War or health: a four-decade armed conflict in Iraq

A Comparison of Ukrainian Hospital Services and Functions Before and During the Russia-Ukraine War

Importance

Since the full-scale Russian invasion, hospitals in Ukraine have been compelled to close or operate at reduced capacity due to inadequate supplies, damage, or destruction caused by war.

Objective

To analyze hospital services in Ukraine during the period before and after the Russian invasion.

Design, Setting, and Participants

Of the 450 hospitals currently functioning in Ukraine, a cross-sectional survey was carried out with the participation of 74 hospitals from 12 oblasts. Hospital administrators responded to an online survey with questions on the use of hospital services. Data were abstracted from hospital databases for the prewar period (before February 23, 2022) and during the war (February 23, 2022, to May 30, 2023).

Main Outcomes and Measures

Hospital services (including emergency services, preventive services, screenings, laboratory tests, obstetrics, telehealth, pharmacy, and rehabilitation services) were compared during the prewar and war periods.

Results

Of 450 Ukrainian hospitals in operation, 74 hospitals (16.0%) across 12 oblasts provided data for the current analyses. During the war, daily emergency admissions increased to 2830, compared with 2773 before the war. At the same time, hospitals reported reduced laboratory testing (72 [97%] vs 63 [85%]), tobacco education (52 [70%] vs 36 [49%]), cancer screening (49 [66%] vs 37 [50%]), gynecological services (43 [58%] vs 32 [43%]), rehabilitation services (37 [50%] vs 27 [36%]), pharmacy services (36 [49%] vs 27 [36%]), and telehealth programs (33 [45%] vs 21 [28%]). Hospitals reported additional difficulties during the war, including disruptions in the supply chain for essential equipment and pharmaceuticals, shortages of laboratory test kits, delays in the delivery of crucial medications, and problems around appropriate medication storage due to power outages.

Conclusions and Relevance

The ongoing war has inflicted profound devastation on Ukraine's hospitals. The findings of this cross-sectional survey offer valuable insights into the formidable challenges that hospitals confront in war-affected regions and underscore the pressing necessity for bolstering support to sustain and enhance hospital services during wartime.

Broken bones and apple brandy: resilience and sensemaking of general practitioners and their at-risk patients during the COVID-19 pandemic in Switzerland

In early 2020, when the first COVID-19 cases were confirmed in Switzerland, the federal government started implementing measures such as national stay-at-home recommendations and a strict limitation of health care services use. General practitioners (GPs) and their at-risk patients faced similar uncertainties and grappled with subsequent sensemaking of the unprecedented situation. Qualitative interviews with 24 GPs and 37 at-risk patients were conducted which were analyzed using thematic analysis. Weick's (1993) four sources of -resilience - improvisation, virtual role systems, attitudes of wisdom and respectful interaction - heuristically guide the exploration of on-the-ground experiences and informal ways GPs and their at-risk patients sought to ensure continuity of primary care. GPs used their metaphorical Swiss army knives of learned tools as well as existing knowledge and relationships to adapt to the extenuating circumstances. Through improvisation, GPs and patients found pragmatic solutions, such as using local farmer apple brandy as disinfectant or at-home treatments of clavicle fractures. Through virtual role systems, GPs and patients came to terms with new and shifting roles, such as "good soldier" and "at-risk patient" categorizations. Both parties adopted attitudes of wisdom by accepting that they could not know everything. They also diversified their sources of information through personal relationships, formal networks, and the internet. The GP-patient relationship grew in importance through respectful interaction, and intersubjective reflection helped make sense of shifting roles and ambiguous guidelines. The empirical analysis of this paper contributes to theoretical considerations of sensemaking, resilience, crisis settings and health systems.

Economic sanctions and spread of infectious diseases

Economic sanctions can induce economic crises and compromise the determinants of health. In the literature, economic crises have been found to increase the risk of infectious disease outbreaks. Presumably, sanctions can increase the risk of infectious disease spreads, indirectly. However, non-economic factors can fuel the adverse impact of sanctions, including political consequences of sanctions and civil war. We performed a systematic literature review of articles in Embase, MEDLINE, Scopus, Web of Science, Cochrane Library, and the grey literature to assess empirically the impact of economic sanctions on the spread of infectious diseases within and beyond the borders of sanctioned countries. Our review did not identify any study meeting our inclusion criteria. Most of the studies did not control for major socio-political events, particularly armed conflicts in the sanctioned countries. This discovery underscores a notable gap in the examination of the impact of economic sanctions on the propagation of infectious diseases, presenting a threat to global health. Using the social-ecological model, we hypothesize how the economic crisis resulting from economic sanctions affects determinants of health, increases the risk of the spread of infectious diseases and hinders the response capacity of health systems.

Impacts of Caregiving for Individuals with Autism in Low-Resource Settings, a Report from the Kurdistan Region of Iraq

Caring for children with different developmental trajectories brings various challenges, which are often exacerbated in low-resource settings. International research has shown that raising a child with autism strongly impacts family caregivers, particularly mothers. There is a dearth of information regarding caregiving for individuals with autism in the Kurdistan Region of Iraq (KRI) and for fathers as well as mothers. This study examined the similarities and differences in caregiving for mothers and fathers of a child with autism in KRI using validated rating scales to measure various aspects of their general well-being. Over two years, a sample of 118 parents of individuals with autism (81 mothers and 37 fathers) self-completed the rating scales, which were further discussed through individual interviews with service personnel mainly known to them. The findings indicated that mothers and fathers were similarly impacted. Although there were no statistically significant differences in the ratings of their general health, sources of stress, family functioning, and satisfaction with caregiving, the majority of parents had elevated ratings on all the measures. In addition, parents who rated their children higher on the Aberrant Behavior Checklist had significantly higher scores on their general health issues and were less satisfied with their caregiving role. Parents of female individuals with autism were also significantly more stressed compared to the male individuals with autism and parents of children who received a diagnosis before three years of age, reported fewer behavioral problems with their child compared to the parents who received a diagnosis when the child was older. In this sample, mothers and fathers seem to be similarly impacted by caring for a child with autism, which is contrary to findings from other countries. However, in this region, family bonds between couples and the wider family may have had an influence which further cross-cultural research in low-resource settings could help elucidate, notwithstanding the challenges this poses. The findings have policy implications for health authorities in the KRI to improve the support provided to both mothers and fathers who care for children with autism, which presently is rarely available to them.

An Insight into the Incorporation of Artificial Intelligence in Paediatrics Practice in Iraq

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Does armed conflict lead to lower prevalence of maternal health-seeking behaviours: theoretical and empirical research based on 55 683 women in armed conflict settings

BACKGROUND

Women and children bear a substantial burden of morbidity and mortality due to armed conflict. Life-saving maternal and child health (MCH) services are low-quality in most conflict-affected regions. Previous studies on armed conflict and MCH services have been mostly cross-sectional, and a causal relationship between armed conflict and MCH services utilisation cannot be inferred.

METHODS

First, we constructed a utility equation for maternal health-seeking behaviour. Next, we extracted MCH data from the Multiple Indicator Cluster Survey led by the UNICEF. Armed conflict data were obtained from the Uppsala Conflict Data Programme; 55 683 women aged 15-49 from Chad, the Central African Republic, the Democratic Republic of Congo (DRC) and the Republic of Iraq were selected as participants. We fitted a difference-in-differences (DID) model, taking before or after the conflict started as an exposure variable to estimate the effects of armed conflict on maternal health-seeking behaviours.

RESULTS

According to the results of the DID model, in the regional sample, armed conflict had a positive effect on tetanus vaccination (β=0.055, 95% CI 0.004 to 0.106, p<0.05), and had a negative effect on antenatal care at least eight visits (ANC8+) (β=-0.046, 95% CI -0.078 to -0.015, p<0.01). And, the effects of armed conflict on ANC, ANC4+, institutional delivery and early initiation of breast feeding (EIB) were not statistically significant. As for the country sample, we found that armed conflict had a negative effect on EIB (β=-0.085, 95% CI -0.184 to 0.015, p<0.1) in Chad. In Iraq, armed conflict had positive impacts on ANC (β=0.038, 95% CI -0.001 to 0.078, p<0.1) and tetanus vaccination (β=0.059, 95% CI 0.012 to 0.107, p<0.05), whereas it had a negative effect on ANC8+ (β=-0.039, 95% CI -0.080 to 0.002, p<0.1). No statistically significant associations were discovered in DRC based on the DID model.

CONCLUSIONS

There might be a mixed effect of armed conflict on maternal health-seeking behaviours. In the absence of humanitarian assistance, armed conflict reduces certain maternal health-seeking behaviours, such as ANC8+. When practical humanitarian health assistance is provided, the damage can be alleviated, and even the prevalence of maternal health-seeking behaviours can be improved, such as tetanus vaccination. Providing humanitarian assistance to conflict-affected regions improved the accessibility of MCH services for women living in those areas. However, the goals of saving lives and alleviating suffering still need to be achieved. In conflict-affected regions, humanitarian assistance on ANC, institutional delivery and breast feeding need strengthening.

Barriers to the Utilization of Primary Health Centers (PHCs) in Iraq

Primary care has been viewed as a means to ensure equitable access to care, enhance efficiency within healthcare systems, and improve health service quality. In recent decades, Iraq has transformed its compromised health system, shifting the healthcare model from hospital-based to primary care through primary health centers (PHCs) and referral mechanisms. Based on an extensive literature review, this qualitative paper explores the healthcare utilization of PHCs in different regions of Iraq. It also identifies some barriers to PHC use and recommends evidence-based approaches for improving PHCs' performance. Some reported challenges to better utilizing PHCs were the poor quality of services, patient dissatisfaction, long walking distance to a health center, and limited availability and affordability of the medications. If Iraq is to use primary care as a tool in achieving sustainable development goals (SDGs), collaborative efforts addressing the facility-related factors should be a priority.

The health consequences of civil wars: evidence from Afghanistan

This study examines the effects of long-run civil wars on healthcare, which is an important component of human capital development and their causality nexus in Afghanistan using the MVAR (modified vector autoregressive) approach and the Granger non-causality model covering data period 2002Q3-2020Q4. The primary results support a significant long-run relationship between variables, while the results of the MVAR model indicate the per capita cost of war, per capita GDP, and age dependency ratio have significantly positive impacts on per capita health expenditures, whereas child mortality rate and crude death rate have negative impacts. The results of the Granger non-causality approach demonstrate that there is a statistically significant bidirectional causality nexus between per capita health expenditure, per capita cost of war, per capita GDP, child mortality rate, crude death rate, and age dependency ratio, while it also supports the existence of strong and significant interconnectivity and multidimensionality between per capita cost of war and per capita health expenditure, with a significantly strong feedback response from the control variables. Important policy implications sourced from the key findings are also discussed.

War and oncology: cancer care in five Iraqi provinces impacted by the ISIL conflict

War and cancer have been intertwined in Iraq for over three decades, a country where the legacies and ongoing impacts of conflict have been commonly associated with both increased cancer rates as well as the deterioration of cancer care. Most recently, the Islamic State of Iraq and the Levant (ISIL) violently occupied large portions of the country's central and northern provinces between 2014 and 2017, causing devastating impacts on public cancer centers across central and northern Iraq. Focusing on the five Iraqi provinces previously under full or partial ISIL occupation, this article examines the immediate and long-term impacts of war on cancer care across three periods (before, during, and after the ISIL conflict). As there is little published data on oncology in these local contexts, the paper relies primarily upon the qualitative interviews and lived experience of oncologists serving in the five provinces studied. A political economy lens is applied to interpret the results, particularly the data related to progress in oncology reconstruction. It is argued that conflict generates immediate and long-term shifts in political and economic conditions that, in turn, shape the rebuilding of oncology infrastructure. The documentation of the destruction and reconstruction of local oncology systems is intended to benefit the next generation of cancer care practitioners in the Middle East and other conflict-affected regions areas in their efforts to adapt to conflict and rebuild from the legacies of war.

The pattern of dyslipidemia among Somali type 2 diabetic patients: a cross-sectional study

BACKGROUND

Diabetes mellitus (DM) is a major public health concern. This study aims to determine frequency, pattern, and potential determinants of dyslipidemia among adults with type 2 DM (T2DM) at Somalia's only diabetes outpatient clinic.

METHODS

Five hundred twenty-nine consecutive patients with T2DM who applied to our outpatient clinic between January 2020 and June 2020 were included in this cross-sectional hospital-based study. Demographic characteristics of participants, including lipid panel, were extracted from the registry system. Correlation analysis was performed between lipid profile and related parameters. Multivariate binary logistic regression models were used to identify independent determinants of dyslipidemia for further analysis.

RESULTS

The overall population's mean age was 51.9 ± 12.2 years, with 177 (33.5%) males. Total and atherogenic dyslipidemias were found in 92.8% and 24.8%, respectively. The most common isolated pattern of dyslipidemia was high non-high-density lipoprotein cholesterol (non-HDL-C) (82.8%), followed by high low-density lipoprotein cholesterol (LDL-C) (72.6%), high total cholesterol (TC) (54.3%), and low HDL-C (48.3%). Females were found to have a higher prevalence of high TC (63.4% vs. 54.2%, p = 0.043) and lower HDL-C (57.4% vs. 46.3%, p = 0.016). High LDL-C with low HDL-C was the most common pattern among combined type dyslipidemias (18.1%), followed by high LDL-C with high triglyceride (TG) (17.8%), as well as low TG with low HDL-C (3.6%). Females had a higher proportion of high LDL-C with low HDL-C than males (20.3% vs. 13.6%, p = 0.036). Age, gender, body mass index, central obesity, spot urinary proteinuria, fasting blood glucose, poor glycemic control, creatinine, and Hs-CRP were all associated with different dyslipidemia patterns in multivariate logistic regression analyses.

CONCLUSIONS

We found that the prevalence of dyslipidemia, especially atherogenic patterns, was extremely high among Somali T2DM patients. An enhanced health policy should, therefore, be established to detect, treat and prevent dyslipidemia.

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 Pilot Randomized Clinical Trial of a Novel, Culturally Adapted, Trauma-Focused Cognitive-Behavioral Intervention for War-Related PTSD in Iraqi Women

Trauma-focused cognitive-behavioral therapy (TF-CBT), broadly, is one of the leading evidence-based treatments for youth with posttraumatic stress disorder (PTSD). Generally, few culturally adapted TF-CBT interventions have been examined among war trauma-affected populations in low- and middle-income countries. Using a randomized clinical trial design, a total of 48 war trauma-exposed women in Iraq, M_age (SD) = 32.91 (5.33), with PTSD were randomly assigned to either TF-CBT or wait-list control (WLC) conditions. The intervention group received 12 individual weekly sessions of a culturally adapted TF-CBT intervention. Significant reductions in PTSD symptom severity were reported by women in the TF-CBT condition from pre- to posttreatment. Women in the TF-CBT condition reported significantly greater reductions in PTSD symptoms compared to WLC at 1-month follow-up. Additionally, levels of depression, anxiety, stress, and use of maladaptive emotion regulation strategies were significantly lower in the TF-CBT condition at posttreatment and 1-month follow-up, compared to the WLC condition. Women in the TF-CBT condition also reported significant improvements in various domains of quality of life at posttreatment and 1-month follow-up. This clinical trial provides preliminary cross-cultural support for the feasibility and efficacy of TF-CBT for the treatment of PTSD symptoms among women in non-Western cultures. Future directions and study limitations are discussed.

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

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.

Vulnerabilities of Arab refugees in primary health care: a scoping review

OBJECTIVE

To map and analyze the vulnerabilities of Arab refugees in the context of primary health care.

METHOD

Scoping review in which studies published in English, Spanish and Portuguese languages from 2011 onwards were reviewed. The following databases were surveyed: Cochrane, Scopus, Health System Evidence, MedLine-PubMed, CINAHL, Embase, Lilacs, Web of Science, SciELO, NYAM Grey Literature, BVS, Capes Thesis and Dissertation Database, Refworld and Journal of Refugee Studies. Data were analyzed in light of the concept of vulnerability.

RESULTS

Of the 854 studies identified, 40 articles were held for analysis and extraction of vulnerability indicators in the individual, social and programmatic dimensions. Regarding the individual dimension, the main indicators identified were unemployment, unstable and overcrowded housing, lack of sanitation and access to water, mental disorders, communicable and chronic noncommunicable diseases, etc. In the programmatic dimension, were identified, mainly, health teams with work overload, lack of preparation to deal with cultural and linguistic barriers, and delays in providing care. In relation to the social dimension, lack of access to schools, to information about health programs in the host countries, and to rights, among others, were found.

CONCLUSION

Vulnerabilities found highlight the disadvantage of refugees regarding health programs, services and system in host countries, in addition to highlighting the deep inequalities that affect this group. It is pointed out the need for programs and policies that promote actions, within the scope of primary health care, which recognize and respond to the health needs of refugees.

The impact of the COVID-19 pandemic on the continuity of care for at-risk patients in Swiss primary care settings: A mixed-methods study

Continuity of care is important for the health of aging individuals with comorbidities. When initial coronavirus mitigation campaigns involved messaging such as "Stay at home-stay safe," and banned provision of non-urgent care, at-risk patients depending upon regular consultations with general practitioners (GPs) faced confusion about the possibility of seeking non-COVID-19 related healthcare. We employed a sequential explanatory mixed-methods design, consisting of a quantitative component followed by a qualitative component, to understand at-risk patients' health services use during the COVID-19 pandemic in Switzerland. Quantitatively, we used electronic medical records data from 272 GPs and 266,796 patients. Based on pre-pandemic data, we predicted weekly consultation counts as well as weekly measurement counts (blood pressure, glycated hemoglobin, and low-density lipoprotein cholesterol) per 100 patients that would be expected in 2020 in absence of a pandemic and compared those to actual observed values. Qualitatively, we conducted 23 semi-structured interviews with 24 GPs (∼45 min) and 37 interviews with at-risk patients (∼35 min). Quantitative results demonstrate a significant decrease in consultation and measurement counts during the first shutdown period, with consultation counts quickly returning to normal and moving within expected values for the rest of 2020. Qualitative data contextualize these findings with GPs describing constantly implementing material, administrative, and communication changes. GPs reported communication gaps with the authorities and noted a lack of clear guidelines delineating how to define "at-risk patients" and what cases were "urgent" to treat during shutdowns. Patient interviews show that patient-level factors, such as fear of contracting coronavirus, perceptions that GPs were overburdened, and a sense of solidarity, influenced patients' decisions to consult less at the beginning of the pandemic. Findings demonstrate communication gaps during pandemic periods and provide valuable lessons for future pandemic preparedness, particularly the need for contingency plans for the overall healthcare system instead of plans focusing only on the infectious agent itself.

Health System Governance in Settings with Conflict-Affected Populations: A Systhematic Review

Health system governance has been recognised as critical to strengthening healthcare responses in settings with conflict-affected populations. The aim of this review was to examine existing evidence on health system governance in settings with conflict-affected populations globally. The specific objectives were: (i) to describe the characteristics of the eligible studies; (ii) to describe the principles of health system governance; (iii) to examine evidence on barriers and facilitators for stronger health system governance; and (iv) to analyse the quality of available evidence. A systematic review methodology was used following PRISMA criteria. We searched six academic databases, and used grey literature sources. We included papers reporting empirical findings on health system governance among populations affected by armed conflict, including refugees, asylum seekers, internally displaced populations, conflict-affected non-displaced populations and post-conflict populations. Data were analysed according to the study objectives and informed primarily by the Siddiqi et al. (2009) governance framework. Quality appraisal was conducted using an adapted version of the Mixed Methods Appraisal Tool. Of the 6,511 papers identified through database searches, 34 studies met eligibility criteria. Few studies provided a theoretical framework or definition for governance. The most frequently identifiable governance principles related to participation and coordination, followed by equity and inclusiveness and intelligence and information. The least frequently identifiable governance principles related to rule of law, ethics and responsiveness. Across studies, the most common facilitators of governance were collaboration between stakeholders, bottom-up and community-based governance structures, inclusive policies, and longer-term vision. The most common barriers related to poor coordination, mistrust, lack of a harmonised health response, lack of clarity on stakeholder responsibilities, financial support, and donor influence. This review highlights the need for more theoretically informed empirical research on health system governance in settings with conflict-affected populations that draws on existing frameworks for governance.

Terrorist Attacks in the Middle East: A Counter-Terrorism Medicine Analysis

BACKGROUND

The Middle East and North Africa (MENA) region has been, like many parts of the world, a hotbed for terrorist activities. Terrorist attacks can affect both demand for and provision of health care services and often places a unique burden on first responders, hospitals, and health systems. This study aims to provide an epidemiological description of all terrorism-related attacks in the Middle East sustained from 1970-2019.

METHODS

Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all events which occurred in Iraq, Yemen, Turkey, Egypt, Syria, West Bank and Gaza Strip, Israel, Lebanon, Iran, Saudi Arabia, Bahrain, Jordan, Kuwait, United Arab Emirates, North Yemen, Qatar, and South Yemen from January 1, 1970 - December 31, 2019. Primary weapon type, primary target type, country where the incident occurred, and number of deaths and injuries were collated and the results analyzed.

RESULTS

A total of 41,837 attacks occurred in the Middle East from 1970-2019 accounting for 24.9% of all terrorist attacks around the world. A total of 100,446 deaths were recorded with 187,447 non-fatal injuries. Fifty-six percent of all attacks in the region occurred in Iraq (23,426), 9.4% in Yemen (3,929), and 8.2% in Turkey (3,428). "Private Citizens and Properties" were targeted in 37.6% (15,735) of attacks, 15.4% (6,423) targeted "Police," 9.6% targeted "Businesses" (4,012), and 9.6% targeted "Governments" (4,001). Explosives were used in 68.4% of attacks (28,607), followed by firearms in 20.4% of attacks (8,525).

CONCLUSION

Despite a decline in terrorist attacks from a peak in 2014, terrorist events remain an important cause of death and injuries around the world, particularly in the Middle East where 24.9% of historic attacks took place. While MENA countries are often clustered together by economic and academic organizations based on geographical, political, and cultural similarities, there are significant differences in terrorist events between countries within the region. This is likely a reflection of the complexities of the intricate interplay between politics, culture, security, and intelligence services unique to each country.

Observational Study of Hand Hygiene Compliance at a Trauma Hospital in Iraqi Kurdistan

Healthcare-associated infections, commonly caused by poor hand hygiene, represent a significant source of disease and economic burden for healthcare systems, especially those in resource-limited settings. The few existing studies on hand hygiene compliance in resource-limited hospital settings suggest that compliance is insufficient. The difference in compliance rates between units in resource-limited trauma hospitals is largely unknown. We aimed to assess hand hygiene compliance rates among healthcare workers at a trauma hospital in Iraqi Kurdistan and compare the levels of compliance between the emergency room (ER), the intensive care unit (ICU), and the acute care ward (ACW). We carried out overt observations in 2018 using the validated World Health Organization ‘five moments for hand hygiene’ observational tool. We observed a total of 622 hand hygiene opportunities performed by 149 healthcare workers. Hand hygiene compliance was defined as handwashing with soap and water or the use of alcohol-based hand rub, in accordance with the ‘five moments for hand hygiene’ concept. Overall, the hand hygiene compliance rate was found to be 6.8% (95% confidence interval 5.0–9.1). Compliance was significantly lower in the ER (1.0%), compared with the ICU (8.1%) (p = 0.0012), and the ACW (11.1%) (p < 0.0001). In all three units, the availability of alcohol-based hand rub and handwashing sinks was insufficient in relation to the number of patient beds. We conclude that the overall level of hand hygiene compliance was low, with the lowest level of compliance in the ER. Our findings call for improved resource allocation and strengthened hand hygiene routines. These relatively simple measures could potentially lower the incidence of healthcare-associated infections and improve the mortality and morbidity of patients in already overburdened healthcare systems.

Resilience of health systems in conflict affected governorates of Iraq, 2014-2018

Objectives

The objective of this study was to assess the resilience of health systems in four governorates affected by conflict from 2014 to 2018, and to convey recommendations.

Methods

Health managers from Al Anbar, Ninawa, Salah al-Din, and Kirkuk governorates discussed resilience factors of Primary Health Care services affected by the 2014–2017 ISIS insurgency in focus groups, and general discussions. Additional information was gathered from key informants and a UNICEF health facility survey. Three specific aspects were examined: (1) meeting health needs in the immediate crisis response, (2) adaptation of services, (3) restructuring and recovery measures. Data from a MoH/UNICEF national health facility survey in 2017 were analyzed for functionality.

Results

There were many common themes across the four governorates, with local variations. (1) Absorption The shock to the public sector health services by the ISIS invasion caught health services in the four governorates unprepared, with limited abilities to continue to provide services. Private pharmacies and private clinics in some places withstood the initial shock better than the public sector. (2) Adaptation After the initial shock, many health facilities adapted by focusing on urgent needs for injury and communicable disease care. In most locations, maternal, neonatal, and child health (MNCH) preventive and promotive PHC services stopped. Ill persons would sometimes consult health workers in their houses at night for security reasons. (3) Restructuring or transformative activities In most areas, health services recovery was continuing in 2020. Some heavily damaged facilities are still functioning, but below pre-crisis level. Rebuilding lost community trust in the public sector is proving difficult.

Conclusion

Health services generally had little preparation for and limited resilience to the ISIS influx. Governorates are still restructuring services after the liberation from ISIS in 2017. Disaster planning was identified by all participants as a missing component, as everyone anticipated future similar emergencies.

Perception of Iraqi youth towards social and psychological impact of COVID-19

Background

COVID-19 pandemic is recently considered as the most public health challenge with global dramatic changes on different aspects of life and health, including the psychological burden on individuals and communities. A convenience sample of youth (university students) aged 18–24 years was chosen in this cross-sectional study that was conducted during the period from October through December 2020. The questionnaire included questions about COVID-19 and its effect on mental and social wellbeing.

Results

Out of the total 762 young adults who responded, 62% were females, with a mean age of 20.75+2.33; 40.4% of them reported severely impaired social leisure activities; 14.7% expressed severely impaired private leisure activities; and 15.5% had severely impaired ability to form and maintain close relationships. Continuous feeling of nervousness, anxiety, stress, or exaggerated worries about the coronavirus was reported by 18%, while 24.9% felt sad or depressed all the time, and 26.4% of the female respondents had depressive symptoms versus 22.5% males.

Conclusion

The findings of this study indicate that the COVID-19 pandemic had created severe limitations on people’s social activities that may be associated with negative changes in mental condition.

Domestic violence in time of unrest, a sample from Iraq

Domestic violence is a worldwide problem, and there are over a billion women who have been exposed to violence from their husband or male partner. In Iraq, since the 2003 invasion, domestic violence has risen dramatically. In this study we aim to estimate the prevalence of domestic violence against women (and some associated factors) in Baghdad city. A sample of 735 women was collected from the attendants of the outpatients-Obstetrics/Gynaecology clinics of four randomly chosen health facilities located on either side of Baghdad city. A questionnaire form was developed to enquire about the occurrence of violence, its frequency, source, and reasons. The results showed that 81.2% of the women were exposed to violence (100% verbal/emotional and 39.18% physical), usually by the husband (41.4%) or brother (20.4%), mostly attributed to a stressful life of unrest (41.9%). Older and currently married women are significantly more exposed to domestic violence (p = 0.001 & 0.004, respectively). Consanguinity was associated with less violence (p = 0.0001) as was higher education (p = 0.001), employment (p = 0.044) and women's independence (p = 0.044). A stressful life of unrest was significantly associated with all types of violence (p < 0.001).

Women's mental health in Iraq post-conflict

Women are the silent sufferers of war, they have higher rates of anxiety and depression after terror events than men who have been similarly exposed. In this study, we aim to explore the prevalence of anxiety, depression and suicidal thoughts/attempts among Iraqi women post-conflict. A sample of 1000 women was collected in this cross-sectional study that was conducted in Baghdad city from January through September 2020. Their mental state was addressed by assessing anxiety and depression on symptomatic basis using standard questions from the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) scale. The results showed that the vast majority (91.1%) of the sampled women had experienced war-related trauma since 2003. Anxiety symptoms were reported by 39.7% of the women, depressive symptoms by 34.2% and suicidal thoughts/attempts by 35.8%. More than two-thirds of the women experienced difficulties in their social life and relationships. The majority of the studied women had negative expectations regarding their future and more than half of them expressed their intention to emigrate. The findings of this study indicate that anxiety, depression and suicidal thoughts/attempts are prevalent among this sample of Iraqi women post-conflict. Significant associated factors were losing a husband and having early married girls in the household.

Cancer Trends in Iraq 2000-2016

OBJECTIVES

Precise and quantitative assessment of the trend of cancer burden enables policymakers and health managers to prioritize diseases and allocate resources better. This infers what caused a decrease or increase in the rate of cancer occurrence, and if it denotes timing of implementation of a control measure, it presents the impact on the disease rate. This study's objective was to evaluate trends in child and adult cancer in Iraq from 2000 onwards.

METHODS

We used the registries of the Iraqi Ministry of Health that were gathered from all governorates from 2000-2016. Data were presented as incidence rates to depict the trends of different types of cancers distributed by age, gender, and governorates.

RESULTS

Breast cancer witnessed a significant increase with predominance in females. Lung cancer rate increased significantly from 4.08 to 5.60/100 000 (p = 0.038), affecting males more than females. The brain cancer trend showed a bimodal pattern (two peaks in 2004 and 2011) with no significant trend change (p = 0.788). Both genders were similarly affected. The trend of stomach and colorectal cancer showed an accelerated increase after 2007.

CONCLUSIONS

Almost all cancers (particularly lung and gastrointestinal) showed constantly raising trends, especially after 2007. Only cervical and laryngeal cancer had a decreasing trend. Most cancers were predominant in males.

Utilization of health services for skin disorders during military operations. A population- based study

In addition to the immediate casualties of armed conflicts, their indirect impact may bring even more damage by causing malfunctioning of health systems and impaired access to diagnosis and treatment. We conducted a population-based study, to assess the utilization rates of health services due to skin disorders, among civilians exposed to missile attacks and siren alarms during three military operations in Israel. The study was designed as a natural experiment, whereas periods of military operations were compared to the non-military times. During the military operations, when sirens and missiles were an everyday experience, the number of visits to dermatologists was 1.07-1.16 times lower [Relative Risk (RR)=0.86-0.92] as compared to the non-military periods, especially evident for patients residing closer to the military zone, where it dropped almost 2- folds (RR=0.52). Although perceived nonurgent in their majority, the routine care should not be delayed to prevent more serious skin conditions.

Invasive Saprochaete capitata Infection in a Patient with Autosomal Recessive CARD9 Deficiency and a Review of the Literature

PURPOSE

Autosomal recessive (AR) CARD9 deficiency is an inherited immune disorder which results in impaired innate immunity against various fungi. Superficial and invasive fungal infections, mainly caused by Candida or Trichophyton species, are the hallmark of CARD9 deficiency. Together with the increasing number of CARD9-deficient patients reported, different pathogenic fungal species have been described such as Phialophora, Exophiala, Corynespora, Aureobasidium, and Ochroconis. Saprochaete capitata is an opportunistic infectious agent in immunocompromised patients and is a common cause of invasive fungal disease in patients with hematological malignancies. In this study, we investigated the causative genetic defect in a patient with S. capitata fungal infection which disseminated to lymph nodes and common bile duct.

METHODS

The identification of the isolated yeast strain was made by direct microscopic examination and confirmed by internal transcribed spacer (ITS) sequencing. We applied whole exome sequencing to search for the disease-causing mutation. Sanger sequencing was used to validate the mutation in the patient and his parents.

RESULTS

S. capitata was isolated from the biopsy specimen as the causative microorganism responsible for the invasive fungal disease in the patient. Whole exome sequencing revealed a homozygous c.883C > T, (p.Q295*) mutation in CARD9, confirmed by Sanger sequencing.

CONCLUSIONS

This is the first report of invasive Saprochaete infection associated with autosomal recessive (AR) CARD9 deficiency in the literature and thereby further extends the spectrum of fungal diseases seen in these patients.

Adverse childhood experiences and their relationship to gender and depression among young adults in Iraq: a cross-sectional study

Background

Adverse childhood experiences (ACEs) are considered as universal public health problem that associate with mental disorders and risky behaviors during adulthood. The aims of the paper are to estimate the prevalence of Adverse childhood experiences (ACEs) among young adults in Iraq as well as to estimate the association between ACEs and depression.

Methods

A convenience sample of young adults of 18–20 years was chosen from centre and west of Iraq, mainly from universities. The adverse childhood experiences were measured by Adverse Childhood Experiences Questionnaire. A depression scale was derived from the Depression, Anxiety and Stress Scales (DASS). Statistical tests: chi square was used to measure the association between adverse childhood experiences and other variables like gender and depression. Odds ratios were computed to estimate the risk for depression. A P value of less than 0.05 was considered statistically significant.

Results

The total number of participants was 401, 38.9% of the subjects were men, while 61.1% were women. The mean age of the participants was 18.88 ± 0.745. The results revealed that the most common forms of ACEs among the subjects were physical neglect (19.8%) and emotional neglect (19.2%) followed by physical abuse (17.21%) while sexual abuse was 7.52%.

There was statistically significant association between most forms of adverse childhood experiences especially emotional abuse, emotional neglect, physical abuse and physical neglect with depression.

Conclusion

ACEs are not uncommon among young adults in Iraq and are associated with depression in adulthood. National programmes to support mental health rehabilitation might be necessary to reduce the effect of ACEs among Iraqi people, especially for adolescents and young adults.