syrian refugee and Lebanese patients with hypertension and/or diabetes at ten Lebanese primary health facilities. Negative binomial hurdle regression models separately evaluate the odds and frequency of care-seeking by each condition and provider type. Utilization was uniformly high in both populations. Refugees were more likely to seek GP care and had higher GP visit frequency; Lebanese relied more on specialists’ care. Multivariate analyses revealed notable associations between housing instability and reduced odds and volume of specialist care for both conditions and with lower odds of GP care-seeking for diabetes. Patient YMCA medication program enrollment was also associated with fewer GP visits for both conditions, although increased odds of specialist care for diabetes. Patient and provider focus groups highlighted factors motivating care utilization (primarily cost and obtaining medication), limited specialist availability, and GP self-doubt concerning effective treatment. Expanded GP training and improving and scaling the YMCA program could further efforts for improved NCD management quality and health outcomes.

Background

Multipurpose cash transfers (MPCs) are used on a widespread basis in the Syrian refugee response; however, there is little to no evidence as to how they affect health in humanitarian crises.

Methods

A prospective cohort study was conducted from May 2018 through July 2019 to evaluate the impact of MPCs on health care-seeking and expenditures for child, adult acute, and adult chronic illness by Syrian refugees in Lebanon. Households receiving MPCs from UNHCR were compared to control households not receiving UNHCR MPCs.

Results

Care-seeking for childhood illness was consistently high in both MPC and non-MPC households. An increased proportion of households did not receive all recommended care due to cost; this increase was 19.3% greater among MPC recipients than controls (P = 0.002). Increases in child hospitalizations were significantly smaller among MPC recipients than controls (DiD -6.1%; P = 0.037).

For adult acute illnesses, care-seeking increased among MPC recipients but decreased in controls (adjusted DiD 11.3%; P = 0.057); differences in change for other utilization outcomes were not significant. The adjusted difference in change in the proportion of MPC households not receiving recommended chronic illness care due to cost compared to controls was − 28.2% (P = 0.073). Access to medication for adult chronic illness also marginally significantly improved for MPC households relative to controls. The proportion of MPC recipients reporting expenses for the most recent child and adult acute illness increased significantly, as did the [log] total visit cost.

Both MPC and control households reported significant increases in borrowing to pay for health expenses over the year study period, but differences in change in borrowing or asset sales were not significant, indicating that MPC was not protective against for household financial risks associated with health.

Abstract

Evidence on experiences and perceptions of care in pregnancy and childbirth in conflict-affected settings is limited. We interviewed 561 maternity care providers and observed 413 antenatal care consultations, 671 births, and 393 postnatal care consultations at public health facilities across Afghanistan. We found that healthcare providers work under stressed conditions with insufficient support, and most women receive mixed quality care. Understanding socio-cultural and contextual factors underpinning acceptance of mistreatment in childbirth, related to conflict, insecurity, gender and power dynamics, is critical for improving the quality of maternity care in Afghanistan and similar fragile and conflict affected settings.

Abstract

Historically, there has been concern that conflict may exacerbate the HIV epidemic. We conducted a systematic review to examine HIV prevalence in conflict-affected populations compared to district-level or countrywide HIV prevalence. Following PRISMA guidelines, studies presenting original HIV prevalence data published between 2005 and 2020 were drawn from PubMed, Scopus, and Embase. Data extracted included HIV prevalence, methods, dates, location, and population type. Studies were assessed for bias. Ten met criteria for data extraction; all focused on populations in sub-Saharan African. Most of the studies reported on mixed population settings while one was in a refugee camp. Six reported HIV prevalence higher than district- or country-level prevalence, while four reported lower HIV prevalence. Seven demonstrated moderate-to-high likelihood of bias in sampling, and five used methods limiting their comparability with local HIV prevalence. The relationship between armed conflict and HIV prevalence remains difficult to evaluate and likely varies by socioeconomic indicators.

The COVID-19 pandemic has stress-tested all sectors and spheres of human activity, exposing countless weaknesses and fault lines - many of which were already known but ignored. The often-neglected health of migrants and refugees is one such area. While the world is still trying to recover and to ‘build forward better’ post-pandemic, there is both an opportunity and an imperative to address migrant and refugee health as an essential component of health systems and public health response ^[1]. Missing this opportunity will not simply perpetuate the inequities and injustices that many migrants and refugees have long experienced 
 it will also make it much more likely that efforts to strengthen global health security and pandemic pre- preparedness will continue to be inadequate, leaving the world at greater risk of severe health, economic and social impacts when the next pandemic strikes.

Background

Cash transfers are an increasingly common intervention in the Syrian refugee response to meet basic needs, though there is little known of their potential secondary impact on health outcomes in humanitarian settings.

Methods

A quasi-experimental prospective cohort study was implemented from October 2018 through January 2020 to assess the effectiveness of multi-purpose cash (MPC), community health volunteer (CHV)-led education, combined with conditional cash transfers (CCT) with respect to health measures among Syrian refugees with type II diabetes in Jordan.