Evidence on public health interventions in humanitarian crises

Sexual and reproductive health implementation research in humanitarian contexts: a scoping review

BACKGROUND

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.

METHODS

A scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Peer-reviewed papers published from 2013 to 2022 were identified through relevant systematic reviews and a literature search of Pubmed, Embase, PsycInfo, CINAHL and Global Health databases. Papers that presented primary quantitative or qualitative data pertaining to a sexual and reproductive health intervention in a humanitarian setting were included.

RESULTS

Seven thousand thirty-six unique records were screened for inclusion, and 69 papers met inclusion criteria. Of these, six papers explicitly described the use of an implementation research framework, three citing use of the Consolidated Framework for Implementation Research. Three additional papers referenced other types of frameworks used in their evaluation. Factors cited across all included studies as helping the intervention in their presence or hindering in their absence were synthesized into the following Consolidated Framework for Implementation Research domains: Characteristics of Systems, Outer Setting, Inner Setting, Characteristics of Individuals, Intervention Characteristics, and Process.

CONCLUSION

This review found a wide range of methodologies and only six of 69 studies using an implementation research framework, highlighting an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization. Three hundred thirty-nine million people globally were in need of humanitarian assistance in 2023, and meeting the health needs of crisis-affected populations is a growing challenge. One in four people living in humanitarian contexts are women and girls of reproductive age, and provision of sexual and reproductive health care is considered to be essential within a humanitarian response. Implementation research can help to better understand how real-world contexts affect health improvement efforts. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on how best to do so is limited. This scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Of 69 papers that met inclusion criteria for the review, six of them explicitly described the use of an implementation research framework. Three used the Consolidated Framework for Implementation Research, a theory-based framework that can guide implementation research. Three additional papers referenced other types of frameworks used in their evaluation. This review summarizes how factors relevant to different aspects of implementation within the included papers could have been organized using the Consolidated Framework for Implementation Research. The findings from this review highlight an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization.

The effect of COVID-19 on the non-COVID health outcomes of crisis-affected peoples: a systematic review

BACKGROUND

The COVID-19 pandemic posed considerable risks to populations affected by humanitarian crises in low- and middle-income countries (LMICs). However, there is limited understanding of how the pandemic may have affected non-COVID health outcomes among crisis-affected populations. Our aim was to examine the evidence on the impact of the COVID-19 pandemic on non-COVID-19 health outcomes for crisis-affected populations in LMICs.

METHODS

A systematic review methodology was applied following PRISMA guidelines. Eligibility criteria were: crisis-affected populations in LMICS; COVID-19; and all health topics, except for sexual and reproductive health which was covered in a linked review. Five bibliographic databases and additional grey literature sources were searched. The search period was from 2019 to 31 July 2022. Eligible papers were extracted and analysed using a narrative synthesis approach based on the study objectives and relevant health access and systems frameworks. A quality appraisal was also conducted.

FINDINGS

4320 articles were screened, and 15 eligible studies were identified and included in this review. Ten studies collected health outcomes data. Eight related to mental health, which generally showed worse mental health outcomes because of the pandemic, and pandemic-related stressors were identified. Two studies assessed physical health outcomes in children, while none addressed physical health outcomes among adults. Nine studies reported on access to healthcare, revealing worse access levels due to the pandemic and noting key barriers to care. Seven studies reported on the impact on health systems, with key challenges including reduced and distorted health care funding, reduced staff capacity, interrupted medicines and supplies, weak information and mixed-messaging, and weak leadership. All fifteen studies on the social determinants of health, particularly highlighting the effect of increasing poverty, the role of gender, and food insecurity on health outcomes. The quality of papers was limited overall.

CONCLUSION

This review found some limited evidence indicating negative mental health effects, increased barriers to accessing care, damage to health systems and magnified impacts on the social determinants of health for crisis-affected people during the COVID-19 pandemic. However, the small number and limited quality of the studies make the overall strength of evidence quite weak.

Prevalence and associated factors of common mental disorders among internally displaced people by armed conflict in Cabo Delgado, Mozambique: a cross-sectional community-based study

Background

Humanitarian emergencies are a major global health challenge with the potential to have a profound impact on people's mental and psychological health. Displacement is a traumatic event that disrupts families and affects physical and psychological health at all ages. A person may endure or witness a traumatic incident, such as being exposed to war, and, as a result, develop post-traumatic stress disorder (PTSD). There is a lack of information about post-traumatic stress disorder, depression, and anxiety disorder in low and middle-income countries in humanitarian emergency contexts such as Mozambique. This study aimed to assess the prevalence of PTSD, depression, and anxiety, and associated factors among armed conflict survivors in Cabo Delgado, north region of Mozambique in 2023.

Methods

A community-based cross-sectional study was conducted between January and April 2023 among 750 participants, who were selected by convenience. A face-to-face interview used the Primary Care Post-Traumatic Stress Disorder Checklist (PC-PTSD-5) to evaluate PTSD, the Generalized Anxiety Disorder Scale (GAD-7) to evaluate anxiety and the Patient Health Questionnaire - Mozambique (PHQ-9 MZ) to evaluate depression. The association between PTSD and demographic and psychosocial characteristics was analyzed using bivariate and multivariable binary logistic regression. We used a 5% significance level.

Results

The three mental disorders assessed were highly prevalent in our sample with 74.3% PTSD, 63.8% depression, and 40.0% anxiety. The chance of developing PTSD was higher in females (AOR = 2.30, 95% CI 1.50-3.51), in patients with depression symptoms (AOR = 8.27, 95% CI = 4.97-13.74) and anxiety symptoms (AOR = 1.45, 95% CI = 0.84-2.50).

Conclusion

This study reported that the prevalence of PTSD, depression, and anxiety were high. Patients having depressive symptoms, anxiety symptoms, and being female are more at risk of developing PTSD. There is a need to integrate screening for common mental disorders in the context of humanitarian emergencies and its adapted integration of psychosocial interventions.

Assessing the Effectiveness of a Multicomponent Intervention on Hand Hygiene and Well-Being in Primary Health Care Centers and Schools Lacking Functional Water Supply in Protracted Conflict Settings: Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

Hand hygiene is crucial in health care centers and schools to avoid disease transmission. Currently, little is known about hand hygiene in such facilities in protracted conflict settings.

OBJECTIVE

This protocol aims to assess the effectiveness of a multicomponent hand hygiene intervention on handwashing behavior, underlying behavioral factors, and the well-being of health care workers and students. Moreover, we report our methodology and statistical analysis plan transparently.

METHODS

This is a cluster randomized controlled trial with 2 parallel arms taking place in 4 countries for 1 year. In Burkina Faso and Mali, we worked in 24 primary health care centers per country, whereas in Nigeria and Palestine, we focused on 26 primary schools per country. Facilities were eligible if they were not connected to a functioning water source but were deemed accessible to the implementation partners. Moreover, health care centers were eligible if they had a maternity ward and ≥5 employees, and schools if they had ≤7000 students studying in grades 5 to 7. We used covariate-constrained randomization to assign intervention facilities that received a hardware, management and monitoring support, and behavior change. Control facilities will receive the same or improved intervention after endline data collection. To evaluate the intervention, at baseline and endline, we used a self-reported survey, structured handwashing observations, and hand-rinse samples. At follow-up, hand-rinse samples were dropped. Starting from the intervention implementation, we collected longitudinal data on hygiene-related health conditions and absenteeism. We also collected qualitative data with focus group discussions and interviews. Data were analyzed descriptively and with random effect regression models with the random effect at a cluster level. The primary outcome for health centers is the handwashing rate, defined as the number of times health care workers performed good handwashing practice with soap or alcohol-based handrub at one of the World Health Organization 5 moments for hand hygiene, divided by the number of moments for hand hygiene that presented themselves during the patient interaction within an hour of observation. For schools, the primary outcome is the number of students who washed their hands before eating.

RESULTS

The baseline data collection across all countries lasted from February to June 2023. We collected data from 135 and 174 health care workers in Burkina Faso and Mali, respectively. In Nigeria, we collected data from 1300 students and in Palestine from 1127 students. The endline data collection began in February 2024.

CONCLUSIONS

This is one of the first studies investigating hand hygiene in primary health care centers and schools in protracted conflict settings. With our strong study design, we expect to support local policy makers and humanitarian organizations in developing sustainable agendas for hygiene promotion.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05946980 (Burkina Faso and Mali); https://www.clinicaltrials.gov/study/NCT05946980 and NCT05964478 (Nigeria and Palestine); https://www.clinicaltrials.gov/study/NCT05964478.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52959.

Guidance on sexual, reproductive, maternal, newborn, child and adolescent health in humanitarian and fragile settings: a scoping review

INTRODUCTION

Progress related to sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) has stalled. COVID-19, conflict and climate change threaten to reverse decades of progress and to ensure the health and well-being of vulnerable populations in humanitarian and fragile settings (HFS) going forward, there is a need for tailored guidance for women, children and adolescents (WCA). This review seeks to map and appraise current resources on SRMNCAH in HFS.

METHODS

In line with the updated Joanna Briggs Institute guidance and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews framework, a manual literature review was conducted of global and regional guidance published between January 2008 and May 2023 from members of the Global Health Cluster, the Global Nutrition Cluster and the Inter-Agency Working Group on Reproductive Health in Crises. A content analysis was conducted. Scores were then calculated according to the Appraisal of Guidelines for Research and Evaluation II scoring tool and subsequently categorised as high quality or low quality.

RESULTS

A total of 730 documents were identified. Of these, 141 met the selection criteria and were analysed. Available guidance for delivering SRMNCH services exists, which can inform policy and programming for the general population and WCA. Important gaps related to beneficiaries, health services and health system strengthening strategies were identified.

CONCLUSION

The review revealed there is evidence-based guidance available to support interventions targeting WCA in HFS, including: pregnant and lactating women, women of reproductive age, adolescents, newborns, small vulnerable newborns, stillbirths, refugees and internally displaced persons and WCA with disabilities. However, gaps related to beneficiaries, health services and health system strengthening strategies must be addressed in updated guidance that is created, disseminated and monitored in a standardised way that is mindful of the need to respond rapidly in HFS.

Improving Retention in Mental Health and Psychosocial Support Interventions: An Analysis of Completion Rates across a Multi-Site Trial with Refugee, Migrant, and Host Communities in Latin America

Research on mental health and psychosocial support (MHPSS) interventions within refugee and migrant communities has increasingly focused on evaluating implementation, including identifying strategies to promote retention in services. This study examines the relationship between participant characteristics, study setting, and reasons for intervention noncompletion using data from the Entre Nosotras feasibility trial, a community-based MHPSS intervention targeting refugee, migrant, and host community women in Ecuador and Panama that aimed to promote psychosocial wellbeing. Among 225 enrolled women, approximately half completed the intervention, with varying completion rates and reasons for nonattendance across study sites. Participants who were older, had migrated for family reasons, had spent more time in the study community, and were living in Panamá (vs. Ecuador) were more likely to complete the intervention. The findings suggest the need to adapt MHPSS interventions to consider the duration of access to the target population and explore different delivery modalities including the role of technology and cellular devices as reliable or unreliable source for engaging with participants. Engaging younger, newly arrived women is crucial, as they showed lower completion rates. Strategies such as consulting scheduling preferences, providing on-site childcare, and integrating MHPSS interventions with other programs could enhance intervention attendance.

Care groups in an integrated nutrition education intervention improved infant growth among South Sudanese refugees in Uganda's West Nile post-emergency settlements: A cluster randomized trial

OBJECTIVE

This study examined the effects of a peer-led integrated nutrition education intervention with maternal social support using Care Groups on infant growth among South Sudanese refugees in Uganda.

METHODS

A community-based cluster-randomized trial (RCT) was conducted among 390 pregnant women (third trimester). Two intervention study arms were Mothers-only(n = 131) and Parents-combined (n = 142) with a Control (n = 117). WHO infant growth standards defined length-for-age z-scores (LAZ) for stunting, weight-for-age z-scores (WAZ) for underweight and weight-for-length z-scores (WLZ) for wasting. The Medical Outcomes Study (MOS) social support index was a proxy measure for social support. A split-plot ANOVA tested the interaction effects of social support, intervention, and time on infant growth after adjusting for covariates. Further, pairwise comparisons explained mean differences in infant growth among the study arms.

RESULTS

The mean infant birth weight was 3.1 ± 0.5 kg. Over the study period, infant stunting was most prevalent in the Control (≥ 14%) compared to Mothers-only (< 9.5%) and Parents-combined (< 7.4%) arms. There were significant interaction effects of the Care Group intervention and social support by time on infant mean LAZ (F (6, 560) = 28.91, p < 0.001), WAZ (F (5.8, 539.4) = 12.70, p = < 0.001) and WLZ (F (5.3, 492.5) = 3.38, p = 0.004). Simple main effects by the end of the study showed that the intervention improved infant mean LAZ (Mothers-only vs. Control (mean difference, MD) = 2.05, p < 0.001; Parents-combined vs. Control, MD = 2.00, p < 0.001) and WAZ (Mothers-only vs. Control, MD = 1.27, p < 0.001; Parents-combined vs. Control, MD = 1.28, p < 0.001).

CONCLUSION

Maternal social support with an integrated nutrition education intervention significantly improved infant stunting and underweight. Nutrition-sensitive approaches focused on reducing child undernutrition among post-emergency refugees may benefit from using Care Groups in programs.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT05584969.

Evidence on the impact of community health workers in the prevention, identification, and management of undernutrition amongst children under the age of five in conflict-affected or fragile settings: a systematic literature review

BACKGROUND

Malnutrition, specifically undernutrition, is a significant global challenge that contributes to nearly half of deaths in children under the age of five. The burden of undernutrition is disproportionately borne by conflict-affected, fragile settings (CAFS); children living in a conflict zone being more than twice as likely to suffer from malnourishment. Community health worker (CHW) models have been employed in CAFS to improve healthcare coverage and identify and treat illnesses. However, there lacks systematic evidence on the impact of CHW models in preventing, identifying, and managing child undernutrition in CAFS. We conducted this review to systematically evaluate evidence of CHW models in preventing, identifying, and managing undernutrition in children under the age of five in CAFS.

METHODOLOGY

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting standards. The search strategy was developed using the Population-Intervention-Comparisons-Outcomes-Setting framework as a guide. Searches were performed using Ovid online database search platform, searching the databases of Ovid MEDLINE(R), COCHRANE, Embase Classic, Embase, Econlit, Global Health, SCOPUS, and Social Policy and Practice. Peer-reviewed publications were eligible for inclusion if they evaluated an intervention using a CHW model that aims to prevent, identify, or manage some form of undernutrition in children under five in a CAFS.

RESULTS

We identified 25 studies-spanning 10 countries-that were included in the systematic review. CHW models were implemented alongside a variety of interventions, including behaviour change communication, supplementary foods, nutrition counselling, and integrated community health programmes. Key barriers in implementing successful CHW models include disruption of programmes due to active conflict, states of emergency, militancy, or political unrest; weak links between the community-based interventions and public health system; weak health system capacity that impeded referral and follow-ups; and cost of care and care-seeking. Key facilitators include CHWs' connection to the community, close proximity of programmes to the community, supervision, and investment in high quality training and tools.

CONCLUSIONS

The findings suggest that CHW models may be effective, cost-effective, acceptable, feasible, and scalable in the prevention, identification, and management child undernutrition in CAFS. The study findings also confirmed a need for greater evidence in the field. These findings may inform policymaking, programme implementation, and design to strengthen best practices for CHW models addressing child undernutrition in CAFS.

Trauma-Informed Leadership in Quality Improvement: What We Learned From Practicing in a Pandemic

In 2020, midway through the Collaborative Improvement and Innovation Network to Advance Care for Children with Medical Complexity project, the coronavirus disease 2019 pandemic erupted and caused significant disruptions for the 10 participating state teams, the project leadership, and collaborative partner organizations. Clinics shut down for in-person care, a scramble ensued to quickly leverage telehealth to fill the gap, and the trauma caused by anxiety, isolation, and exhaustion affected the health and wellbeing of children, families, and clinicians alike. We conducted a series of key informant interviews and surveys, alongside other process measures, to learn from state teams what it was like "on the ground" to try to continue improving care delivery, child quality of life, and family wellbeing under such upheaval. In this article, we synthesize qualitative and descriptive findings from these varied data sources within the framework of the trauma-informed principles we applied as a leadership team to prevent burnout, increase resilience, and maintain progress among all project participants, especially clinicians and the uniquely vulnerable family leaders. Lessons learned will be offered that can be applied to future natural and human-made emergencies that impact responsive pediatric care delivery improvement.

Health Problems of Increasing Man-Made and Climate-Related Disasters on Forcibly Displaced populations: A Scoping Review on Global Evidence

Forcibly displaced populations are among the most vulnerable groups in disasters. They experience poorer health conditions compared with nondisplaced individuals. However, a clear picture is lacking regarding the overall health problems encountered by disaster-induced mid- to long-term displaced people. This study investigated these disorders prevalence and identified their correlates among long-settled displaced populations worldwide. The current scoping review follows the PRISMA-ScR guidelines; a systematic search was conducted on PubMed, Web of Science, and CINAHL and included original peer-reviewed studies, commentary, reviews, and grey literature published in English between January 1990 to June 2022. In the thematic and content analysis, the authors applied the narrative review approach to identify themes and sub-themes. Forty-eight documents were identified as fully relevant to this study. The largest number of published papers were from Asia, followed by the Middle East, the United States, and Europe. IDPs in developed countries were the most researched populations. Human-made disasters were addressed by 89% of the included studies. The four main thematic categories included were "physical health," "mental health," "inadequate facilities," and "lack of healthy behaviour." The worsening of noncommunicable diseases had the highest prevalence, followed by communicable diseases. Due to their condition, forcibly displaced migrants face a triple burden of communicable diseases and noncommunicable diseases such as mental health issues. Health-related research and policy need to consider the links among disasters, health problems, and forced migration as a determinant of health in the new era of climate change-driven displacements.

A Systematic Review of Vaccination Guidance for Humanitarian Responses

Delivering vaccines in humanitarian response requires rigourous and continuous analysis of evidence. This systematic review mapped the normative landscape of vaccination guidance on vaccine-preventable diseases in crisis-affected settings. Guidance published between 2000 and 2022 was searched for, in English and French, on websites of humanitarian actors, Google, and Bing. Peer-reviewed database searches were performed in Global Health and Embase. Reference lists of all included documents were screened. We disseminated an online survey to professionals working in vaccination delivery in humanitarian contexts. There was a total of 48 eligible guidance documents, including technical guidance (n = 17), descriptive guidance (n = 16), operational guidance (n = 11), evidence reviews (n = 3), and ethical guidance (n = 1). Most were World Health Organization documents (n = 21) targeting children under 5 years of age. Critical appraisal revealed insufficient inclusion of affected populations and limited rigour in guideline development. We found limited information on vaccines including, yellow fever, cholera, meningococcal, hepatitis A, and varicella, as well as human papilloma virus (HPV). There is a plethora of vaccination guidance for vaccine-preventable diseases in humanitarian contexts. However, gaps remain in the critical and systematic inclusion of evidence, inclusion of the concept of "zero-dose" children and affected populations, ethical guidance, and specific recommendations for HPV and non-universally recommended vaccines, which must be addressed.

Resilience in childhood vaccination: analysing delivery system responses to shocks in Lebanon

INTRODUCTION

Despite rapidly growing academic and policy interest in health system resilience, the empirical literature on this topic remains small and focused on macrolevel effects arising from single shocks. To better understand health system responses to multiple shocks, we conducted an in-depth case study using qualitative system dynamics. We focused on routine childhood vaccination delivery in Lebanon in the context of at least three shocks overlapping to varying degrees in space and time: large-scale refugee arrivals from neighbouring Syria; COVID-19; and an economic crisis.

METHODS

Semistructured interviews were performed with 38 stakeholders working at different levels in the system. Interview transcripts were analysed using purposive text analysis to generate individual stakeholder causal loop diagrams (CLDs) mapping out relationships between system variables contributing to changes in coverage for routine antigens over time. These were then combined using a stepwise process to produce an aggregated CLD. The aggregated CLD was validated using a reserve set of interview transcripts.

RESULTS

Various system responses to shocks were identified, including demand promotion measures such as scaling-up community engagement activities and policy changes to reduce the cost of vaccination to service users, and supply side responses including donor funding mobilisation, diversification of service delivery models and cold chain strengthening. Some systemic changes were introduced-particularly in response to refugee arrivals-including task-shifting to nurse-led vaccine administration. Potentially transformative change was seen in the integration of private sector clinics to support vaccination delivery and depended on both demand side and supply side changes. Some resilience-promoting measures introduced following earlier shocks paradoxically increased vulnerability to later ones.

CONCLUSION

Flexibility in financing and human resource allocation appear key for system resilience regardless of the shock. System dynamics offers a promising method for ex ante modelling of ostensibly resilience-strengthening interventions under different shock scenarios, to identify-and safeguard against-unintended consequences.

Humanitarian Outpatient Pediatric Endeavor (HOPE): A Novel Specialist Ambulatory Health-Care Concept in Conflict Areas

With the collapse of the medical system in Syria, Israel began providing Syrians with humanitarian aid, first to the war-injured and then general medical treatment. We developed a novel specialist ambulatory care concept to provide medical care for Syrian children. Children with their caregivers were transported by bus across the border from Syria to our medical center in Israel for day-stay outpatient-clinic advanced evaluation and treatment due to coordination between Syrian, Red Cross, and Israeli authorities, including Israeli Defense Forces. This retrospective field report includes 371 Syrian children treated as outpatients at Galilee Medical Center between January 2016 and September 2018. In our experience, this novel pediatric ambulatory care concept has been feasible, efficient, and successful in providing specialist care for children in a crisis region devoid of access to health care. We believe it can also serve adult patients and be implemented in other crises and disasters scenarios.

Health Systems Preparedness for Infectious Disease Outbreaks: Relevance for Nephrology

The coronavirus disease (COVID-19) crisis glaringly highlighted the critical need to develop resilient health care systems that are better prepared for epidemics. Millions of people died from COVID-19 itself, but almost three times as many died from health system disruptions. People living with kidney disease are highly vulnerable during outbreaks and pandemics and their needs must be included in preparedness planning. Health systems preparedness requires not only early identification and containment of outbreaks and maintenance of critical services during crises, but also bolstering population resilience and ensuring the safety of both health personnel and patients. Planning for surge capacity in an outbreak must include provision for both acute and chronic dialysis, and ensure access to medications for people with kidney diseases. Quality of care should not be compromised and must be monitored and improved where necessary. Technology, such as telemedicine, can support quality and continuity of care and minimize infection risks. Communication at all levels is crucial to ensure all stakeholders, including communities, have the necessary information to support cooperation and collaboration in effective outbreak responses. Research is important during and after pandemics to improve knowledge and build resilience at all levels, from outbreak detection to the development of therapeutics and optimizing equity in access to interventions. Only with adequate preparation and more resilient health systems can we hope, as a global community, to build on the harsh lessons learned during COVID-19, and improve the response to the next infectious disease outbreak, epidemic, or even pandemic.

How is the implementation of empirical research results documented in conflict-affected settings? Findings from a scoping review of peer-reviewed literature

Implementation science scholars argue that knowing 'what works' in public health is insufficient to change practices, without understanding 'how', 'where' and 'why' something works. In the peer reviewed literature on conflict-affected settings, challenges to produce research, make decisions informed by evidence, or deliver services are documented, but what about the understanding of 'how', 'where' and 'why' changes occur? We explored these questions through a scoping review of peer-reviewed literature based on core dimensions of the Extended Normalization Process Theory. We selected papers that provided data on how something might work (who is involved and how?), where (in what organizational arrangements or contexts?) and why (what was done?). We searched the Global Health, Medline, Embase databases. We screened 2054 abstracts and 128 full texts. We included 22 papers (of which 15 related to mental health interventions) and analysed them thematically. We had the results revised critically by co-authors experienced in operational research in conflict-affected settings. Using an implementation science lens, we found that: (a) implementing actors are often engaged after research is produced to discuss feasibility; (b) new interventions or delivery modalities need to be flexible; (c) disruptions affect how research findings can lead to sustained practices; (d) strong leadership and stable resources are crucial for frontline actors; (e) creating a safe learning space to discuss challenges is difficult; (f) feasibility in such settings needs to be balanced. Lastly, communities and frontline actors need to be engaged as early as possible in the research process. We used our findings to adapt the Extended Normalization Process Theory for operational research in settings affected by conflicts. Other theories used by researchers to document the implementation processes need to be studied further.

War and Health Care Services Utilization for Chronic Diseases in Rural and Semiurban Areas of Tigray, Ethiopia

Importance

The war in Tigray, Ethiopia, has disrupted the health care system of the region. However, its association with health care services disruption for chronic diseases has not been well documented.

Objective

To assess the association of the war with the utilization of health care services for patients with chronic diseases.

Design, Setting, and Participants

Of 135 primary health care facilities, a registry-based cross-sectional study was conducted on 44 rural and semiurban facilities of Tigray. Data on health services utilization were extracted for patients with tuberculosis, HIV, diabetes, hypertension, and psychiatric disorders in the prewar period (September 1, to October 31, 2020) and during the first phase of the war period (November 4, 2020, to June 30, 2021).

Main Outcomes and Measures

Records on the number of follow-up, laboratory tests, and patients undergoing treatment of the aforementioned chronic diseases were counted during the prewar and war periods.

Results

Of 4645 records of patients with chronic diseases undergoing treatment during the prewar period, 998 records (21%) indicated having treatment during the war period. Compared with the prewar period, 59 of 180 individuals (33%; 95% CI, 26%-40%) had tuberculosis, 522 of 2211 (24%; 95% CI, 22%-26%) had HIV, 228 of 1195 (19%; 95% CI, 17%-21%) had hypertension, 123 of 632 (20%; 95% CI, 16%-22%) had psychiatric disorders, and 66 of 427 (15%; 95% CI, 12%-18%) had type 2 diabetes records, which revealed continued treatment during the war period. Of 174 records of patients with type 1 diabetes in the prewar period, at 2 to 3 months into the war, the numbers dropped to 10 with 94% decline compared with prewar observations.

Conclusions and Relevance

This study found that the war in Tigray has resulted in critical health care service disruption and high loss to follow-up for patients with chronic disease, likely leading to increased morbidity and mortality. Local, national, and global policymakers must understand the extent and impact of the service disruption and urge their efforts toward restoration of those services.

Post-malnutrition growth and its associations with child survival and non-communicable disease risk: a secondary analysis of the Malawi 'ChroSAM' cohort

OBJECTIVE

To explore patterns of post-malnutrition growth (PMGr) during and after treatment for severe malnutrition and describe associations with survival and non-communicable disease (NCD) risk 7 years post-treatment.

DESIGN

Six indicators of PMGr were derived based on a variety of timepoints, weight, weight-for-age z-score and height-for-age z-score (HAZ). Three categorisation methods included no categorisation, quintiles and latent class analysis (LCA). Associations with mortality risk and seven NCD indicators were analysed.

SETTING

Secondary data from Blantyre, Malawi between 2006 and 2014.

PARTICIPANTS

A cohort of 1024 children treated for severe malnutrition (weight-for-length z-score < 70 % median and/or MUAC (mid-upper arm circumference) < 110 mm and/or bilateral oedema) at ages 5-168 months.

RESULTS

Faster weight gain during treatment (g/d) and after treatment (g/kg/day) was associated with lower risk of death (adjusted OR 0·99, 95 % CI 0·99, 1·00; and adjusted OR 0·91, 95 % CI 0·87, 0·94, respectively). In survivors (mean age 9 years), it was associated with greater hand grip strength (0·02, 95 % CI 0·00, 0·03) and larger HAZ (6·62, 95 % CI 1·31, 11·9), both indicators of better health. However, faster weight gain was also associated with increased waist:hip ratio (0·02, 95 % CI 0·01, 0·03), an indicator of later-life NCD risk. The clearest patterns of association were seen when defining PMGr based on weight gain in g/d during treatment and using the LCA method to describe growth patterns. Weight deficit at admission was a major confounder.

CONCLUSIONS

A complex pattern of benefits and risks is associated with faster PMGr. Both initial weight deficit and rate of weight gain have important implications for future health.

Effectiveness of humanitarian health interventions: a systematic review of literature published between 2013 and 2021

OBJECTIVES

To provide a thorough mapping of the current quality and depth of evidence examining the effectiveness of health interventions in humanitarian settings in low and middle-income countries published in peer-reviewed journals since 2013.

METHODS

We searched MEDLINE, Embase and Global Health for English language peer-reviewed literature published from May 2013 through April 2021 to analyse the strength of evidence on health interventions' effectiveness in humanitarian settings in low and middle-income countries across nine thematic areas. Quality was assessed using standardised criteria and critical appraisal tools based on study design.

RESULTS

A total of 269 publications were included in this review. The volume of publications increased since the first Elrha Humanitarian Health Evidence Review in 2013, but non-communicable diseases and water, sanitation and hygiene remain the areas with the most limited evidence base on intervention effectiveness in addition to injury and rehabilitation. Economic evaluations continued to constitute a small proportion (5%) of studies. Half of studies had unclear risk of bias, while 28% had low, 11% moderate and 11% high risk of bias. Despite increased diversity in studied interventions, variations across and within topics do not necessarily reflect the health issues of greatest concern or barriers to quality service delivery in humanitarian settings.

CONCLUSIONS

Despite an increasing evidence base, the challenge of implementing high-quality and well-reported humanitarian health research persists as a critical concern. Improvements in reporting and intervention description are needed as are study designs that allow for attribution, standard indicators and longer term follow-up and outcome measures. There is a clear need to prioritise expansion of cross-cutting topics, namely health service delivery, health systems and cost-effectiveness.

PROSPERO REGISTRATION NUMBER

CRD42021254408.

Primary healthcare delivery models in African conflict-affected settings: a systematic review

BACKGROUND

In conflict-affected settings, access to primary healthcare for displaced populations is constrained by multiple challenges. These include geographical, cultural, communication, logistical and financial barriers, as well as risks posed to health workers and the population by insecurity. Different models of care are used to provide primary healthcare to affected communities. However, there is a paucity of evidence on how these models are selected and implemented by organisations working in conflict and displacement-affected settings. Our aim was to explore the different primary healthcare delivery models used in conflict-affected settings to understand gaps in existing healthcare delivery models.

METHODS

We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The review protocol was registered with the International Prospective Register of Systematic Reviews. We searched six databases for manuscripts published from January 1992 to December 2020. Publications were included if they reported primary healthcare models of care in conflict-affected settings of Africa. Data was analyzed descriptively and thematically using tables, charts and text.

RESULTS

Forty-eight primary research articles were included for analysis from which thirty-three were rated as "high" quality. The results showed that the models of care in place in these conflict-affected settings include health facility-based, community-based, mobile clinics, outreach and home visits. Primary healthcare for internally displaced persons and refugees is provided by a wide range of actors including national and international organisations. A range of services is offered, most commonly nutrition, mental health and sexual/reproductive health. Some organisations offer vertical (stand-alone) services, while others use an integrated service delivery model. Multiple cadres of healthcare workers provide services, frequently lay healthcare workers such as Community Health Workers.

CONCLUSION

Understanding the different modalities of primary healthcare delivery in conflict-affected settings is important to identify existing practices and gaps in service delivery. Service delivery using community health workers in conflict-affected settings is a low-cost primary care delivery strategy that may help optimize contributions of existing personnel through task shifting.

Exploring factors influencing the selection of primary health care delivery models in conflict-affected settings of North West and South West regions of Cameroon and North-East Nigeria: A study protocol

BACKGROUND

In conflict-affected settings, access to health care for displaced populations is constrained by barriers including geographical, cultural, communication, logistical, financial and insecurity. A six year humanitarian crises in the North West and South West regions of Cameroon has caused 27% of health facilities to be non-functional. The eleven year crisis in North-East Nigeria, has caused the closure of 26% of health facilities. These closure of health facilities and population displacement led to health care delivery using humanitarian funding by multiple different agencies. However, there is a paucity of evidence on the selection and design of the primary health care delivery models used in humanitarian settings. To ensure efficient use of resources and quality of services, model of care selection should be evidence based and informed by the specific humanitarian context. This research protocol aims to explore how primary health care models are selected by humanitarian organizations.

METHODS

We will conduct a cross sectional quantitative survey to map the range of primary health care delivery models used by humanitarian organisations in Cameroon and Nigeria. Using in-depth interviews and focus group discussions with staff from humanitarian organizations and internally displaced persons, we will explore the factors influencing the selection of primary health care models in these settings and determine the coverage and gaps in services across the different primary health care models. Quantitative data will be analysed in a descriptive manner and qualitative data will be analysed thematically.

DISCUSSION

Different models of care have been reported to be used by humanitarian organisations in conflict-affected settings, yet evidence on how different models are selected is lacking. A detailed understanding of the rationale for selection, the design and quality considerations of the strategies used to deliver health care will be obtained using a survey, in-depth interviews and focus group discussions.

Evaluating a research training programme for frontline health workers in conflict-affected and fragile settings in the middle east

BACKGROUND

Health Research Capacity Building (HRCB) is key to improving research production among health workers in LMICs to inform related policies and reduce health disparities in conflict settings. However, few HRCB programmes are available in the MENA region, and few evaluations of HRCB globally are reported in the literature.

METHODS

Through a qualitative longitudinal design, we evaluated the first implementation of the Center for Research and Education in the Ecology of War (CREEW) fellowship. Semi-structured interviews were conducted with fellows (n = 5) throughout the programme at key phases during their completion of courses and at each research phase. Additional data was collected from supervisors and peers of fellows at their organizations. Data were analysed using qualitative content analysis and presented under pre-identified themes.

RESULTS

Despite the success of most fellows in learning on how to conduct research on AMR in conflict settings and completing the fellowship by producing research outputs, important challenges were identified. Results are categorized under predefined categories of (1) course delivery, (2) proposal development, (3) IRB application, (4) data collection, (5) data analysis, (6) manuscript write-up, (7) long-term effects, and (8) mentorship and networking.

CONCLUSION

The CREEW model, based on this evaluation, shows potential to be replicable and scalable to other contexts and other health-related topics. Detailed discussion and analysis are presented in the manuscript and synthesized recommendations are highlighted for future programmes to consider during the design, implementation, and evaluation of such programmes.

Exploring the feasibility of establishing a core set of sexual, reproductive, maternal, newborn, child, and adolescent health indicators in humanitarian settings: results from a multi-methods assessment in Jordan

BACKGROUND

Reliable and rigorously collected sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH) data in humanitarian settings is often sparse and variable in quality across different humanitarian settings. To address this gap in data quality, the World Health Organization (WHO) developed a core set of indicators for monitoring and evaluating SRMNCAH services and outcomes in humanitarian settings, and assessed their feasibility in the field in Jordan, in addition to three other countries; with the goal of aggregating information from global consultations and field-level assessments to reach consensus on a set of core SRMNCAH indicators for services and outcome evaluation in humanitarian settings among WHO global partners.

METHODS

The feasibility assessment in Jordan focused on the following constructs: relevance/usefulness, feasibility of measurement, systems and resources, and ethical issues. The multi-methods assessment included five components; a desk review, key informant interviews, focus group discussions, facility assessments, and observational sessions.

RESULTS

Findings suggest that there is widespread support among regional, national, as well as global stakeholders for developing a core list of SRMNCAH indicators for monitoring and evaluation of services and outcomes in humanitarian settings in Jordan. There are numerous resources and data collection systems that could be leveraged, built upon, and improved to ensure the feasibility of collecting this proposed set of indicators. However, the data collection load requested from donors, the national government, international and UN agencies, coordination/cluster systems must be better harmonized, standardized, and less burdensome.

CONCLUSIONS

Despite stakeholder support in developing a core set of indicators, this would only be useful if it has the buy-in from the international community. Greater harmonization and coordination, alongside increased resource allocation, would improve data collection efforts and allow stakeholders to meet indicators' reporting requirements.

Do we really want to know? The journey to implement empirical research recommendations in the ICRC's responses in Myanmar and Lebanon

Efforts to reduce the gap between the research evidence base and humanitarian responses have focused on producing quality evidence and ensuring its use in decision-making. Yet, how evidence translates into field-level implementation is not well understood in humanitarian contexts. This study analysed how recommendations produced through academic research partnerships were implemented by the International Committee of the Red Cross (ICRC) in Lebanon and Myanmar. The methodology included: social network analysis to represent collective dynamics; document reviews to assess implementation; qualitative interviews to comprehend why actors engaged; and a critical appraisal of these combined results. The application of Extended Normalization Process Theory provided information on 'anticipation of constraints' (access to information, staff turnover, context specificity, and the need to engage as a cohesive group). Future research efforts should concentrate explicitly on identifying and tackling implementation barriers such as power imbalances and ethical dilemmas related to service delivery by humanitarian actors.

A Peer-Led Integrated Nutrition Education Intervention through Care Groups Improved Complementary Feeding of Infants in Postemergency Settlements in the West-Nile Region in Uganda: A Cluster Randomized Trial

Background

Complementary feeding of infants in refugee settlements remains inadequate. Furthermore, there has been limited evaluation of interventions addressing these nutrition challenges.

Objective

This study examined the effects of a peer-led integrated nutrition education intervention on infant complementary feeding by South Sudanese refugee mothers in the West-Nile region in Uganda.

Methods

A community-based randomized trial enrolled 390 pregnant women (during third trimester) as the baseline. Two arms [mothers-only and parents-combined (both mothers and fathers)] comprised treatments with a control. Infant feeding was assessed using WHO and UNICEF guidelines. Data were collected at Midline-II and Endline. The medical outcomes study (MOS) social support index was used to measure social support. An overall mean score of >4 was considered optimal social support, a score of ≤2 was none or little support. Adjusted multivariable logistic regression models determined the effects of the intervention on infant complementary feeding.

Results

At the end of the study, infant complementary feeding improved significantly in both mothers-only and parents-combined arms. There was a positive effect on the introduction of solid, semisolid, and soft foods (ISSSF) in the mothers-only arm at both Midline-II {adjusted odds ratio (AOR) = 4.0]} and Endline (AOR = 3.8). Likewise, ISSSF was better for the parents-combined arm at both Midline-II (AOR = 4.5) and Endline (AOR = 3.4). Minimum dietary diversity (MDD) was significantly better at the Endline for the parents-combined arm (AOR = 3.0). Minimum acceptable diet (MAD) was significantly better at Endline for both mothers-only (AOR = 2.3) and parents-combined arms (AOR = 2.7). Infant consumption of eggs and flesh foods (EFF) was improved only in the parents-combined arm at both Midline-II (AOR = 3.3) and Endline (AOR = 2.4). Higher maternal social support was associated with better infant MDD (AOR = 3.3), MAD (AOR = 3.6), and EFF (AOR = 4.7).

Conclusion

Engaging both fathers and mothers in care groups benefited complementary feeding of infants. Overall, this peer-led integrated nutrition education intervention through care groups improved infant complementary feeding in the West-Nile postemergency settlements in Uganda.This trial was registered at clinicaltrials.gov as NCT05584969.

Accelerating UN Sustainable Development Goals with AI-Driven Technologies: A Systematic Literature Review of Women's Healthcare

In this paper, we critically examine if the contributions of artificial intelligence (AI) in healthcare adequately represent the realm of women's healthcare. This would be relevant for achieving and accelerating the gender equality and health sustainability goals (SDGs) defined by the United Nations. Following a systematic literature review (SLR), we examine if AI applications in health and biomedicine adequately represent women's health in the larger scheme of healthcare provision. Our findings are divided into clusters based on thematic markers for women's health that are commensurate with the hypotheses that AI-driven technologies in women's health still remain underrepresented, but that emphasis on its future deployment can increase efficiency in informed health choices and be particularly accessible to women in small or underrepresented communities. Contemporaneously, these findings can assist and influence the shape of governmental policies, accessibility, and the regulatory environment in achieving the SDGs. On a larger scale, in the near future, we will extend the extant literature on applications of AI-driven technologies in health SDGs and set the agenda for future research.

The state of cancer research in fragile and conflict-affected settings in the Middle East and North Africa Region: A bibliometric analysis

Background

Cancer represents a disproportionate burden in LMICs, especially conflict-affected countries in the MENA region. Research output on cancer fails to match the growing burden in the region. This bibliometric study aims to examine the status and trends of cancer research in fragile and conflict-affected settings in the MENA region from 2000 to 2021, while also incorporating economic and demographic indicators as additional factors of analysis.

Methods

The Web of Science databases were searched for publications related to cancer research in Iraq, Lebanon, Libya, Palestine, Syria, and Yemen from January 1, 2000, to December 31, 2021. The retrieved publications were screened based on preset eligibility criteria and the final list was analyzed using the Bibliometrix Package in R to generate the annual scientific production and citations, journals, institutions, authors, collaborations, keywords, and title co-occurrence. Each country's annual scientific production was analyzed against its annual GDP per capita.

Results

A total of 4,280 documents met the inclusion criteria in this research. The annual number of publications revealed a significant increase over the past 20 years. These publications were mostly published in international journals that had impact factors rated in the 3rd or 4th quartiles. The overall contribution of researchers from Fragile and Conflict-Affected Settings (FCS) to cancer research was 6.5% of the MENA cancer research productivity, despite comprising around 23% of the total MENA region's population. Lebanon had the highest publication productivity at the country level, followed by Iraq and Syria. GDP per capita was not significantly correlated with cancer research across the countries under investigation. At the institutional level, the American University of Beirut was the most prolific institution and had the highest number of collaborations and the widest range of cooperative partners. Most first authors were male researchers. There is an interest in cancer expression, prevalence, diagnosis, and management in terms of commonly researched topics.

Conclusion

This study underscores the need for a concerted effort to improve cancer research outcomes in FCS, which can be achieved through targeted research, increased investment in research infrastructure and capacity-building initiatives, and greater regional and global collaboration.

Barriers in accessing family planning services in Nepal during the COVID-19 pandemic: A qualitative study

BACKGROUND

The COVID-19 virus is still with us, and in resource-limited countries, like Nepal, resurgence of a new variant is still a threat. In this pandemic, low-income countries struggle to provide essential public health services, including family planning. This study was conducted to explore what sorts of barriers are faced by women needing family planning services in Nepal during the pandemic.

METHODS

This qualitative study was conducted in five districts of Nepal. Telephonic in-depth interviews were conducted with 18 women of reproductive age (18-49 years) who were the regular clients of family planning services. Data were coded deductively using the preexisting themes based on a socio-ecological model (e.g., individual, family, community, and health-facility levels).

RESULTS

Individual level barriers included low self-confidence, inadequate knowledge on COVID-19, myths and misconception related to COVID-19, limited access to FP services low priority to SRH services, low autonomy in family and limited financial ability. Family level barriers comprised of partner's support, social stigma, increased time at home with husbands or parents, un-acceptance of family planning services as essential health services, financial hardship due to loss of jobs, and communication with in-laws. Movement restrictions and transportation hindering access, unsecured feeling, violation of privacy, and obstacles from security personnel were the community level barriers and unavailability of preferred choice of contraception, increased waiting time, limited outreach services by community health workers, limited physical infrastructures, the behavior of health workers, stock out of commodities, and absence of health workers were health facility level barriers.

CONCLUSION

This study highlighted key barriers faced by women in seeking family planning services during the COVID-19 lockdown in Nepal. Policymakers and program managers should consider strategies to ensure continued availability of the full method mix during emergency, particularly since disruptions may go unnoticed and strengthen the provision of services through alternative service delivery channels to ensure sustained uptake of such services in this sort of pandemic.

Scaling up a monitoring and evaluation framework for sexual, reproductive, maternal, newborn, child, and adolescent health services and outcomes in humanitarian settings: A global initiative

Background

Reliable and rigorously collected sexual, reproductive, maternal, newborn, child, and adolescent (SRMNCAH) data from humanitarian settings are often sparse and variable in quality across different settings due to the lack of a standardised set of indicators across the different agencies working in humanitarian settings. This paper aims to summarise a WHO-led global initiative to develop and scale up an SRMNCAH monitoring and evaluation framework for humanitarian settings.

Methods

This research revolved around three phases. The first and the last phase involved global consultations with lead international agencies active in SRMNCAH in humanitarian settings. The second phase tested the feasibility of the proposed indicators in Afghanistan, Bangladesh, the Democratic Republic of the Congo, and Jordan, using different qualitative research methods (interviews with 92 key informants, 26 focus group discussions with 142 key stakeholders, facility assessments and observations at 25 health facilities or sites).

Results

Among the 73 proposed indicators, 47 were selected as core indicators and 26 as additional indicators. Generally, there were no major issues in collecting the proposed indicators, except for those indicators that relied on death reviews or population-level data. Service availability and morbidity indicators were encouraged. Abortion and SGBV indicators were challenging to collect due to political and sociocultural reasons. The HIV and PMTCT indicators were considered as core indicators, despite potential sensitivity in some settings. Existing data collection and reporting systems across the four assessed humanitarian settings were generally fragmented and inconsistent, mainly attributed to the lack of coordination among different agencies.

Interpretation

Implementing agencies need to collaborate effectively to scale up this agreed-upon set of SRMNCAH framework to enhance accountability and transparency in humanitarian settings.

Communicable diseases in humanitarian operations and disasters

Military organisations have battled communicable disease for millennia. They have pioneered disease prevention from the Crusades to the World Wars and continue to do so today. Predeployment vaccinations and chemoprophylaxis are effective in preventing communicable disease, as is reliable vector destruction and bite prevention, especially in the era of multidrug resistant organisms. These measures are unlikely to be fully possible in disasters, but reactive vaccination and efforts to reduce exposure to communicable disease should be a priority. Communicable diseases can be challenging to diagnose-the UK Defence Medical Services have become familiar with tools such as multiplex PCR and mass spectrometry. These have the potential to accurately identify organisms and sensitivity patterns in austere environments. Management of communicable diseases depends on accurate diagnosis and has a largely well-established evidence base but can be limited by a lack of resources and skills in an austere setting, therefore telemedicine can assist diagnosis and treatment of infections by projecting specialist skill. Systems such as EpiNATO2 are useful in monitoring diseases and identifying trends in order to establish control measures. Many of these tools and techniques are effective in austere environments and offer learning opportunities for those providing care in similar settings. Further research is ongoing into diagnostic tools as well as remote management.

Sexual and reproductive health and access: Results of a rapid epidemiological assessment among migrant peoples in transit through Darién, Panamá

BACKGROUND

The foot transit of migrant peoples originating from the Caribbean, South America, Asia, and Sub-Saharan Africa through the Darién Forest (DF) in Eastern Panamá towards North America has increased in recent years from approximately 30,000 people/year to >133,000 in 2021. In the DF, there is no food/housing provision nor healthcare access. Very little is known of sexual and reproductive health (SRH) among this population. This study used rapid epidemiological methods to describe the SRH situation among migrant peoples in transit through the DF.

METHODS

This cross-sectional study randomly selected migrant people in transit (men and women) at a Migrant Reception Station in Darién, Panamá, between January 4-11, 2022. Data collection included a self-applied questionnaire (≥18 years); clinical screening (≥12 years); and HCG, treponemal antibodies, and HIV(I/II) lateral-flow tests with blood samples (≥12 years). Descriptive analyses were used to report findings.

RESULTS

In all, 69 men and 55 women participated in the self-applied questionnaire, 70 men and 51 women in clinical screening; 78 men and 63 women in HCG, treponemal antibody and HIV testing. Overall, 26.1% (18/69) men and 36.4% (20/55) women reported sexual intercourse within the past month. The last sex partner was casual among 43.0% (21/49) of men and 27.8% (10/36) of women; of those, 42.9% (9/21) of men and 80.0% (8/10) of women reported this sex was condomless. Among women, 20.0% (11/55) tested positive for pregnancy; 5 of these pregnancies were planned. Of those screened, a reproductive tract infection symptom was reported by 5.7% (4/70) of men and 58.8% (30/51) of women. A total of 32.7% (18/55) of men and 18.2% (8/44) of women reported no prior HIV testing. Of 78 men, HIV and treponemal antibodies were found among 1.3% (n = 1) and 2.6% (n = 2), and among 63 women, 3.2% (n = 2) and 3.2% (n = 2), respectively.

CONCLUSIONS

This rapid epidemiological assessment found high recent sexual activity, low condom use with casual partners, and a need for increased HIV and syphilis testing and treatment. There is a need for increased testing, condom provision, and SRH healthcare access at migrant reception stations that receive migrant peoples in transit through Panamá.

Strengthening vaccination delivery system resilience in the context of protracted humanitarian crisis: a realist-informed systematic review

Background

Childhood vaccination is among the most effective public health interventions available for the prevention of communicable disease, but coverage in many humanitarian settings is sub-optimal. This systematic review critically evaluated peer-review and grey literature evidence on the effectiveness of system-level interventions for improving vaccination coverage in protracted crises, focusing on how they work, and for whom, to better inform preparedness and response for future crises.

Methods

Realist-informed systematic review of peer-reviewed and grey literature. Keyword-structured searches were performed in MEDLINE, EMBASE and Global Health, CINAHL, the Cochrane Collaboration and WHOLIS, and grey literature searches performed through the websites of UNICEF, the Global Polio Eradication Initiative (GPEI) and Technical Network for Strengthening Immunization Services. Results were independently double-screened for inclusion on title and abstract, and full text. Data were extracted using a pre-developed template, capturing information on the operating contexts in which interventions were implemented, intervention mechanisms, and vaccination-related outcomes. Study quality was assessed using the MMAT tool. Findings were narratively synthesised.

Results

50 studies were included, most describing interventions applied in conflict or near-post conflict settings in sub-Saharan Africa, and complex humanitarian emergencies. Vaccination campaigns were the most commonly addressed adaptive mechanism (n = 17). Almost all campaigns operated using multi-modal approaches combining service delivery through multiple pathways (fixed and roving), health worker recruitment and training and community engagement to address both vaccination supply and demand. Creation of collaterals through service integration showed generally positive evidence of impact on routine vaccination uptake by bringing services closer to target populations and leveraging trust that had already been built with communities. Robust community engagement emerged as a key unifying mechanism for outcome improvement across almost all of the intervention classes, in building awareness and trust among crisis-affected populations. Some potentially transformative mechanisms for strengthening resilience in vaccination delivery were identified, but evidence for these remains limited.

Conclusion

A number of interventions to support adaptations to routine immunisation delivery in the face of protracted crisis are identifiable, as are key unifying mechanisms (multi-level community engagement) apparently irrespective of context, but evidence remains piecemeal. Adapting these approaches for local system resilience-building remains a key challenge.

The need for standardised methods of data collection, sharing of data and agency coordination in humanitarian settings

Humanitarian crises and emergencies are prevalent all over the world. With a surge in crises in the last decade, humanitarian agencies have increased their presence in these areas. Initiatives such as the Sphere Project and the Minimum Initial Service Package known as MISP were formed to set standards and priorities for humanitarian assistance agencies. MISP was initiated to coordinate and standardise data and collection methods and involve locals for programme sustainability. Developing policies and programmes based on available data in humanitarian crises is necessary to make evidence-based decisions. Data sharing between humanitarian agencies increases the effectiveness of rapid responses and limits duplication of services and research. In addition, standardising data collection methods helps alleviate the risk of inaccurate information and allows for comparison and estimates among different settings. Big data is a new collection method that can help assemble timely data if resources are available and turn the data into information. Further research on setting priority indicators for humanitarian situations can help guide agencies to collect quality data.

How are hygiene programmes designed in crises? Qualitative interviews with humanitarians in the Democratic Republic of the Congo and Iraq

BACKGROUND

Hygiene behaviour change programmes are complex to design. These challenges are heightened during crises when humanitarian responders are under pressure to implement programmes rapidly despite having limited information about the local situation, behaviours and opinions-all of which may also be rapidly evolving.

METHODS

We conducted in-depth interviews with 36 humanitarian staff involved in hygiene programme design in two crisis-affected settings-one a conflict affected setting (Iraq) and the other amid a cholera outbreak (Democratic Republic of the Congo). Interviews explored decision-making in each phase of the humanitarian project cycle and were thematically analysed.

RESULTS

Participants considered the design and implementation of hygiene programmes in crises to be sub-optimal. Humanitarians faced sector-specific challenges as well as more general constraints associated with operating within the humanitarian system. Programme-design decisions were made naturalistically and relied heavily on the intuitions and assumptions of senior staff. National organisations were often side-lined from programme design processes despite being in a better position to gather situational data. Consequently, programme design and decision-making processes adopted by humanitarians were similar across the two settings studied and led to similar types of hygiene promotion activities being delivered.

CONCLUSION

Hygiene programming in crises-affected settings could be strengthened by initiatives targeted at supporting humanitarian staff during the pre-implementation programme design phase. This may include rapid assessment tools to better understand behavioural determinants in crisis-affected contexts; the use of a theory of change to inform the selection of programme activities; and funding mechanisms which encourage equitable partnerships, phased programming, regular adaptation and have programmatic components targeted at sustainability and sector capacity building. Initiatives aimed at sector reform should be cognisant of inter and intra-organisational dynamics, the ways that expertise is created and valued by the sector, and humanitarian habits and norms that arise in response to system constraints and pressures. These micro-organisational processes affect macro-level outcomes related to programme quality and acceptability and determine or limit the roles of national actors in programme design processes.

Psychosocial health and quality of life among North African women

Studies on relationships between psychosocial factors and health among North African (NA) women are scarce. This research investigated the self-perceived psychosocial well-being of NA women by a structured questionnaire and anthropometric survey examining the possible explanatory variables of their mental health in comparison to a sample of NA migrants. The association of endogenous stress, psychological well-being, discomfort, and quality of life with migrant/non-migrant status, demographic characteristics, and adiposity indices was examined. Moreover, the internal consistency of the questionnaire was tested using Cronbach's alpha. A sample of 228 women living in Tunis and Casablanca participated in a survey in Tunisia and Morocco. According to multiple regression models, migrant/non-migrant status was the best explanatory variable of well-being and quality of life, marital status, educational level and the number of children were explanatory variables of discomfort and endogenous stress. Among anthropometric variables, central adiposity was a significant explanatory variable of well-being. The comparison with women who migrated mainly from Morocco and Tunisia to Italy (NA migrants) exhibited higher weight status and central adiposity in NA migrants. The perceived stress and discomfort were the same in the two groups; the migrants, despite reporting lower psychological well-being, presented a higher quality of life than residents. Our findings emphasise the potential to promote monitoring of the psychosocial health of NA women, planning effective interventions.

Measurement of perceived needs in humanitarian contexts using the HESPER scale: a scoping study with reflections on the collaboration between researchers and humanitarian actors

BACKGROUND

Needs assessment is one of the fundamental humanitarian responses to sudden-onset or long-lasting emergencies. The Humanitarian Emergency Settings Perceived Needs Scale (HESPER)/ HESPER Web are valid scales for identifying perceived needs among humanitarian or disaster-affected populations, both in humanitarian practice and in science. This scoping review aimed to determine the scientific use of HESPER or HESPER Web, report on previously published perceived needs in humanitarian emergencies, and discuss how scientific and humanitarian actors can work together in a partnership in needs assessment in humanitarian settings.

RESULTS

In all, eight papers were found in which the HESPER or HESPER Web had been used in conflict- or post-conflict settings or natural disasters. The study samples varied from 85 to 1000 participants (mean 440). The mean number of perceived needs in all studies was 8, varying from 4.25 to 12.18. The top three needs varied in all the studies. A high number of perceived needs was associated with mental health problems. No paper has reported on how the assessment outcomes were shared between the researchers and humanitarian actors.

CONCLUSION

Inventorying the needs from the perspective of the affected population is important to tailor the response to each humanitarian emergency. The HESPER scale and the HESPER Web are multisectoral tools that can be used to take inventory of the perceived needs and indicate the mental health problems that arise in conflict-ridden and natural disaster contexts. It is essential that results from a scientific needs inventory are shared with adequate humanitarian stakeholders to not only facilitate a proper response, but also to foster a closer collaboration between scientists, humanitarians, and the affected population. Doing so would increase the development and use of evidence in practice when providing humanitarian aid.

Models of care for non-communicable diseases for displaced populations in Iraq: a scoping review

Non-communicable diseases (NCDs) are the leading cause of death and disability globally. Their importance in humanitarian settings is increasingly recognised, but evidence about how best to address NCDs in these setting is limited. This scoping review aimed to explore models of NCD care for displaced populations in Iraq, in order to build evidence to design context adapted models of care. A search of key databases (Medline, Embase, Scopus, EconLit, Global Health, Web of Science, and the Iraqi Academic Scientific Journals) was conducted and complemented with grey literature and snowballing searches. Documents were included if they referred to models of NCD care for displaced populations. We synthesised the data using a conceptual model of care framework. The findings were reported according to the PRISMA guidelines for scoping reviews. We identified 4036 documents of which 22 were eligible for inclusion. Only six documents were peer-reviewed studies with most being internal reports, commentaries, or press releases. Of the 14 documents that reported on their methods, most applied quantitative approaches (n = 7), followed by mixed-methods (n = 5) and qualitative approaches (n = 2). Only one document reported on outcome data and none applied longitudinal study designs. Documents generally described individual framework dimensions, mostly centring around medicines, facility-based services, and selected access dimensions. Most dimensions had few or no references. The most common model for displaced populations in Iraq was primary-level centred care that complemented or supported existing—mostly tertiary—public health system structures. Additionally, private facilities played an important role and were frequently accessed by displaced populations in most settings. Quality of care, particularly patient-perceived quality, emerged as a critical factor for designing context-adapted models of NCD care. This review also identified a strong regionality of NCD care, particularly in terms of access rates and barriers. We concluded that there is a scarcity of evidence on the effectiveness of models of NCD care for displaced populations in Iraq, calling for capacity building initiatives focused on implementation research and evaluation.

A systematic review of newborn health interventions in humanitarian settings

BACKGROUND

Almost half of the under-5 deaths occur in the neonatal period and most can be prevented with quality newborn care. The already vulnerable state of newborns is exacerbated in humanitarian settings. This review aims to assess the current evidence of the interventions being provided in these contexts, identify strategies that increase their utilisation and their effects on health outcomes in order to inform involved actors in the field and to guide future research.

METHODS

Searched for peer-reviewed and grey literature in four databases and in relevant websites, for published studies between 1990 and 15 November 2021. Search terms were related to newborns, humanitarian settings, low-income and middle-income countries and newborn health interventions. Quality assessment using critical appraisal tools appropriate to the study design was conducted. Data were extracted and analysed using a narrative synthesis approach.

RESULTS

A total of 35 articles were included in this review, 33 peer-reviewed and 2 grey literature publications. The essential newborn care (ENC) interventions reported varied across the studies and only three used the Newborn Health in Humanitarian Settings: Field Guide as a guideline document. The ENC interventions most commonly reported were thermal care and feeding support whereas delaying of cord clamping and administration of vitamin K were the least. Training of healthcare workers was the most frequent strategy reported to increase utilisation. Community interventions, financial incentives and the provision of supplies and equipment were also reported.

CONCLUSION

There is insufficient evidence documenting the reality of newborn care in humanitarian settings in low-income and middle-income countries. There is a need to improve the reporting of these interventions, including when there are gaps in service provision. More evidence is needed on the strategies used to increase their utilisation and the effect on health outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020199639.

Strengthening the primary care workforce to deliver high-quality care for non-communicable diseases in refugee settings: lessons learnt from a UNHCR partnership

Non-communicable disease (NCD) prevention and care in humanitarian contexts has been a long-neglected issue. Healthcare systems in humanitarian settings have focused heavily on communicable diseases and immediate life-saving health needs. NCDs are a significant cause of morbidity and mortality in refugee settings, however, in many situations NCD care is not well integrated into primary healthcare services. Increased risk of poorer outcomes from COVID-19 for people living with NCDs has heightened the urgency of responding to NCDs and shone a spotlight on their relative neglect in these settings. Partnering with the United Nations Refugee Agency (UNHCR) since 2014, Primary Care International has provided clinical guidance and Training of Trainer (ToT) courses on NCDs to 649 health professionals working in primary care in refugee settings in 13 countries. Approximately 2300 healthcare workers (HCW) have been reached through cascade trainings over the last 6 years. Our experience has shown that, despite fragile health services, high staff turnover and competing clinical priorities, it is possible to improve NCD knowledge, skills and practice. ToT programmes are a feasible and practical format to deliver NCD training to mixed groups of HCW (doctors, nurses, technical officers, pharmacy technicians and community health workers). Clinical guidance must be adapted to local settings while co-creating an enabling environment for health workers is essential to deliver accessible, high-quality continuity of care for NCDs. On-going support for non-clinical systems change is equally critical for sustained impact. A shared responsibility for cascade training—and commitment from local health partners—is necessary to raise NCD awareness, influence local and national policy and to meet the UNHCR’s objective of facilitating access to integrated prevention and control of NCDs.

Cash-like vouchers improve psychological well-being of vulnerable and displaced persons fleeing armed conflict

The psychological burden of conflict-induced displacement is severe. Currently, there are 80 million displaced persons around the world, and their number is expected to increase in upcoming decades. Yet, few studies have systematically assessed the effectiveness of programs that assist displaced persons, especially in settings of extreme vulnerability. We focus on eastern Democratic Republic of Congo, where myriad local armed conflicts have driven cycles of displacement for over 20 years. We conducted a within-village randomized field experiment with 976 households, across 25 villages, as part of the United Nations' Rapid Response to Population Movements program. The program provided humanitarian relief to over a million people each year, including vouchers for essential nonfood items, such as pots, pans, cloth, and mattresses. The vouchers led to large improvements in psychological well-being: a 0.32 standard deviation unit (SDU) improvement at 6 weeks, and a 0.18 SDU improvement at 1 year. There is no evidence that the program undermined social cohesion within the village, which alleviates worries related to programs that target some community members but not others. Finally, there was no improvement in child health.

Measuring the impacts of maternal child marriage and maternal intimate partner violence and the moderating effects of proximity to conflict on stunting among children under 5 in post-conflict Sri Lanka

This study aimed to understand whether maternal child marriage and past year intimate partner violence (IPV) impact stunting among Sri Lankan children under 5 years old, and, secondarily, whether proximity to conflict is associated with stunting. Additionally, we assessed whether proximity to conflict moderates the relationships between maternal child marriage and past year IPV (sexual, physical, and emotional). We tested these questions using logistic regression analyses of the 2016 Sri Lankan Demographic and Health Survey (n = 4941 mother-child dyads). In country-wide adjusted analyses, we did not find associations between maternal child marriage or IPV and stunting (p > 0.05). Children in districts proximal and central to conflict were significantly less likely to be stunted compared to children in districts distal to conflict (proximal adjusted odds ratio/aOR: 0.43, 95% confidence interval/CI: 0.22–0.82; central aOR: 0.53, CI: 0.29–0.98). We found significant interaction effects on stunting between proximity to conflict and both sexual and emotional IPV, which we further explored in stratified analyses. In districts distal to conflict, maternal sexual IPV was significantly associated with increased odds of stunting (aOR: 2.71, CI: 1.16–6.35), and in districts central to conflict, maternal emotional IPV was significantly associated with increased odds of stunting (aOR: 1.80, CI: 1.13–2.89). Maternal emotional IPV was significantly associated with decreased odds of stunting in districts proximal to conflict (aOR: 0.42, CI: 0.18–0.96). Maternal child marriage and physical IPV were not associated with stunting in Sri Lanka. Variations in associations between maternal IPV and stunting across Sri Lanka may reflect the lasting and differential impact of conflict, as well as differential humanitarian responses which may have improved child nutrition practices and resources in districts central and proximal to conflict. Policies and programs addressing stunting in Sri Lanka should consider the role of maternal IPV as well as community-level variations based on proximity to conflict.

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Across Sri Lanka, stunting is reduced in areas proximal and central to conflict.

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Proximity to conflict moderates the impact of sexual and emotional IPV on stunting.

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Children's vulnerability to stunting and IPV varies by proximity to conflict.

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Humanitarian aid may have decreased stunting in areas most impacted by conflict.

Implementation of maternal and perinatal death surveillance and response (MPDSR) in humanitarian settings: insights and experiences of humanitarian health practitioners and global technical expert meeting attendees

BACKGROUND

Maternal and perinatal death surveillance and response (MPDSR) is a system of identifying, analysing and learning lessons from such deaths in order to respond and prevent future deaths, and has been recommended by WHO and implemented in many low-and-middle income settings in recent years. However, there is limited documentation of experience with MPDSR in humanitarian settings. A meeting on MPDSR in humanitarian settings was convened by WHO, UNICEF, CDC and Save the Children, UNFPA and UNHCR on 17th-18th October 2019, informed by semi-structured interviews with a range of professionals, including expert attendees.

CONSULTATION FINDINGS

Interviewees revealed significant obstacles to full implementation of the MPDSR process in humanitarian settings. Many obstacles were familiar to low resource settings in general but were amplified in the context of a humanitarian crisis, such as overburdened services, disincentives to reporting, accountability gaps, a blame approach, and politicisation of mortality. Factors more unique to humanitarian contexts included concerns about health worker security and moral distress. There are varying levels of institutionalisation and implementation capacity for MPDSR within humanitarian organisations. It is suggested that if poorly implemented, particularly with a punitive or blame approach, MPDSR may be counterproductive. Nevertheless, successes in MPDSR were described whereby the process led to concrete actions to prevent deaths, and where death reviews have led to improved understanding of complex and rectifiable contextual factors leading to deaths in humanitarian settings.

CONCLUSIONS

Despite the challenges, examples exist where the lessons learnt from MPDSR processes have led to improved access and quality of care in humanitarian contexts, including successful advocacy. An adapted approach is required to ensure feasibility, with varying implementation being possible in different phases of crises. There is a need for guidance on MPDSR in humanitarian contexts, and for greater documentation and learning from experiences.

Measuring contraceptive use in a displacement-affected population using the Multiple Indicator Cluster Survey: the case of Iraq

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Offers substantive and methodological contributions to the literature on IDP health.

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Uses Multiple Indicator Cluster Survey data with displacement screening questions.

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Tests associations between modern contraceptive use and displacement in Iraq.

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Total survey error and feminist approaches highlight the limits of national household surveys.

Access to safe, effective, affordable, and acceptable contraceptive methods of choice is a basic right for displaced people. Yet displaced people are typically invisible in national sample surveys on population health, and quantitative evidence on their reproductive health outcomes is limited. This study focuses on the case of Iraq, a country with widespread displacement and where contraceptive use is a government policy priority. Using displacement screening questions in the Iraq 2018 Multiple Indicator Cluster Survey questionnaires, I construct two displacement-related indicators based on reason for last move and previous household residence. Descriptive statistics and binary logistic regression are used to test associations between modern contraceptive use and displacement, demographic, and socioeconomic factors. Controlling for the variables in the models, factors significantly associated with modern contraceptive use among married women aged 15–49 in Iraq are Federal Iraq region (reference Kurdish Region of Iraq, OR 1.78), upper secondary and primary education (reference pre-primary or no education, OR 1.50 and 1.20, respectively), parity, age, and exposure to television. The association between displacement (reason for last move) and modern contraceptive use significantly depends on a woman's level of education and whether they live in an urban or rural area. Women who previously lived in a camp are almost half as likely to use modern contraception compared to other previous residence types. This paper highlights the methodological potential and substantive value of using national household surveys to analyse reproductive health outcomes through a displacement lens. It also critically examines the limitations of these data and measures, drawing on total survey error and feminist theory.

Management resilience of Internally Displaced Persons (IDPs) living in camp-like settings: a Northern Nigeria case study

Background

There are about 55 million Internally Displaced Persons (IDP), and some live in camp settlements, often for protracted periods. However, there is limited evidence on camp management and self-management strategies adopted by camp-dwelling IDPs. This paper reflects on the camp management and health resilience strategies practised by IDPs settled in camp-like settings, based on the first strategic objective of the International Organisation for Migration (IOM) Progressive Resolution of Displacement Situations (PRDS).

Methods

Eight focus group discussions were conducted with 49 IDP camp leaders across eight camp-like settings in Northern Nigeria. Issues explored included community structure, leadership, public interaction, communication, and health management. Data were analysed using a framework approach under five factors related to the IOM PRDS first objective.

Findings

IDPs exhibited resilience by adapting to their current locations, establishing internal camp and health management structures, and advocating with external organisations. Supportive communal relationships were an integral element in their adaptation. Methods of resilience involved social cohesion, setting up camp leadership committees, and seeking alternative means of income, protection, and healthcare management. Additionally, selecting representatives who could advocate for their well-being allowed them to request support and exercise their rights.

Conclusion

Despite resource shortages, the IDPs adapted by setting up techniques for managing their affairs and available resources, finding innovative ways to cater for themselves, advocating for their needs, and supporting each other. These observations showed how displaced populations can be active actors in their change and development if basic and essential management support is provided. Engaging IDPs in camp management could reduce long-term dependency on humanitarian aid.

Leadership, politics, and communication: challenges of the epidemiology workforce during emergency response

BACKGROUND

Improving the epidemiological response to emergencies requires an understanding of who the responders are, their role and skills, and the challenges they face during responses. In this paper, we explore the role of the epidemiologist and identify challenges they face during emergency response.

METHODS

We conducted a cross-sectional survey to learn more about epidemiologists who respond to public health emergencies. The online survey included open and closed-ended questions on challenges faced while responding, the roles of epidemiology responders, self-rating of skills, and support needed and received. We used purposive sampling to identify participants and a snowballing approach thereafter. We compared data by a number of characteristics, including national or international responder on their last response prior to the survey. We analysed the data using descriptive, content, and exploratory factor analysis.

RESULTS

We received 166 responses from individuals with experience in emergency response. The most frequently reported challenge was navigating the political dynamics of a response, which was more common for international responders than national. National responders experienced fewer challenges related to culture, language, and communication. Epidemiology responders reported a lack of response role clarity, limited knowledge sharing, and communication issues during emergency response. Sixty-seven percent of participants reported they needed support to do their job well; males who requested support were statistically more likely to receive it than females who asked.

CONCLUSIONS

Our study identified that national responders have additional strengths, such as better understanding of the local political environment, language, and culture, which may in turn support identification of local needs and priorities. Although this research was conducted prior to the COVID-19 pandemic, the results are even more relevant now. This research builds on emerging evidence on how to strengthen public health emergency response and provides a platform to begin a global conversation to address operational issues and the role of the international epidemiology responder.

Feasibility, acceptability, and effectiveness of non-pharmaceutical interventions against infectious diseases among crisis-affected populations: a scoping review

Background

Non-pharmaceutical interventions (NPIs) are a crucial suite of measures to prevent and control infectious disease outbreaks. Despite being particularly important for crisis-affected populations and those living in informal settlements, who typically reside in overcrowded and resource limited settings with inadequate access to healthcare, guidance on NPI implementation rarely takes the specific needs of such populations into account. We therefore conducted a systematic scoping review of the published evidence to describe the landscape of research and identify evidence gaps concerning the acceptability, feasibility, and effectiveness of NPIs among crisis-affected populations and informal settlements.

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. We analysed the data to produce descriptive summaries according to a number of categories: date of publication; geographical region of intervention; typology of crisis, shelter, modes of transmission, NPI, research design; study design; and study quality.

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 and patient care and burial restrictions were found to be less acceptable, despite apparent effectiveness.

Conclusions

Overall, the evidence base was variable, with substantial knowledge gaps which varied between settings and pathogens. Based on the current landscape, robust evidence-based guidance is not possible, and a research agenda is urgently required that focusses on these specific vulnerable populations. Although implementation of NPIs presents unique practical challenges in these settings, it is critical that such an agenda is put in place, and that the lessons learned from historical and present experiences are documented to build a firm evidence base.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-022-00935-7.

The health of internally displaced people in Syria: are current systems fit for purpose?

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At 6.7 million, Syria has the largest number of internally displaced people globally.

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Health of IDPs in Syria is often not disaggregated from that of other populations.

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IDPs face intersecting vulnerabilities and social determinants which impact health.

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Syria's fragmented health system results in different system responses for IDPs.

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The evidence base on IDP health in Syria is weak and requires strengthening.

Introduction: Syria has the largest number of internally displaced people (IDPs) globally with 6.7 million forced from their homes since the uprising erupted in 2011. Most face multiple intersecting vulnerabilities with adverse health impacts. We explore the key health concerns among IDPs, how the various health systems in Syria have responded to the dynamic health needs of IDPs and what modalities have been used by humanitarian actors to address these needs. Methods: We undertook a scoping review of academic and grey literature for available evidence regarding the health of IDPs in Syria. We then organised an online workshop in November 2021 with around 30 participants who represent local, regional, and international organisations and who have relevant expertise. The discussion focused on how the health systems in Syria's various territories have responded to the health needs of IDPs, what this means to the structure and dynamics of these health systems and their intended outcomes and responsiveness. Findings: These emphasised the weak evidence base around IDP health in Syria, particularly in certain geographical areas. Workshop participants explored the applicability of the term IDP in the Syrian context given the fragmented health system and its impact on IDPs, the importance of considering co-determinants (beyond forced displacement) on the health of IDPs and taking a transectoral, community led approach to identify and respond to needs. Conclusion: This manuscript presents some of the current issues with regards to IDP health in Syria, however, there remain numerous unknowns, both for the health of IDP as well as non-IDP populations. We hope that it will be the foundation for further discussions on practical steps relating to research, analysis and interventions which can support health system responses for IDPs in Syria.