Armed conflict and public health: into the 21st century

Nearby armed conflict affects girls' education in Africa

Female education is a crucial input to women's agency and empowerment, and has wide-ranging impacts, from improved labor market outcomes to reducing child mortality. Existing gender-specific evidence on the effect of armed conflict on education is conflict-specific and mixed. We link granular data on conflict events to georeferenced survey data on educational attainment from 28 countries in Africa, and use a regression-based approach to estimate the local effect of conflict exposure on female years of schooling. We find that conflict events occurring within 25 kilometers during a female child's primary school years reduces years of schooling by 0.4 years by adolescence. We do not find the same effect for males. Exposure to only low intensity conflict events with at most two casualties has persistent negative and significant effects. Consecutive years of conflict, however, can have positive effects in later years, which offset earlier negative effects, suggesting a habituation to violence. In the past two decades, we estimate excess child mortality in Africa associated with the indirect channel of women's education to be similar in magnitude to the number of direct child casualties due to conflict.

The impact of war on ACS admissions and triage - a single center experience

Introduction

Contemporary data regarding the impact of war on cardiovascular disease is scarce. The Israel-Gaza war that erupted on October 7th, 2023, provided a tragic opportunity to explore the effect of war on the epidemiology, characteristics, and management of patients with acute coronary syndrome (ACS) living in areas of active armed conflict.

Methods

All patients admitted with ACS to our medical center, between October 7th, 2023, and January 6th, 2024, were retrospectively included. Crucial time intervals in the management of individuals with ACS were collected in a predetermined spreadsheet. In-hospital and 30-day outcomes were obtained from the medical records and contrasted with ACS cases admitted in the period preceding the war.

Results

A total of 449 individuals (102 females [22.7 %]) with a diagnosis of ACS were recruited, 358 patients (144 STEMI and 214 NSTEMI) were admitted during the 9 months before October 7th and 91 patients (42 STEMI and 49 NSTEMI) in the 3 months after October 7th. Compared to the control period, a significant reduction in ACS admissions per month was noted (38.91 vs. 28.79, p < 0.001) driven by fewer cases of both STEMI and NSTEMI (15.65 vs. 13.29, p = 0.011 and 23.26 vs. 15.5, p < 0.001, respectively). In patients with STEMI, the total ischemic time was similar before and after the war (179 min vs. 187 min, p = 0.849).

Conclusions

War has a dramatic impact on cardiovascular incidence and outcomes which, however, are not necessarily linked to higher admission rates. Nevertheless, with the adoption of systematic approach and increased awareness, patients with ACS can be managed effectively even at times of extremely limited resources such as war.

Coping, meaning in life, and quality of life during ongoing conflict: insights from Israeli populations

BACKGROUND

Conducted in May 2024, this study examines the well-being of Israeli evacuees and non-evacuees from conflict zones. We assess health-related quality of life (HRQoL), meaning in life (MIL), coping strategies, psychological symptoms, and self-mastery. Aims include exploring effects of trauma and socio-demographics on HRQoL and MIL, analyzing mediating roles of psychological symptoms and coping, and evaluating if evacuation status moderates these relationships during ongoing conflict.

METHODS

In May 2024, seven months post-October 7th attacks, we conducted a cross-sectional study with 366 participants (221 evacuated, 145 non-evacuated) via a survey company. We assessed HRQoL (SF-12), MIL (MLQ), psychological symptoms (PHQ-4), self-related and other-related coping strategies (Brief COPE), and self-mastery (Self-Mastery Scale) through self-reported measures. Path and moderated mediation analyses evaluated relationships among socio-demographics, psychological symptoms, coping variables, HRQoL, and MIL.

RESULTS

Except for self-mastery, northern and southern evacuees showed no significant differences and were combined into one group. Path analysis revealed significant associations between traumatic life events, HRQoL, and MIL. Traumatic events were negatively associated with the physical component summary (PCS) of HRQoL and positively with anxiety, depression, and coping (self and others- problem-solving). Depression negatively related to PCS, mental component summary (MCS), and MIL, while coping (self and others) was positively associated with MIL. Moderated mediation analysis showed evacuated participants had higher dysfunctional coping, whereas non-evacuated participants demonstrated a stronger positive relationship between anxiety and the search for meaning.

CONCLUSION

Despite regional differences, evacuees exhibited similar psychological responses, likely due to the shared experience of displacement. Traumatic events negatively impacted their HRQoL and MIL. Adaptive coping strategies-self-related and problem-focused coping through helping others-played significant roles in mitigating these effects. The theoretical frameworks of Conservation of Resources (COR) theory, Taylor's "tend and befriend" model, and Frankl's existential framework provided a basis for explaining these findings.

Occupational Balance and Meaning Mediate Higher Education Students' Mental Health During War: A Structural Equation Modeling Analysis

IMPORTANCE

Exposure to trauma and extensive changes in daily life circumstances and occupations as a result of an ongoing armed conflict can significantly affect mental health.

OBJECTIVE

To examine factors related to the mental health status of Israeli students during the Swords of Iron war.

DESIGN

A cross-sectional study.

SETTING

Online survey.

PARTICIPANTS

Students in higher education institutions across Israel (N = 863).

OUTCOMES AND MEASURES

Self-report validated questionnaires were used to assess students' mental health status, resilience, satisfaction with life, executive functions, environmental factors, and occupations.

RESULTS

Moderate levels of depression (Mdn = 18, interquartile range [IQR] = 10-28), anxiety (Mdn = 10, IQR = 4-20), and stress (Mdn = 24, IQR = 14-34) were found for 50% of participants, along with extensive changes in daily life occupations, occupational balance, and meaning. Using structured equation modeling, χ2(15) = 15.969, p = .384, the authors found that satisfaction with life, psychological resilience, religious status, executive functions, occupational balance, and variability in occupational change were directly associated with mental health status, whereas occupational balance and occupational change mediated these connections.

CONCLUSIONS AND RELEVANCE

The modifiable factors related to reduced mental health after exposure to traumatic threat included change in occupational patterns, occupational balance, and sense of belonging, which may all serve as goals for occupation-based interventions and contribute to better coping mechanisms with traumatic events. This study used a cross-sectional design and an online survey with self-reported data, which may limit the generalizability of the findings. Plain-Language Summary: Higher education students in Israel were exposed to traumatic events and changes in daily life because of war. This study aimed to understand their mental health, resilience, executive functions, environments, and changes in their occupational patterns and the complex interplay between these factors. An online survey showed a notable decline in the students' mental health status, with around 50% experiencing at least moderate levels of depression, anxiety, and stress. Changes in occupations, occupational meaning, and balance were also common. The study found that satisfaction with life, mental resilience, occupational balance, religious status, executive functions, and variability in occupational change all contributed directly to the students' mental health status. The findings suggest that modifiable factors such as occupational balance and belongingness could be addressed through interventions to enhance mental health and coping mechanisms of students facing trauma and stressful life events.

War Anxiety: A Review

PURPOSE OF REVIEW

This review critically evaluates literature on war-induced anxiety, highlighting findings from 2021 to 2024, especially during the Russia-Ukraine war.

RECENT FINDINGS

Measures and prevalence estimates of anxiety and fear are updated. Populations affected by armed conflicts include residents of conflict zones and neighboring countries, internally displaced persons, refugees, combatants, and healthcare and humanitarian aid workers. Socioeconomic factors predict anxiety incidence and individuals differ in coping strategies. Anxiety could have long-term adverse effects over the life-course and across generations. Community and online interventions may reduce anxiety. The review underscores research directions in war-related anxiety's definition and assessment, risk and protective factors, health and societal consequences, and prevention and treatment approaches. The review provides an update for mental health researchers and practitioners working with the victims of war and other crises, often compounded by additional layers of stress of social inequalities, political divisions, and ethnic and racial tensions.

Decision-making for childhood vaccination in crisis settings: a survey of practice & barriers

BACKGROUND

Children, particularly those who have received no routine vaccinations (zero-dose children), are at high risk of vaccine-preventable diseases in humanitarian crisis settings. However, the decision-making processes underlying vaccine intervention design and delivery in such settings are poorly understood. The present study investigated the decision-making practices of organisations involved in childhood vaccination in humanitarian crisis settings globally via an online survey.

METHODS

Individuals involved in the design or delivery of childhood vaccination programmes in humanitarian crisis settings were invited to fill out a self-administered online survey. Respondents were asked about factors influencing intervention design and vaccine delivery; use of technical guidance, specifically the WHO decision-making framework for vaccination in acute humanitarian emergencies (WHO Framework); and practices for reaching zero-dose children.

RESULTS

Fourteen responses were received. Large international organisations and UN agencies were overrepresented in the sample. Technical guidance was considered of high importance when designing vaccine interventions. However, the WHO Framework is not available in relevant languages and has not been well-distributed to local and national actors. Awareness of initiatives to reach zero-dose children was high within our sample, though this may not accurately reflect global awareness. Security and resource availability were key barriers to vaccine delivery and reaching zero-dose children. Problems with vaccine access in our sample pertained primarily to issues with the procurement system rather than vaccine cost.

CONCLUSIONS

The WHO Framework should be provided in more languages, and vaccination actors at local and national level should be engaged to improve its practicality and increase awareness of its aims. In order to reach zero-dose children, vaccines must be made available for use in expanded age groups, which is sometimes not currently feasible within the Gavi/UNICEF procurement system. Clarifying this policy would allow relevant organisations to reach more zero-dose children. Additionally, security is a key barrier impeding vaccine delivery, including for zero-dose children. Safe operational space for humanitarian actors in conflict must be maintained and global conflict resolution mechanisms improved.

A narrative review on emerging issues about war-related trauma in perinatal women: good practice for assessment, prevention, and treatment

BACKGROUND

Wars, in addition to causing death and destruction, have a negative impact on mental health, especially on perinatal women. The literature has identified psychological trauma as one of the most prevalent mental health issues associated with wars, but few studies have summarized how to assess, prevent, or treat this problem in perinatal women. To address this gap, the purpose of this study is to provide a narrative review of the current state of assessment, prevention, and treatment interventions of trauma among perinatal women living in war conditions or displaced as a result of a war.

METHOD

A literature search was performed in different research databases (e.g., Medline, PsycInfo). The search terms include a combination of trauma and stressor-related disorders and focused on diagnosis, prevention, and treatment.

RESULTS

Most of the results were related to post traumatic stress disorder (PTSD) more than acute stress disorder, although there are not many assessments, and interventions (prevention or treatment) dedicated specifically to perinatal women affected by war conditions.

CONCLUSION

Research in this area is still scarce. Recommendations for evidence-based practices in assessment and prevention and treatment interventions and future directions in research and clinical practice are provided.

HIGHLIGHTS

• The literature on trauma in perinatal women is sparse, and especially among perinatal women living in conditions of war. • This paper presents a narrative review of evidence-based assessment and treatment for perinatal women victims of war who experience trauma.

The association of delivery during a war with the risk for postpartum depression, anxiety and impaired maternal-infant bonding, a prospective cohort study

OBJECTIVE

To examine the impact of war conditions on maternal mental health postpartum outcomes, specifically depression and anxiety, as well as on maternal-infant bonding (MIB).

STUDY DESIGN

A prospective cohort study was performed on women who gave birth in a tertiary medical center during (October-November 2023) and before (March-May 2020) the Israel-Hamas War. All participants completed validated self-reported questionnaires: The Edinburgh Postnatal Depression Scale (EPDS ≥ 10), State-Trait Anxiety Inventory (STAI > 39) and the Postpartum Bonding Questionnaire (PBQ ≥ 26).

RESULTS

A total of 502 women were included in the study, with 230 delivering during the war and 272 delivered before. The rates of postpartum depression (PPD) were higher in women delivering during the war (26.6% vs. 12.4%, p < 0.001), while multivariable regression revealing a two-fold higher risk (adjusted OR 2.35, 95% CI 1.16-4.74, p = 0.017). The rate of postpartum anxiety (PPA) risk was also higher (34.3% vs 17.0%, p < 0.001), reaching a trend towards significance when accounting for other risk factors (adjusted OR 2.06, 95% CI 0.97-4.36, p = 0.058). Additionally, delivery during the war was associated with specific factors of impaired maternal-infant bonding (MIB), although it did not increase the overall impaired MIB (PBQ ≥ 26) (10.2 ± 14.1 vs 8.3 ± 6.9, p = 0.075).

CONCLUSION

The study revealed an increased risk of PPD, a marginally risk for PPA, and some aspects of impaired MIB among women delivering during the war. Maternal mental illness in the postpartum period has negative impacts on the entire family. Therefore, comprehensive screening and adequate resources should be provided for women delivering in war-conflict zones.

Fecal carriage of extended-spectrum β-lactamase-producing, and carbapenem-resistant gram-negative bacteria among hemodialysis patients in a palestinian tertiary care hospital

The study explores the presence of extended-spectrum β-lactamase-producing Gram-negative bacteria (ESBL-GNB) and carbapenem-resistant Gram-negative bacteria (CR-GNB) in the stool of hemodialysis patients, reflecting a significant concern amid rising antibiotic resistance. This cross-sectional study included 137 outpatients conducted from October to December 2023 at An-Najah National University Hospital. Samples were incubated on appropriate MacConkey-based agar for bacterial analysis, and potential risk factors were evaluated using logistic regression. Out of 137 stool samples, 116 (84.7%) were positive for ESBL-producing bacteria, and 8 (5.8%) for carbapenem-resistant bacteria. Age of the patients (aOR: 1.068; p: 0.012), hypertension (aOR: 15.582; p: 0.0107), ischemic heart disease (aOR: 5.381; p: 0.040), the timing of the dialysis shift (aOR: 8.864; p: 0,005), and the level of blood urea nitrogen (aOR: 1.049; p: 0.045) were independently associated with ESBL-GNB colonization. Carbapenem-resistant bacteria colonization presented an inverse association with ischemic heart disease (aOR: 0.052; p: 0.041). This study highlights a significant prevalence of ESBL-GNB colonization linked with age and comorbidities such as hypertension. An inverse association of CR-GNB colonization with ischemic heart disease was observed, suggesting a complex interplay between patient health status and antibiotic-resistant bacterial colonization.

Provision of supportive care by an NGO in the face of a dual challenge: cancer and wartime

PURPOSE

In this study, we explored the work of Halasartan (Stop Cancer), an Israeli nongovernmental organization (NGO) and unique social support network for cancer patients and survivors aged 18-44, during a war period. Drawing on the conservation of resources (COR) theory, we examined whether self-efficacy, social support, psychological distress, and participation in activities that were geared toward alleviating the war situation at Time 1 (T1) would predict engagement in such activities at Time 2 (T2).

METHODS

A longitudinal design with two time-points was used, and NGO members completed self-report questionnaires. At T1, the cohort comprised 250 members (cancer patients/ survivors); at T2, there were 213. However, only 90 NGO members completed the questionnaires at both time-points.

RESULTS

A significant reduction in psychological distress was observed over time among participants engaged in the NGO's activities, but no differences were observed in participants' self-efficacy or social support. Moreover, participation in NGO activities during wartime at T2 was predicted by biological sex (female), lower self-efficacy, and participation in NGO activities at T1.

CONCLUSION

Halasartan (Stop Cancer) played a pivotal role in offering a sense of normalcy, community, and support to young-adult cancer patients and survivors during a period of war. The study underscores the essential nature of NGO activities tailored to the unique needs of this demographic, particularly in times of crisis. A broader implementation of such supportive interventions to enhance the well-being of vulnerable populations is suggested.

Kidnapping-Induced Trauma and secondary stress in armed conflicts: a comparative study among women in hostage families, volunteers, and the General Population

BACKGROUND

Exposure to armed conflict negatively impacts health. However, there is limited data on secondary stress from ambiguous loss contexts, such as kidnapping. In this study we aimed to quantify changes in modifiable health behaviors and well-being among women in hostage families and hostage crisis volunteers versus the general female population within the first two months of the 2023 Israel-Hamas war.

METHODS

A cross-sectional online survey was conducted on 318 Hebrew-speaking women aged 18-75 in Israel comparing: (1) a general population sample (n = 245); (2) hostage crisis volunteers (n = 40); and (3) hostage family members (n = 33). Participants provided demographic information, details on chronic illnesses, and responded to Likert-scale questions covering self-rated health, mental health, and lifestyle habits before the conflict and in current state.

RESULTS

Hostage family members reported the most severe health impacts, followed by volunteers. Fair/poor physical health status increased significantly in all groups during the war, with hostages' families reporting the highest rate (61.6%). Mental health deterioration was more pronounced among hostages' families, with 84% expressing a need for mental health support. Hostages' families also reported the highest rates of sleep problems, reduced adherence to a healthy lifestyle, and weight loss. Mental and physical health declined significantly across the exposed groups, as measured by multiple assessments, with hostage families experienced the most pronounced impairments across various domains of well-being.

CONCLUSIONS

This period of conflict severely harmed the well-being of all women in the study population. Women from all three groups - hostage families, volunteers, and those from the general population - experienced health deterioration due to varying levels of stress and exposure to conflict-related factors. Hostage families faced the greatest impact with nearly all members of this group showing significant health damage. Long-term support is needed to help restore post-conflict health for all affected women. Further research may be needed to determine the most effective interventions for addressing these impacts across the different groups.

Insights and inspirations: A qualitative exploration of community health workers' motivations in Myanmar and Bangladesh

Community Health Workers (CHWs) play significant roles in various settings, with their motivations and retention strategies widely studied. Yet, literature is sparse on CHWs from Myanmar, who are key to primary health care in marginalized and conflict-affected areas. This study explores the unique challenges these CHWs face, using firsthand accounts. Life story interviews, enhanced with a lifeline tool, were conducted with 34 CHWs from conflict-affected regions in Myanmar and in Rohingya camps in Bangladesh. Additionally, eight key informant interviews were held with leaders from organizations that work with CHWs. Data analysis was facilitated by NVivo 14 software and four layers of influence adapted from Urie Bronfenbrenner's ecological systems theory of human development. The findings reveal that, CHWs primarily joined organizations to acquire skills and knowledge. In Bangladesh, the focus was on job-related skills, whereas in Myanmar, healthcare skills were prioritized. Despite remuneration being inadequate, it remained crucial for retention, as did the sense of being valued by the community in Myanmar. Mental health support emerged as a potential need for CHWs. Funding deficits and fragmented support presented organizational challenges, thereby impacting both program implementation and retention of CHWs. To address these challenges, effective, sustainable CHW programs in conflict-affected regions require a shift towards long-term support for organizations and health systems. This includes focusing on CHWs' mental health and stakeholder engagement. Short-term, fragmented solutions may revert to pre-existing situations once removed. Sustainability planning is key to break the CHW turnover cycle and maximize investments in these contexts.

Developing the Scale of the Social Health Impact of War

Background/Aim: This study was conducted to develop the "Scale of the Effects of War on Social Health" to better understand the effects that news of have on individuals. Method: 389 adult individuals participated in the study. The scale was developed using exploratory and confirmatory factor analyses to test its structural validity.Results: As a result of exploratory and confirmatory factor analyses, the scale was found to consist of four dimensions: "worry and despair", "concentration", "shame and guilt" and "anger and control". The scale consists of a total of 16 statements. The calculated CR and AVE values show that the scale has a reliable structure. Conclusion: This study, conducted to determine the effect of war news on the social health of individuals, provides a scientific tool to identify and measure the potential effects of the frames reflected in mass media news during wartime on the social health status of individuals. The scale developed can contribute to a more comprehensive understanding of the effects of war news on the people who are not directly involved in the war but listen or read the news.

The Prevalence and Correlates of Anxiety, Stress, Mood Disorders, and Sleep Disturbances in Poland after the Outbreak of the Russian-Ukrainian War 2022

BACKGROUND

The conflict of the Russian-Ukrainian War that began on 24 February 2022 has profoundly changed Europe. The primary objective of this study was to assess the prevalence of anxiety, stress, depression, and insomnia among a group of surveyed Poles in the first months after the outbreak of war in 2022. The secondary goal was to analyze potential risk factors for these mental disorders.

METHODS

A cross-sectional survey-based study was conducted. An anonymous questionnaire was created using Google Forms and distributed through social media from March 2022 to June 2022. The questionnaire included the Depression, Anxiety and Stress Scale (DASS-21) and an evaluation of the Insomnia Severity Index (ISI).

RESULTS

Overall, 11.26% of 311 participants had depression, 10.29% had anxiety, and 24.12% experienced stress. Further, 62.05% of them declared sleep disturbances, and about 60% of them reported experiencing fears associated with the war. The outcomes of the assessment of psychiatric symptoms (depression, anxiety, stress and sleep disturbance) were associated with following factors: self-reported health status, fear of Russian invasion of Ukraine, and fear of the war extending to Poland. When the results for psychiatric symptoms were categorized into two groups, severe and non-severe, logistic regression analysis was only feasible for the insomnia variable. For this variable, multivariate logistic regression identified key potential factors: age, stress, and fear of Russian invasion of Ukraine.

CONCLUSIONS

The respondents were found to be highly concerned about the war. In total, almost half of them manifested symptoms of anxiety, depression, and/or stress. Slightly less than two-thirds had sleep disorders. This study confirms that in a crisis situation, mental health screening is necessary.

Temporal trends in lower extremity amputation in Middle East and North Africa (MENA) region: analysis of the GBD dataset 1990-2019

BACKGROUND

Lower extremity amputations (LEAs) significantly contribute to mortality and morbidity, often resulting from peripheral artery disease and diabetes mellitus (DM). Traumatic injuries also account for many LEAs. Despite the global burden, the epidemiology of LEAs, particularly in the Middle East and North Africa (MENA) region, remains underexplored. This study utilizes the Global Burden of Disease (GBD) dataset to analyze temporal trends in LEAs in the MENA region from 1990 to 2019.

METHODS

The study utilized the 2019 GBD dataset, which includes estimates for incidence, prevalence, and disability-adjusted life-years (DALYs) across 369 diseases. Age-standardized incidence rates (ASIRs) for LEAs were extracted for 21 MENA countries. Trends were analyzed using percentage change calculations and Joinpoint regression to identify significant shifts in LEA rates over time.

RESULTS

From 1990 to 2019, male LEA rates generally decreased, while female rates increased. Significant increases in LEA rates were observed in Syria, Yemen, and Afghanistan, correlating with periods of conflict and instability. Conversely, countries like Iraq, Palestine, Sudan, Lebanon, Iran, and Kuwait saw marked decreases. The study highlighted a complex interplay of socio-political factors, natural disasters, and chronic diseases like DM in shaping LEA trends across the region.

CONCLUSION

The study reveals variable LEA trends in the MENA region, influenced by conflicts, natural disasters, and chronic diseases. These findings underscore the need for targeted public health interventions, improved healthcare access, and robust data collection systems to reduce the burden of LEAs and improve patient outcomes in the MENA region.

Khartoum War's echoes in oil and energy sectors: Economic and environmental implications for Sudan and South Sudan

The energy sector is a main driver of African growth, particularly in regions with geopolitical conflicts like Sudan and South Sudan. The oil and gas industry notably influences these regions' economy, politics, humanitarian situation, and social stability. This study seeks to investigate how the Khartoum War affected the energy sector of both Sudan and South Sudan, particularly looking at the disruptions caused by recent conflicts and their impact on oil production, economic stability, and environmental conditions. The study employs a multi-disciplinary approach, utilising different sources such as regional legal agreements, government reports, academic articles, and press releases from international organisations. The key methodology includes qualitative analysis of several documents and quantitative assessment of production data and economic reports. The study's key findings show a significant decline in oil production and transportation due to the shutdown of key oilfields and pipelines, intensifying economic and humanitarian crises. Additionally, the damage to oil infrastructure has presented serious environmental risks, highlighting the delicate balance between resource management and regional stability. In conclusion, the study's findings underscore the intense impact of the Khartoum War on the energy sector of Sudan and South Sudan, and the urgent need for policy recommendations to mitigate these effects and foster sustainable development.

Exploring the Self-Reported Physical and Psychological Effects in a Population Exposed to a Regional Conflict

BACKGROUND

Conflict profoundly impacts community health and well-being. While post-conflict research exists, little is known about initial effects during active hostilities.

OBJECTIVE

To assess self-reported changes in health behaviors, distress, and care access within one month of regional warfare onset in a conflict-affected community.

METHODS

An online survey was conducted in November 2023 among 501 residents (mean age 40.5 years) of a community where war began October 7th. Measures evaluated physical health, mental health, diet, substance use, sleep, weight changes, and healthcare access before and after the declaration of war.

RESULTS

Relative to pre-war, respondents reported significantly increased rates of tobacco (56%) and alcohol (15%) consumption, worsening sleep quality (63%), elevated distress (18% sought help; 14% needed but didn't receive it), and postponed medical care (36%). Over a third reported weight changes. Distress was higher among females and those endorsing maladaptive coping.

CONCLUSION

Within one month, substantial impacts on community psychosocial and behavioral health emerged. Unmet mental health needs and risk-taking behaviors were early indicators of conflict's health consequences. Continuous monitoring of conflict-affected communities is needed to inform tailored interventions promoting resilience and prevent entrenchment of harms over time.

Humanitarian health education and training state-of-the-art: a scoping review

Introduction

In the past decade, humanitarian emergencies have been increasing, leading to an higher demand for humanitarian health professionalization. Education and training are critical for preparing these workers to provide effective care during crises. Understanding the current state-of-the-art in humanitarian health education is essential to inform research and development of future educational programs. This review surveys the peer-reviewed literature to provide insights into the current thinking in the field.

Methods

A review was conducted in March 2023 and updated in May 2024 using PubMed, Web of Science, Scopus, and Education Resources Information Center databases for English-language peer-reviewed articles published since January 2013. The review followed the Joanna Briggs Institute methodology for scoping reviews and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Data were analyzed using qualitative content analysis and presented as a narrative descriptive summary.

Results

After screening, 32 articles met the inclusion criteria. The themes of the selected articles focus on education and training frameworks, mapping, and programs. Despite the growing opportunities, most education and training programs are based in the Global North. The gaps identified include a lack of standardized curriculum or competency frameworks and evaluation frameworks to guide the development and evaluation of further standardized training programs. Interdisciplinary and collaborative partnerships, iterative design, and mixed teaching methods and modalities, including e-learning, facilitated successful training. However, logistical and technical constraints and the lack of standardized training frameworks were barriers to developing, implementing, and evaluating such training programs.

Conclusion

This review provides an overview of the humanitarian health education trends over the last decade and identifies key areas for future educational development and research. The findings emphasize the importance of adapting interdisciplinary and collaborative partnerships and prioritizing the training of local staff through regional centers, local leadership, and accessible e-learning, including e-simulation. The review also highlights the need for continued research and evaluation of humanitarian health education and training programs with standardized metrics to evaluate training programs and identify areas for improvement. These steps will help ensure that humanitarian health professionals receive adequate training to provide effective healthcare in crisis situations.

Treating wartime injuries amidst attack: insights from a medical facility on the edge of combat

BACKGROUND

Providing emergency care during conflict poses unique challenges for frontline hospitals. Barzilai Medical Center (BUMCA) in Ashkelon, Israel is a Level I trauma center located close to the Gaza border. During the November 2023 escalation of conflict, BUMCA experienced surging numbers of civilian and military trauma patients while also coming under rocket fire.

METHODS

We conducted a retrospective review of BUMCA operational records and 827 de-identified patient records from October 7-14, 2023. Records provided data on daily patient volumes, injury patterns, resource constraints, and impacts of rocket attacks on hospital function. Basic demographic data was obtained including age, gender, injury severity scores, and disposition.

RESULTS

Of the 827 patients brought to BUMCA, most (n = 812, 98.2%) presented through the emergency department. Tragically, 99 individuals were pronounced dead on arrival. Injury severity assessments found nearly half (47%) had minor injuries such as lacerations, contusions and sprains, while 25% exhibited moderate injuries like deep lacerations and fractures. 15% sustained severe or critical injuries including severe head injuries. The largest age group consisted of adults aged 19-60 years. No pediatric patients were admitted despite proximity to residential neighborhoods. The majority of cases (61%) involved complex polytrauma affecting multiple body regions. BUMCA served as both the primary treatment facility and a triage hub, coordinating secondary transports to other trauma centers as needed. Patient volumes fluctuated unpredictably from 30 to an overwhelming 125 daily, straining emergency services. Resources faced shortages of beds, medical staff, supplies and disruptions to power from nearby missile impacts further challenging care delivery.

CONCLUSION

Despite facing surging demand, unpredictable conditions and external threats, BUMCA demonstrated resilience in maintaining emergency trauma services through an adaptive triage approach and rapid surges in capacity. Their experience provides insights for improving frontline hospital preparedness and continuity of care during conflict through advance contingency planning and surge protocols. Analysis of patient outcomes found a mortality rate of 15% given the complex, multi-region injuries sustained by many patients. This study highlights the challenges faced and strengths exhibited by medical professionals operating under hazardous conditions in minimizing loss of life.

PATIENT AND PUBLIC INVOLVEMENT IN RESEARCH

Given that the study analyzed patient data from a hospital treating casualties of an ongoing armed conflict, directly engaging patients or the public during the sensitive research process could have posed risks. The volatile security situation and restrictions and protections in place amidst the crisis made it not feasible or appropriate to involve them in the study's design, methods, reporting of results, or dissemination plans. Our aim was to conduct this retrospective analysis in a way that did not endanger those affected or compromise the hospital's emergency response operations.

Global health diplomacy in humanitarian action

This commentary explores the intersection of Global Health Diplomacy (GHD) and humanitarian action within Fragility, Conflict, and Violence (FCV) contexts. It aims at addressing the multifaceted challenges faced by communities living in these environments, where a convergence of multiple factors, including over 110 active armed conflicts, creates complex emergencies impact on large populations globally. This commentary holds three primary significances: 1)  it scrutinizes the profound and enduring health consequences of major humanitarian crises on last-mile populations, highlighting the pivotal role of health diplomacy for better navigating humanitarian challenges; 2) it advocates for a paradigm shift in humanitarian approaches, recognizing GHD's potential in shaping international cooperation, building consensus on inclusive global health policies, and enabling more effective interventions; 3) it underscores the operational impact of health diplomacy, both at diplomatic tables and on the frontlines of humanitarian efforts. Through real-world cases such as the cholera outbreak in Yemen and the response to Ebola outbreaks in DRC, the paper illustrates how diplomatic dialogue can impact health outcomes in fragile settings.

Learning from history of natural disasters in the Sahel: a comprehensive analysis and lessons for future resilience

One of the first environmental crises to attract interest in development initiatives and aid was the great drought of the 1970s in the Sahel. This study investigates the extent of damage caused by natural disasters from one of the most widely used databases-EM-DAT-with a sample size of 16 Sahelian countries over the period 1960-2020. These countries have been divided into three regions: Western Africa Sahel (WAS), Central Africa Sahel (CAS), and Eastern Africa Sahel (EAS). The analyses encompass four categories of natural hazards, namely, biological, climatological, hydrological, and meteorological. We used descriptive and test statistics to summarize the natural disaster records. Through this approach, we explore tendencies to identify the most frequently reported natural hazards; we examine their spatial distribution and evaluate their impacts in terms of socioeconomic damage and causalities. During the study period, a total of 1000 events were recorded in the database. The Western Africa Sahel (WAS) region had the highest number of disasters, with 476 events, followed by the Eastern Africa Sahel (EAS) region with 369 events. The most common hazards in the Sahel were hydrological (41.8%), mainly floods, and biological (39.5%) hazards. Approximately 300 million people in the Sahel were affected by natural hazards, with 59.17% in EAS, 36.48% in WAS, and 4.35% in CAS. Although droughts occurred less frequently (14%), they had a significant impact on the population, affecting 84% of those affected by natural hazards. In general, EAS experiences a higher impact from natural hazards, potentially influenced by the pastoral lifestyle of its population. However, WAS is also very vulnerable to natural hazards especially epidemics and nowadays floods. The uncontrolled urbanization in the area may contribute to this vulnerability.

A mini-review on safeguarding global health amidst a "Pandemic" of armed conflicts

The year 2022 witnessed an alarming surge in state-based armed conflicts globally, reaching a staggering 56, with major hostilities in Ukraine, Myanmar, and Nigeria resulting in over 10,000 estimated conflict-related deaths. This trend continued with the onset of a significant conflict between Israel and Hamas in October 2023. The escalating frequency of armed conflicts, reaching the highest number since 1946, poses a critical threat to global health. This paper explores the multifaceted health impacts of armed conflicts, encompassing physical injuries, infectious diseases, malnutrition, and profound mental health consequences. Healthcare systems in conflict zones face severe strain, and achieving Sustainable Development Goals by 2030 becomes increasingly challenging. The surge in armed conflicts globally is characterized as a "pandemic," justifying urgent attention. The paper identifies and discusses strategies to safeguard public health in conflict zones, emphasizing humanitarian response, protecting healthcare workers and infrastructure, building preparedness and resilience, and promoting mental health support. In navigating this "pandemic" of armed conflicts, comprehensive strategies are imperative to address the intricate challenges and secure a healthier global future.

The urban political ecology of antimicrobial resistance: A critical lens on integrative governance

The objective of this paper is to integrate Urban Political Ecology (UPE) as a theory for identifying under-exposed urban dimensions of Antimicrobial Resistance (AMR). A UPE lens allows us to conceptualize urbanization as a ubiquitous socio-ecological process and an interpretive frame that could inform AMR governance strategies across related contexts by: a) situating AMR risks in relation to urbanization processes shaping social and political co-determinants of such systemic threats as climate change; b) aligning UPE scholarship with One Health (OH) approaches that address AMR to reveal the under-exposed link of AMR to environmental threats and broader structural dimensions that influence these threats; and c) identifying shared AMR and environmental governance pathways that inform the rationale for more equitable governance arrangements. We delineate a context in which the speed and scale of human activity in the larger context of urbanization, driven by global market integration strategies, impacts human-animal-environmental health threats such as AMR. We demonstrate how UPE scholarship can be leveraged to offer theoretical depth to approaches considering the interdependencies of AMR and climate change threats. We then propose a strategic approach focused on identifying shared governance pathways and intersectoral accountability frameworks to address upstream structural drivers of AM-Environmental threats. The co-benefits of a UPE-informed framework to human-animal-environmental health that leverages enabling policy environments to foster a more collaborative, equitable and sustainable approach to address systemic global health threats are clarified. Just as the concept of "health in all policies" emphasized taking health implications into account in all public policy development, the integration of UPE in AMR governance arrangements would emphasize the need to take other sectors into account through an intersectoral whole-of-government approach that fosters shared AMR - climate change governance pathways.

Women's experiences of trauma-informed care for forced migrants: A qualitative interview study

Introduction

Forced migration affect the health and wellbeing of millions of women. The aim was to explore experiences of trauma-informed care among women who are forced migrants.

Methods

This was an exploratory qualitative study. Eleven women who had concluded treatment at multidisciplinary trauma centers in Sweden were interviewed, recruited through consecutive sampling. Audio-recorded interviews were transcribed and analyzed with systematic text condensation.

Results

Women dealt with mental and physical manifestations in a challenging psychosocial situation. Various structural and individual barriers were addressed that hindered access to adequate health services. Women appreciated various benefits of the treatment and recalled the care as supportive and compassionate. However, undergoing treatment was considered demanding, requiring significant determination and energy. Participants suggested that peer support could enhance the support.

Conclusions

Migrant women experience a range of health-related burdens and encounter barriers to trauma-informed care. While demanding, treatment has the potential to alleviate symptoms. Health professionals and stakeholders providing trauma-informed care need to ensure that their services are accessible and culturally sensitive towards the unique needs of women. Peer support has the potential to enhance support further, which need further evaluation.

Impact of war-associated factors on spread of sexually transmitted infections: a systemic review

Introduction

Statistical data indicate a link between war and the spread of sexually transmitted infections (STIs), then it is necessary to carefully analyze the factors that directly affect the identified pattern in order to overcome this problem. Therefore, the purpose of the study was to systematically analyze the factors that influence the spread of STIs during war.

Methods

The study included all original research articles and meta-analyses on the impact of war on the spread of sexually transmitted infections that met the following eligibility criteria: (1) articles published exclusively in English; (2) articles published in the period 2013-2023; (3) studies with quantitative, qualitative or mixed design. The search for relevant literature was conducted using four databases: PubMed, Embase, Web of Science, and Ebsco.

Results

The articles selected for our systematic review had different research designs and were mainly published as original studies (n = 8) and literature reviews (n = 6). As a result of the evaluation of the selected articles for the systematic review, the authors identified migration, a decrease in access to health care, difficult access to contraception, sexual violence as the most frequent factors directly affecting the spread of STIs during the war.

Conclusion

This systematic review systematizes data on the impact of hostilities on the spread of STIs and outlines the main factors that contribute to the dissemination of pathogens far beyond the territory at the epicenter of the conflict.Systematic review registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023479808, CRD42023479808.

WHO's end of TB targets: unachievable by 2035 without addressing under nutrition, forced displacement, and homelessness: trend analysis from 2015 to 2022

Tuberculosis (TB) remains a significant global health challenge, despite the World Health Organization (WHO) actively working towards its eradication through various initiatives and programs. Undernutrition, forced displacement, and homelessness worsen TB's burden and challenge control efforts; however, there is still no adequate research that shows the trend of these underlying factors to attain the WHO's ambitious TB targets. So, this study aims to analyze the trend analysis of these underlying factors worldwide from 2015 to 2022 and their impact on the feasibility and implications of reaching the End TB targets by 2035. We utilized international databases, including UNHCR, FAO, and WHO reports, as secondary data sources. Data were extracted chronologically from 2015 to 2022 to illustrate trends in undernutrition, forced displacement, and homelessness on a global level.This trend analysis reveals that undernutrition, forced displacement, and homelessness have worsened over time. Undernutrition rose from 8.4 to 9.8% globally between 2015 and 2021, affecting 22.7 million additional individuals each year. In 2022, undernutrition affected 735 million people globally. Africa (21.9%) and Asia (10.6%) had the highest rates, while Western Europe and North America had lower rates than the global average: 3.4% and 2.5%, respectively.Similarly, the global rate of forced displacement increased from 65.1 million people in 2015 to 108.4 million in 2022, a 21% increase from 2021. This means that an extra 19 million people were displaced in 2021. Globally, homelessness, affecting 1.6 billion people, has worsened over time. Despite being a highly vulnerable group to TB, homeless individuals are often neglected in TB control efforts. Our findings underscore the critical importance of addressing undernutrition, forced displacement, and homelessness in achieving the World Health Organization's ambitious End TB targets by 2035, as highlighted through trend analysis from 2015 to 2022. Implementing policies focusing on nutrition, stable housing, and the challenges faced by displaced populations is imperative for progress toward a TB-free world.

Excess Child Mortality Associated With Colombia's Armed Conflict, 1998-2019

Importance

Armed conflicts are directly and indirectly associated with morbidity and mortality due to destruction of health infrastructure and diversion of resources, forced displacement, environmental damage, and erosion of social and economic security. Colombia's conflict began in the 1940s and has been uniquely long-lasting and geographically dynamic.

Objective

To estimate the proportion of infant and child mortality associated with armed conflict exposure from 1998 to 2019 in Colombia.

Design, Setting, and Participants

This ecological cohort study includes data from all 1122 municipalities in Colombia from 1998 to 2019. Statistical analysis was conducted from February 2022 to June 2023.

Exposure

Armed conflict exposure was measured dichotomously by the occurrence of conflict-related events in each municipality-year, enumerated and reported by the Colombian National Center for Historic Memory.

Main Outcomes and Measures

Deaths among children younger than 5 years and deaths among infants younger than 1 year, offset by the number of births in that municipality-year, enumerated by Colombia's national vital statistics.

Results

The analytical sample included 24 157 municipality-years and 223 101 conflict events covering the period from 1998 to 2019. Overall, the presence of armed conflict in a municipality was associated with a 52% increased risk of death for children younger than 5 years of age (relative risk, 1.52 [95% CI, 1.34-1.72]), with similar results for 1- and 5-year lagged analyses. Armed conflict was associated with a 61% increased risk in infant (aged <1 year) death (relative risk, 1.61 [95% CI, 1.43-1.82]). On the absolute scale, this translates to a risk difference of 3.7 excess child deaths per 1000 births (95% CI, 2.7-4.7 per 1000 births) and 3.0 excess infant deaths per 1000 births (95% CI, 2.3-3.6 per 1000 births) per year, beyond what would be expected in the absence of armed conflict. Across the 22-year study period, the population attributable risk was 31.7% (95% CI, 23.5%-39.1%) for child deaths and 35.3% (95% CI, 27.8%-42.0%) for infant deaths.

Conclusions and Relevance

This ecological cohort study of Colombia's spatiotemporally dynamic armed conflict suggests that municipal exposure to armed conflict was associated with excess child and infant deaths. With a record number of children living near active conflict zones in 2020, policy makers and health professionals should understand the magnitude of and manner in which armed conflicts directly and indirectly undermine child health.

Refugee women's and providers' perceptions of person-centered maternity care: a qualitative study in two refugee camps in Chad

BACKGROUND

Globally, mistreatment of women during labor and delivery is a common human rights violation. Person-centered maternity care (PCMC), a critical component of quality of care, is respectful and responsive to an individual's needs and preferences. Factors related to poor PCMC are often exacerbated in humanitarian settings.

METHODS

We conducted a qualitative study to understand Sudanese refugee women's experiences, including their perceptions of quality of care, during labor and delivery at the maternities in two refugee camps in eastern Chad, as well as maternity health workers' perceptions of PCMC and how they could be better supported to provide this. In-depth interviews were conducted individually with 22 women who delivered in the camp maternities and five trained midwives working in the two maternities; and in six dyads with a total of 11 Sudanese refugee traditional birth attendants and one assistant midwife. In addition, facility assessments were conducted at each maternity to determine their capacity to provide PCMC.

RESULTS

Overall, women reported positive experiences in the camp maternities during labor and delivery. Providers overwhelmingly defined respectful care as patient-centered and respect as being something fundamental to their role as health workers. While very few reported incidents of disrespect between providers and patients in the maternity, resource constraints, including overwork of the providers and overcrowding, resulted in some women feeling neglected.

CONCLUSIONS

Despite providers' commitment to offering person-centered care and women's generally positive experiences in this study, one of few that explored PCMC in a refugee camp, conflict and displacement exacerbates the conditions that contribute to mistreatment during labor and delivery. Good PCMC requires organizational emphasis and support, including adequate working conditions and ensuring suitable resources so health workers can effectively perform.

Neurological Practice in the Time of War: Perspectives and Experiences from Ukraine

The full-scale Russian invasion of Ukraine has significantly impacted the country's healthcare system. Insufficient infrastructure, destruction of medical facilities, and barriers to prevention and treatment efforts hinder the provision of timely, high-quality care to our patients. We aim to describe the impact of the war on neurological care across Ukraine. In this article, leading national experts in stroke, epilepsy, multiple sclerosis, and movement disorders describe their personal experience and efforts in organizing and providing care since the war started in February 2022. A neurologist who cared for patients in Mariupol recounts the first weeks of the war when the city was under constant attacks. An international stroke expert describes the role of Task Force for Ukraine, a European Stroke Organization initiative to support the Ukrainian stroke community. We discuss a series of critical challenges facing Ukraine's neurologists, patients, and healthcare delivery system, including shortages of personnel and medical supplies, disrupted logistics, and lack of funding. In addition, we highlight various interventions and strategies aimed at counteracting these challenges, including international support, collaborations within Ukraine, and initiatives enhancing the resilience of the Ukrainian neurology community. As the war is ongoing, this article emphasizes the pressing need for continuous support and investment in the Ukrainian healthcare system to preserve guaranteed access to high-quality healthcare for the Ukrainian people during the war and in its aftermath. Insights from the essays can inform the development and implementation of effective strategies and interventions tailored to such extraordinary circumstances.

Evaluating emergency response at a hospital near the Gaza border within 24 h of increased conflict

BACKGROUND

Frontline hospitals near active hostilities face unique challenges in delivering emergency care amid threats to infrastructure and personnel safety. Existing literature focuses on individual aspects like mass casualty protocols or medical neutrality, with limited analysis of operating acute services directly under fire.

OBJECTIVES

To describe the experience of a hospital situated meters from hostilities and analyze strategies implemented for triage, expanding surge capacity, and maintaining continuity of care during attacks with limited medical staff availability due to hazardous conditions. A focus will be placed on assessing how the hospital functioned and adapted care delivery models in the event of staffing limitations preventing all teams from arriving on site.

METHODS

A retrospective case study was conducted of patient records from Barzilai University Medical Center at Ashkelon (BUMCA) Medical Center in Israel within the first 24 h after escalated conflict began on October 7, 2023. Data on 232 admissions were analyzed regarding demographics, treatment protocols, time to disposition, and mortality. Missile alert data correlated patient surges to attacks. Statistical and geospatial analyses were performed.

RESULTS

Patients predominantly male soldiers exhibited blast/multisystem trauma. Patient surges at the hospital were found to be correlated with the detection of incoming missile attacks from Gaza within 60 min of launch. While 131 (56%) patients were discharged and 55 (24%) transferred within 24 h, probabilities of survival declined over time reflecting injury severity limitations. 31 deaths occurred from severe presentation.

CONCLUSION

Insights gleaned provide a compelling case study on managing mass casualties at the true frontlines. By disseminating BUMCA's trauma response experience, strategies can strengthen frontline hospital protocols optimizing emergency care delivery during hazardous armed conflicts through dynamic surge capacity expansion, early intervention prioritization, and infrastructure/personnel protection measures informed by risks.

Short-term high temperature may increase the incidence risk of collective conflicts: A case-crossover study in the Greater Middle East

BACKGROUND

Violent conflict is a formidable global challenge, with long-lasting impacts on individual health and society security. There has been compelling evidence that heat can increase aggression intention on the individual level. However, little is known about the short-term relationship between ambient temperature and collective violent conflicts, especially in less developed regions.

METHOD

We conducted a time-stratified case-crossover study combined with the distributed lag nonlinear model (DLNM) among 247,773 violent conflicts from 29 countries or regions in the Greater Middle East, between 1997 and 2021. Potential modification effects of economic status and climate conditions were explored by stratified analyses. Negative control and sensitivity analyses were also performed to test the robustness of our model.

RESULTS

We observed significant associations between higher temperature and the onset of five categories of violent conflicts. The effects generally occurred within the first several days after exposure. The incidence risks of battles, violence against civilians, explosions/remote violence, protests and riots were 1.60 [95 % confidence interval (CI): 1.31-1.95], 1.82 (95 % CI: 1.37-2.42), 1.24 (95 % CI: 1.08-1.41), 1.16 (95 % CI: 1.09-1.24) and 1.54 (95 % CI: 1.22-1.95) when comparing extreme high temperatures to minimum-risk temperatures. The associations were generally more prominent in areas with lower economic levels and associations in regions of the continental climate are also stronger.

CONCLUSIONS

Our finding reveals novel and concrete evidence that short-term high temperature could increase the risk of multiple forms of violent conflict in the Greater Middle East and provides new insights into the potential short-term mechanisms under the heat-collective violence association.

Assessment of factors leading to resilience among adults in violence-affected area of Kashmir: an exploratory study employing content analysis and best-worst method

Exposure to violence can have profound and lasting effects on individuals and communities, impacting various aspects of their lives. Understanding the relationship between exposure to violence and resilience is crucial for designing effective interventions and support systems. This study aims to identify resilience factors among adults living in such areas and rank them from most to least important. Two staged mixed-method approaches, including face-to-face interviews and the best-worst method, were used to identify factors, assign weights, and rank them. A total of twenty-three sub-factors classified under seven broader factors were identified and ranked by triangulating the opinions of victims, experts, and scholars. Out of twenty-three sub-factors, the top-ranked six factors included family support, trusting higher powers, peer support, better interpersonal relationships, engaging in regular prayers, and better role models, which contributes fifty two percent to resilience formation. By promoting these factors, individuals and communities can better cope with the stress and trauma of violence, promote positive adaptation and growth, and build social support networks to help promote recovery and healing. Implications for practice, policy, and future directions are discussed.

The Effect of War on STEMI Incidence: Insights from Intensive Cardiovascular Care Unit Admissions

(1) Background: The impact of armed conflicts on public health is undeniable, with psychological stress emerging as a significant risk factor for cardiovascular disease (CVD). Nevertheless, contemporary data regarding the influence of war on CVD, and especially on acute coronary syndrome (ACS), are scarce. Hence, the aim of the current study was to assess the repercussions of war on the admission and prognosis of patients admitted to a tertiary care center intensive cardiovascular care unit (ICCU). (2) Methods: All patients admitted to the ICCU during the first three months of the Israel-Hamas war (2023) were included and compared with all patients admitted during the same period in 2022. The primary outcome was in-hospital mortality. (3) Results: A total of 556 patients (184 females [33.1%]) with a median age of 70 (IQR 59-80) were included. Of them, 295 (53%) were admitted to the ICCU during the first three months of the war. Fewer Arab patients and more patients with ST-segment elevation myocardial infraction (STEMI) were admitted during the war period (21.8% vs. 13.2%, p < 0.001, and 31.9% vs. 24.1%, p = 0.04, respectively), whereas non-STEMI (NSTEMI) patients were admitted more frequently in the pre-war year (19.3% vs. 25.7%, p = 0.09). In-hospital mortality was similar in both groups (4.4% vs. 3.4%, p = 0.71; HR 1.42; 95% CI 0.6-3.32, p = 0.4). (4) Conclusions: During the first three months of the war, fewer Arab patients and more STEMI patients were admitted to the ICCU. Nevertheless, in-hospital mortality was similar in both groups.

Impact of Ebola and COVID-19 on maternal, neonatal, and child health care among populations affected by conflicts: a scoping review exploring demand and supply-side barriers and solutions

INTRODUCTION

Armed conflicts have a severe impact on the health of women and children. Global health emergencies such as pandemics and disease outbreaks further exacerbate the challenges faced by vulnerable populations in accessing maternal, neonatal, and child healthcare (MNCH). There is a lack of evidence that summarizes the challenges faced by conflict-affected pregnant women, mothers, and children in accessing MNCH services during global health emergencies, mainly the Ebola and COVID-19 pandemics. This scoping review aimed to analyze studies evaluating and addressing barriers to accessing comprehensive MNCH services during Ebola and COVID-19 emergencies in populations affected by conflict.

METHODS

The search was conducted on PubMed, Scopus, and Web of Science databases using terms related to Ebola and COVID-19, conflicts, and MNCH. Original studies published between 1990 and 2022 were retrieved. Articles addressing the challenges in accessing MNCH-related services during pandemics in conflict-affected settings were included. Thematic analysis was performed to categorize the findings and identify barriers and solutions.

RESULTS

Twenty-nine studies met the inclusion criteria. Challenges were identified in various MNCH domains, including antenatal care, intrapartum care, postnatal care, vaccination, family planning, and the management of childhood illnesses. Ebola-related supply-side challenges mainly concerned accessibility issues, health workforce constraints, and the adoption of stringent protocols. COVID-19 has resulted in barriers related to access to care, challenges pertaining to the health workforce, and new service adoption. On the demand-side, Ebola- and COVID-19-related risks and apprehensions were the leading barriers in accessing MNCH care. Community constraints on utilizing services during Ebola were caused by a lack of trust and awareness. Demand-side challenges of COVID-19 included fear of disease, language barriers, and communication difficulties. Strategies such as partnerships, strengthening of health systems, service innovation, and community-based initiatives have been employed to overcome these barriers.

CONCLUSION

Global health emergencies amplify the barriers to accessing MNCH services faced by conflict-affected populations. Cultural, linguistic, and supply-side factors are key challenges affecting various MNCH domains. Community-sensitive initiatives enhancing primary health care (PHC), mobile clinics, or outreach programs, and the integration of MNCH into PHC delivery should be implemented. Efforts should prioritize the well-being and empowerment of vulnerable populations. Addressing these barriers is crucial for achieving universal health coverage and the Sustainable Development Goals.

Gender-based violence in the context of armed conflict in Northern Ethiopia

BACKGROUND

Gender-based violence (GBV) particularly against women is unfortunately common during armed conflicts. No rigorous and comprehensive empirical work has documented the extent of GBV and its consequences that took place during the two years of devastating armed conflict in Northern Ethiopia. This study aims to assess GBV and its consequences in war-torn areas of northern Ethiopia.

METHODS

We used a qualitative method augmented by quantitative method to enroll research participants. We conducted in-depth interviews to characterize the lived experiences of GBV survivors. All interviews were conducted confidentially. The data were collected to the point of data saturation. All interviews were transcribed verbatim into local language, translated into English, and analyzed using a thematic analysis approach. We also used reports from healthcare facilities and conducted a descriptive analysis of the demographic characteristics of study participants.

RESULTS

One thousand one hundred seventy-seven persons reported GBV to healthcare providers. The qualitative study identified several forms of violence (sexual, physical, and psychological). Gang rape against women including minors as young as 14 years old girls was reported. Additionally, the perpetrators sexually violated women who were pregnant, and elderly women as old as 65 years, who took refuge in religious institutions. The perpetrators committed direct assaults on the body with items (e.g., burning the body with cigarette fire) or weapons, holding women and girls as captives, and deprivation of sleep and food. GBV survivors reported stigma, prejudice, suicide attempts, nightmares, and hopelessness. GBV survivors dealt with the traumatic stress by outmigration (leaving their residences), seeking care at healthcare facilities, self-isolation, being silent, dropping out of school, and seeking counseling.

CONCLUSION

GBV survivors were subjected to multiple and compounding types of violence, with a wide range of adverse health consequences for survivors and their families. GBV survivors require multifaceted interventions including psychological, health, and economic support to rehabilitate them to lead a productive life.

The role of university clinics in advancing higher medical education

OBJECTIVE

Aim: To explore the multifaceted role of university clinics in shaping medical professionals, advancing medical knowledge, and improving healthcare delivery. Special attention is given to their function as primary platforms for practical training, the development of professional competencies, and the implementation of innovative teaching methods in medical education..

PATIENTS AND METHODS

Materials and Methods: This article employs an analysis of the organizational structure, educational programs, and research initiatives of university clinics. Case studies, including the experience of the University Clinic of Taras Shevchenko National University of Kyiv, are utilized to provide insights into their operational challenges, successes, and future prospects.

CONCLUSION

Conclusions: University clinics play a crucial role in medical education by fostering professional skills, clinical competencies, and ethical standards in future physicians. They significantly contribute to the evolution of medical education and healthcare improvement through innovative teaching methods and impactful research.

Adaptive Mechanisms of Health Zones to Chronic Traumatic Events in Eastern DRC: A Multiple Case Study

BACKGROUND

The Eastern part of the Democratic Republic of Congo (DRC) has been affected by armed conflict for several years. Despite the growing interest in the impact of these conflicts on health service utilisation, few studies have addressed the coping mechanisms of the health system. The purpose of this study is to describe the traumatic events and coping mechanisms used by the health zones (HZs) in conflict settings to maintain good performance.

METHODS

This multiple case study took place from July to October 2022 in four HZs in the South Kivu Province of DRC. HZs were classified into "cases" according to their conflict profile: accessible and stable (Case 1), accessible but remote (Case 2), unstable (Case 3), and intermediate (Case 4). Eight performance indicators and the amount of funding provided to the HZs by non-governmental organizations (NGOs) were recorded. A graph was created to compare their evolution from 2013 to 2018. A thematic analysis of qualitative data from individual interviews with selected health workers was conducted.

RESULTS

Both battle-related events (war and its effects) and non-battle-related events (epidemics, disasters, strikes) were recorded according to the case conflict-profile. Although the cases (3 and 4) most affected by armed conflicts occasionally performed better than the stable ones (1 and 2), their operational action plan was poorly carried out. The coping mechanisms developed in cases 3 and 4 were the deployment of military nurses in preventive and supervisory activities, the solicitations of subsidies from NGOs, the relocation of health care facilities and the implementation of negotiation strategies with the belligerents.

CONCLUSION

Armed conflict results in traumatic events that disrupt the execution of the operational action plan of HZs. The HZs' management team expertise, its strong leadership, and substantial financial support would enable this system to develop reliable and sustainable adaptive mechanisms.

Distribution, preparedness and management of Ukrainian adult refugees on dialysis-an international survey by the Renal Disaster Relief Task Force of the European Renal Association

BACKGROUND

Due to the Russian-Ukrainian war, some of the about 10 000 adults requiring dialysis in Ukraine fled their country to continue dialysis abroad. To better understand the needs of conflict-affected dialysis patients, the Renal Disaster Relief Task Force of the European Renal Association conducted a survey on distribution, preparedness and management of adults requiring dialysis who were displaced due to the war.

METHODS

A cross-sectional online survey was sent via National Nephrology Societies across Europe and disseminated to their dialysis centers. Fresenius Medical Care shared a set of aggregated data.

RESULTS

Data were received on 602 patients dialyzed in 24 countries. Most patients were dialyzed in Poland (45.0%), followed by Slovakia (18.1%), Czech Republic (7.8%) and Romania (6.3%). The interval between last dialysis and the first in the reporting center was 3.1 ± 1.6 days, but was ≥4 days in 28.1% of patients. Mean age was 48.1 ± 13.4 years, 43.5% were females. Medical records were carried by 63.9% of patients, 63.3% carried a list of medications, 60.4% carried the medications themselves and 44.0% carried their dialysis prescription, with 26.1% carrying all of these items and 16.1% carrying none. Upon presentation outside Ukraine, 33.9% of patients needed hospitalization. Dialysis therapy was not continued in the reporting center by 28.2% of patients until the end of the observation period.

CONCLUSIONS

We received information about approximately 6% of Ukrainian dialysis patients, who had fled their country by the end of August 2022. A substantial proportion were temporarily underdialyzed, carried incomplete medical information and needed hospitalization. The results of our survey may help to inform policies and targeted interventions to respond to the special needs of this vulnerable population during wars and other disasters in the future.

Impact of wars and natural disasters on emerging and re-emerging infectious diseases

Emerging Infectious Diseases (EIDs) and Re-Emerging Infectious Diseases (REIDs) constitute significant health problems and are becoming of major importance. Up to 75% of EIDs and REIDs have zoonotic origin. Several factors such as the destruction of natural habitats leading humans and animals to live in close proximity, ecological changes due to natural disasters, population migration resulting from war or conflict, interruption or decrease in disease prevention programs, and insufficient vector control applications and sanitation are involved in disease emergence and distribution. War and natural disasters have a great impact on the emergence/re-emergence of diseases in the population. According to a World Bank estimation, two billion people are living in poverty and fragility situations. Wars destroy health systems and infrastructure, curtail existing disease control programs, and cause population movement leading to an increase in exposure to health risks and favor the emergence of infectious diseases. A total of 432 catastrophic cases associated with natural disasters were recorded globally in 2021. Natural disasters increase the risk of EID and REID outbreaks by damaging infrastructure and leading to displacement of populations. A Generic National Action Plan covering risk assessment, mechanism for action, determination of roles and responsibilities of each sector, the establishment of a coordination mechanism, etc. should be developed.

Extreme Violence and Weight-Related Outcomes in Mexican Adults

Sociological research suggests that violent environments contribute to excess weight, a pressing health issue worldwide. However, this research has neglected extreme forms of violence, such as armed conflicts, a theoretically significant omission because armed conflict could reasonably lead to weight loss, not weight gain. I examine the weight-related, short-term consequences of the Mexican "War on Organized Crime." I combine body mass index (N = 3,341) and waist circumference (N = 3,509) measures from the Mexico Family Life Survey with a novel data set on aggressions, confrontations, and executions between 2009 and 2011 (CIDE-PPD database) and exploit variation in the timing of the outcome relative to violent events taking place in the same residential environment. I find a robust and large positive association between armed conflict events and weight gain in adults and suggestive evidence of the behavioral, emotional, and physiological/biochemical pathways connecting those variables.

Population mental health in Burma after 2021 military coup: online non-probability survey

BACKGROUND

Humanitarian crises and armed conflicts lead to a greater prevalence of poor population mental health. Following the 1 February 2021 military coup in Burma, the country's civilians have faced humanitarian crises that have probably caused rising rates of mental disorders. However, a dearth of data has prevented researchers from assessing the extent of the problem empirically.

AIMS

To better understand prevalence of depressive and anxiety disorders among the Burmese adult population after the February 2021 military coup.

METHOD

We fielded an online non-probability survey of 7720 Burmese adults aged 18 and older during October 2021 and asked mental health and demographic questions. We used the Patient Health Questionnaire-4 to measure probable depression and anxiety in respondents. We also estimated logistic regressions to assess variations in probable depression and anxiety across demographic subgroups and by level of trust in various media sources, including those operated by the Burmese military establishment.

RESULTS

We found consistently high rates of probable anxiety and depression combined (60.71%), probable depression (61%) and probable anxiety (58%) in the sample overall, as well as across demographic subgroups. Respondents who 'mostly' or 'completely' trusted military-affiliated media sources (about 3% of the sample) were significantly less likely than respondents who did not trust these sources to report symptoms of anxiety and depression (AOR = 0.574; 95% CI 0.370-0.889), depression (AOR = 0.590; 95% CI 0.383-0.908) or anxiety (AOR = 0.609; 95% CI 0.390-0.951).

CONCLUSIONS

The widespread symptoms of anxiety and depression we observed demonstrate the need for both continuous surveillance of the current situation and humanitarian interventions to address mental health needs in Burma.

Exposure to Armed Conflict and HIV Risk Among Rwandan Women

This article focuses on the link between past exposure to violence and a critical public health issue in sub-Saharan Africa: HIV-positive status in women of reproductive age. Specifically, we use biosocial data from the Rwandan Demographic and Health Survey (2005‒2014) to assess how the timing and intensity of women's exposure to the war and genocide in Rwanda (1990‒1994) may be associated with their HIV status. We find significant differences in risk across age cohorts, with the late adolescence cohort (women born in 1970‒1974, who were aged 16‒20 at the start of the conflict) having the highest risk of being HIV positive 10‒20 years after the violence, even after controlling for current socioeconomic and demographic characteristics. Women who reported two or more sibling deaths, excluding those related to maternal mortality, during the conflict years also had higher odds of being HIV positive, net of cohort and control variables. Age at first sexual intercourse and number of lifetime sexual partners partially-but not fully-explain the associations between cohort and sibling deaths and HIV. These findings advance research related to armed conflict and population health and indicate that experiencing conflict during key stages of the life course and at higher intensity may affect women's long-term sexual health.

Perinatal experiences of Ukrainian women at the beginning of the war

OBJECTIVE

Pregnancy and childbirth are related to the experience of distress at their core. However, this distress is significantly increased under war conditions. The study aims to examine the perinatal experience of women during the war in Ukraine.

METHODS

12 Ukrainian women who were pregnant and lived in Kyiv or the suburbs of Kyiv from February to May 2022 took part in the study. In-depth interviews were conducted online in the form of semi-structured interviews, and the thematic analysis technique was used.

RESULTS

The perinatal experiences of women during the war in Ukraine were divided into 2 basic groups: negative perinatal experiences and positive perinatal experiences during the war. The negative perinatal experiences were grouped into three main themes: 1) negative emotions experienced in association with war, 2) dissatisfaction with medical support during the war, 3) suffering associated with separation from a husband and relatives. The positive perinatal experiences include 6 main themes: 1) the joy of returning or/and staying home, 2) satisfaction with medical support during the war, 3) coping with stress during the war, 4) family relationships and support during the war, 5) positive attitudes towards the child (or unborn child), 6) patriotic sentiments.

CONCLUSION

The study revealed negative and positive aspects of the perinatal experience of Ukrainian women during the war. Providing access to medical advice, facilitating uncertainty reduction, and communication between women and their families contribute to positive perinatal experiences of pregnant women and new mothers during the war.