Population-based survey methods to quantify associations between human rights violations and health outcomes among internally displaced persons in eastern Burma

Effects of Nutrition Counselling and Unconditional Cash Transfer on Child Growth and Family Food Security in Internally Displaced Person Camps in Somalia-A Quasi-Experimental Study

The effects of nutrition counselling (NC) and unconditional cash transfer (UCT) in improving growth in children under five and household food security are poorly understood in humanitarian settings. Therefore, this study aimed to evaluate the effects of NC and NC combined with unconditional cash transfer (NC + UCT) on children's growth and food security in Somalia. The study was performed with a quasi-experimental design in two districts in the Banadir region of Somalia. Caregivers (n = 255) with mildly to moderately malnourished children aged 6 to 59 months old (n = 184) were randomized to the NC, NC + UCT and control groups. The interventions consisted of weekly NC for three months alone or in combination with UCT. The outcome variables were wasting, underweight, stunting, and food security. Difference-indifferences analysis was used to estimate the effect of the interventions. Our study did not find any significant impacts of NC or NC + UCT on child wasting, underweight, stunting, food security or household expenses. In conclusion, NC, alone or in combination with UCT, did not impact children's growth or household food security. Thus, a culturally tailored NC programme over a longer period, supplemented with cash transfer, could be beneficial to consider when designing interventions to reduce malnutrition and food insecurity.

How political engineering can make health a bridge to peace: lessons from a Primary Health Care Project in Myanmar's border areas

This case study analyses a health project that focused on peacebuilding in addition to service provision, and the impacts of this dual focus in contested territories of Southeast Myanmar. The Swiss-funded Primary Health Care Project provided equal funds to both ‘sides’ in a decades-long conflict, and brought people together in ways designed to build trust. The case study demonstrates that health can play a valuable role in peace formation, if relationships are engineered in a politically sensitive way, at the right time. Whereas much of the literature on ‘health as a bridge to peace’ focuses on the apolitical in health, here the explicitly political approach and the deliberate adoption of neutrality as a tool for engaging with different parties were what enabled health to contribute to peace, using a political window of opportunity created by ceasefires and the beginnings of democratic transition in Myanmar. We argue that this approach was essential for health to contribute to bottom-up processes of peace formation—though the scope of the gains is necessarily limited. Crises like the COVID-19 pandemic and military coup in Myanmar can undermine the resilience and limit the impacts of such endeavours, yet there is reason to be hopeful about the small but significant contributions that can be made to peace through politically sensitive health projects.

Access to community-based reproductive health services and incidence of low birthweight delivery among refugee and displaced mothers: a retrospective study in the Thailand-Myanmar border region

OBJECTIVES

Over 2.4 million people have been displaced within the Thailand-Myanmar border region since 1988. The efficacy of community-driven health models within displaced populations is largely unstudied. Here, we examined the relationship between maternal healthcare access and delivery outcomes to evaluate the impact of community-provided health services for marginalised populations.

SETTING

Study setting was the Thailand-Myanmar border region's single largest provider of reproductive health services to displaced mothers.

PARTICIPANTS

All women who had a delivery (n=34 240) between 2008 and 2019 at the study clinic were included in the performed retrospective analyses.

PRIMARY AND SECONDARY OUTCOME MEASURES

Low birth weight was measured as the study outcome to understand the relationship between antenatal care access, family planning service utilisation, demographics and healthy deliveries.

RESULTS

First trimester (OR=0.86; 95% CI=0.81 to 0.91) and second trimester (OR=0.86; 95% CI=0.83 to 0.90) antenatal care visits emerged as independent protective factors against low birthweight delivery, as did prior utilisation of family planning services (OR=0.82; 95% CI=0.73 to 0.92). Additionally, advanced maternal age (OR=1.36; 95% CI=1.21 to 1.52) and teenage pregnancy (OR=1.27, 95% CI=1.13 to 1.42) were notable risk factors, while maternal gravidity (OR=0.914; 95% CI=0.89 to 0.94) displayed a protective effect against low birth weight.

CONCLUSION

Access to community-delivered maternal health services is strongly associated with positive delivery outcomes among displaced mothers. This study calls for further inquiry into how to best engage migrant and refugee populations in their own reproductive healthcare, in order to develop resilient models of care for a growing displaced population globally.

Understanding the health needs of internally displaced persons: A scoping review

We seek to strengthen understanding of the health needs of internally displaced persons (IDPs) in contexts of conflict or violence. Based upon a scoping review, our paper identified limited evidence on IDP health, but nevertheless indicates that IDPs tend to experience worse health outcomes than other conflict-affected populations across a range of health issues; and this is due to the particularly vulnerable situation of IDPs relative to these other populations, including reduced access to health services. Further research is required to better understand these needs and the interventions that can most effectively address these needs.

A mixed methods evaluation of Advanced Life Support in Obstetrics (ALSO) and Basic Life Support in Obstetrics (BLSO) in a resource-limited setting on the Thailand-Myanmar border

Background: Short emergency obstetric care (EmOC) courses have demonstrated improved provider confidence, knowledge and skills but impact on indicators such as maternal mortality and stillbirth is less substantial. This manuscript evaluates Advanced Life Support in Obstetrics (ALSO) and Basic Life Support (BLSO) as an adult education tool, in a protracted, post-conflict and resource-limited setting. Methods: A mixed methods evaluation was used. Basic characteristics of ALSO and BLSO participants and their course results were summarized. Kirkpatrick's framework for assessment of education effectiveness included: qualitative data on participants' reactions to training (level 1); and quantitative health indicator data on change in the availability and quality of EmOC and in maternal and/or neonatal health outcomes (level 4), by evaluation of the post-partum haemorrhage (PPH) related maternal mortality ratio (MMR) and stillbirth rate in the eight years prior and following implementation of ALSO and BLSO. Results: 561 Thailand-Myanmar border health workers participated in ALSO (n=355) and BLSO (n=206) courses 2008-2020. Pass rates on skills exceeded 90% for both courses while 50% passed the written ALSO test. Perceived confidence significantly improved for all items assessed. In the eight-year block preceding the implementation of ALSO and BLSO (2000-07) the PPH related MMR per 100,000 live births was 57.0 (95%CI 30.06-108.3)(9/15797) compared to 25.4 (95%CI 11.6-55.4)(6/23620) eight years following (2009-16), p=0.109. After adjustment, PPH related maternal mortality was associated with birth before ALSO/BLSO implementation aOR 3.825 (95%CI 1.1233-11.870), migrant (not refugee) status aOR 3.814 (95%CI 1.241-11.718) and attending ≤four antenatal consultations aOR 3.648 (95%CI 1.189-11.191). Stillbirth rate per 1,000 total births was 18.2 (95%CI 16.2-20.4)(291/16016) before the courses, and 11.1 (95%CI 9.8-12.5)(264/23884) after, p=0.038. Birth before ALSO/ BLSO implementation was associated with stillbirth aoR 1.235 (95%CI 1.018-1.500). Conclusions: This evaluation suggests ALSO and BLSO are sustainable, beneficial, EmOC trainings for adult education in protracted, post-conflict, resource-limited settings.

A mixed methods evaluation of Advanced Life Support in Obstetrics (ALSO) and Basic Life Support in Obstetrics (BLSO) in a resource-limited setting on the Thailand-Myanmar border

Background: Short emergency obstetric care (EmOC) courses have demonstrated improved provider confidence, knowledge and skills but impact on indicators such as maternal mortality and stillbirth is less substantial. This manuscript evaluates Advanced Life Support in Obstetrics (ALSO) and Basic Life Support (BLSO) as an adult education tool, in a protracted, post-conflict and resource-limited setting. Methods: A mixed methods evaluation was used. Basic characteristics of ALSO and BLSO participants and their course results were summarized. Kirkpatrick's framework for assessment of education effectiveness included: qualitative data on participants' reactions to training (level 1); and quantitative health indicator data on change in the availability and quality of EmOC and in maternal and/or neonatal health outcomes (level 4), by evaluation of the post-partum haemorrhage (PPH) related maternal mortality ratio (MMR) and stillbirth rate in the eight years prior and following implementation of ALSO and BLSO. Results: 561 Thailand-Myanmar border health workers participated in ALSO (n=355) and BLSO (n=206) courses 2008-2020. Pass rates on skills exceeded 90% for both courses while 50% passed the written ALSO test. Perceived confidence significantly improved for all items assessed. In the eight-year block preceding the implementation of ALSO and BLSO (2000-07) the PPH related MMR per 100,000 live births was 57.0 (95%CI 30.06-108.3)(9/15797) compared to 25.4 (95%CI 11.6-55.4)(6/23620) eight years following (2009-16), p=0.109. After adjustment, PPH related maternal mortality was associated with birth before ALSO/BLSO implementation aOR 3.825 (95%CI 1.1233-11.870), migrant (not refugee) status aOR 3.814 (95%CI 1.241-11.718) and attending ≤four antenatal consultations aOR 3.648 (95%CI 1.189-11.191). Stillbirth rate per 1,000 total births was 18.2 (95%CI 16.2-20.4)(291/16016) before the courses, and 11.1 (95%CI 9.8-12.5)(264/23884) after, p=0.038. Birth before ALSO/ BLSO implementation was associated with stillbirth aoR 1.235 (95%CI 1.018-1.500). Conclusions: This evaluation suggests ALSO and BLSO are sustainable, beneficial, EmOC trainings for adult education in protracted, post-conflict, resource-limited settings.

Reproductive health at conflict borders: a cross-sectional survey of human rights violations and perinatal outcomes at the Thai-Myanmar border

BACKGROUND

Human rights violations (HRVs) are common in conflict and displacement contexts. Women are especially vulnerable to HRVs in these contexts, and perinatal health is acutely sensitive to related stressors and health care barriers. However, how HRVs affect immediate and long-term perinatal health in chronic displacement settings has not been closely investigated. Furthermore, it remains unclear whether and how HRVs in these contexts are tied directly to displacement circumstances or other marginalizing factors affecting local migrant and minority populations generally.

METHODS

We investigated these questions using novel survey data from 577 women at the northern Thai-Myanmar border, where thousands of people have fled conflict in Shan State, Myanmar, for refuge in a range of precarious settings in Thailand, including unofficial refugee camps, villages, and worksites. We compared HRV exposures by ethnicity, country of birth, legal documentation, and residential setting. We then analyzed perinatal outcomes associated with HRV frequency, timing, and type.

RESULTS

Birth in Myanmar, and ethnic minority and precarious legal status more broadly, predicted higher HRV prevalence. HRV frequency significantly predicted unmet antenatal care and lower birth weight, along with HRVs related to labor exploitation and violence or conflict. HRVs timed closer to pregnancies were more adversely associated with perinatal outcomes. Resource/property deprivation was the strongest predictor of pregnancy complications.

CONCLUSIONS

Human rights must be urgently attended to, through expanded HRV screenings and responsive care, and policy changes to further protect migrant workers, displaced persons, and others in precarious legal status situations.

The Embodiment of War: Growth, Development, and Armed Conflict

Armed conflict regularly presents extremely adverse circumstances not only for combatants, but also for civilians. In fact, estimates from various wars over the past 70 years suggest that noncombatants comprise the majority of casualties. For survivors, war's effects are often embodied, leaving long-term effects on health and biology. Some of these effects, such as injuries and psychological trauma, are well known. Yet other effects may be subtle and may be elucidated by a developmental biological perspective. In early life, when growth rates are highest, conditions of war may have their greatest impact. Depending on local circumstances, a developing embryo, infant, or child growing in a place embroiled in armed conflict is likely to face—directly or indirectly—various stressors, including malnutrition, infectious disease, and/or psychological stress. Thus, the conditions of war and forced displacement may become embodied, getting under the skin for fundamental biological reasons.

Displacement contexts and violent landscapes: How conflict and displacement structure women's lives and ongoing threats at the Thai-Myanmar border

Chronic conflict and displacement carry consequences for personal and social violence. How is violence embedded in displacement-related histories and ongoing circumstances? How might it underlie social and health inequities in host countries? For addressing these questions, I offer a new approach to conceptualizing and measuring displacement contexts and the structural violence embedded therein. I present the empirical case of the Thai-Myanmar border. Myanmar's civil conflict has fueled one of the largest and most chronically displaced populations globally. Thailand's border population has consequently grown with people displaced from the varied conflict-related circumstances within Myanmar. I administered a novel survey in two sub-districts along Thailand's northern border with Myanmar in 2016-17. With data from 520 respondents, I used clustering of life events and circumstances to uncover displacement-related contexts and violence. I uncovered livelihood- and security-based threat contexts, which disproportionately affected ethnic minority women. Among women from Myanmar, past military occupation and acute violence co-occurred with unexpectedly low perceived past oppression-indicative of covert everyday violence. In contrast, women who fled home destruction or deprivation, but often less overt military violence, were more likely to perceive oppression. Women born in Myanmar also experienced acute potential violence at the border, including severe livelihood and security threats. These threats were most prevalent among women that experienced the most forceful and abrupt displacement. This study uses a person-centered perspective to characterize and measure violence embedded in displacement, including the structural violence against women that is perpetuated across displacement contexts and embodied over time.

Migration patterns & their associations with health and human rights in eastern Myanmar after political transition: results of a population-based survey using multistaged household cluster sampling

Background

Myanmar transitioned to a nominally civilian government in March 2011. It is unclear how, if at all, this political change has impacted migration at the household level.

Methods

We present household-level in- and out-migration data gathered during the Eastern Burma Retrospective Mortality Survey (EBRMS) conducted in 2013. Household level in-and out-migration information within the previous year was gathered via a cross-sectional, retrospective, multi-stage population-based cluster randomized survey conducted in eastern Myanmar. Univariate, bivariate and regression analyses were conducted.

Results

We conducted a cross-sectional survey of 6620 households across Eastern Myanmar between July and September of 2013. Out-migration outstripped in-migration more than 6:1 overall during the year prior to the survey - for international migration this ratio was 29:1. Most in-migrants had moved to their present location in the study area from other areas in Myanmar (87%). Only 11.3% (27 individuals) had returned from another country (Thailand). Those who migrated out of eastern Myanmar during the previous year were more likely to be male (55.2%), and three times more likely to be between the ages of 15-25 (49.5%) than non-migrants. The primary reason cited for a return to the household was family (26.3%) followed by work (23.2%). The primary reason cited for migrating out of the household was for education (46.4%) followed by work (40.2%). Respondents from households that reported out-migration in the past year were more likely to screen positive for depressive symptoms than households with no migration (PR 1.85; 95% CI 1.16, 2.97). Women in households with in-migration were more likely to be malnourished and had a higher unmet need for contraception. Forced labor, one subset of human rights violations experienced by this population, was reported by more in-migrant (8%) than out-migrant households (2.2%), though this finding did not reach statistical significance.

Conclusions

These analyses suggest that opportunities for employment and education are the primary drivers of migration out of the household, despite an overall improvement in stability and decrease in prevalence of human rights violations found by EBRMS 2013. Additionally, migration into and out of households in eastern Myanmar is associated with changes in health outcomes.

Improving Mental Health Outcomes of Burmese Migrant and Displaced Children in Thailand: a Community-Based Randomized Controlled Trial of a Parenting and Family Skills Intervention

The negative effects of displacement and poverty on child mental health are well-known, yet research on prevention interventions in low- and middle-income countries, especially fragile states, remains limited. We examined the effectiveness of a parenting skills intervention on mental health outcomes among Burmese migrant and displaced children living in 20 communities in Thailand. Participants were primary caregivers and children aged 7 to 15 years (n = 479 families). Families were randomly assigned to receive an adapted version of the Strengthening Families Program (n = 240) or a wait-list control condition (n = 239). Assessments were conducted at baseline and 1-month post-intervention for both conditions and at 6 months for treatment group only. One month after the program, children in the treatment condition showed significant reductions in externalizing problems (caregiver effect size (ES) -0.22, p = 0.02; child report ES -0.11, p = 0.02) and child attention problems compared with controls (caregiver report ES -0.23, p = 0.03). There was no significant treatment effect on children's internalizing problems (ES -0.06; p = 0.31). Children reported a significant increase in prosocial protective factors relative to controls (ES 0.20, p < 0.01). Results suggest that an evidence-based parenting skills intervention adapted for a displaced and migrant Burmese population facing high levels of adversity can have positive effects on children's externalizing symptoms and protective psychosocial factors.

TRIAL REGISTRATION

Clinicaltrials.gov: https://clinicaltrials.gov/show/NCT01829815.

Large funding inflows, limited local capacity and emerging disease control priorities: a situational assessment of tuberculosis control in Myanmar

There are numerous challenges in planning and implementing effective disease control programmes in Myanmar, which is undergoing internal political and economic transformations whilst experiencing massive inflows of external funding. The objective of our study-involving key informant discussions, participant observations and linked literature reviews-was to analyse how tuberculosis (TB) control strategies in Myanmar are influenced by the broader political, economic, epidemiological and health systems context using the Systemic Rapid Assessment conceptual and analytical framework. Our findings indicate that the substantial influx of donor funding, in the order of one billion dollars over a 5-year period, may be too rapid for the country's infrastructure to effectively utilize. TB control strategies thus far have tended to favour medical or technological approaches rather than infrastructure development, and appear to be driven more by perceived urgency to 'do something' rather informed by evidence of cost-effectiveness and sustainable long-term impact. Progress has been made towards ambitious targets for scaling up treatment of drug-resistant TB, although there are concerns about ensuring quality of care. We also find substantial disparities in health and funding allocation between regions and ethnic groups, which are related to the political context and health system infrastructure. Our situational assessment of emerging TB control strategies in this transitioning health system indicates that large investments by international donors may be pushing Myanmar to scale up TB and drug-resistant TB services too quickly, without due consideration given to the health system (service delivery infrastructure, human resource capacity, quality of care, equity) and epidemiological (evidence of effectiveness of interventions, prevention of new cases) context.

Stress and Health of Internally Displaced Female Yezidis in Northern Iraq

Burden and vulnerability factors after the genocide by ISIS accumulate to a high risk of health for displaced Yezidi women having survived or escaped the "ISIS" persecutions and massacres 2014. In May 2017, standardized interviews, including tests for the acquisition of healthrelated quality of life (SF12), stress (PSS10) and experienced trauma were performed with 29 and a medical anamnesis with 10 displaced female Yezidi in camps for internally displaced people (IDP) and unofficial settlements in Northern Iraq. 58, 62% stated their general health as "poor", 17.24% each as "fair" or "good" and 3.45% each as "very good" or "excellent". In the assessment of health-related quality of life, physical as well as mental health showed significantly reduced values, while simultaneously a high level of stress was recorded. 79.3% reported about having experienced at least one traumatic event. Chronic stress due to living conditions and traumatization is most likely responsible for the recorded poor health.

Challenges to measuring Chinese students’ perceptions of freedom of expression: An application of Rasch analysis

Rapid social development and recent changes in views concerning childhood have urged a more holistic approach to measuring children’s well-being, particularly in the domain of rights. In light of articulated provisions within the United Nations Convention on the Rights of the Child, there is obvious interest in understanding more about how children’s perceptions of their rights have evolved. Using both traditional measurement (exploratory factor analysis and confirmatory factor analysis) and Rasch analysis, this study focused on measures gauging Chinese high school students’ perceptions of freedom of expression. The survey was designed to capture students’ perceptions over various forms of freedom of expression (e.g. student publications, dress code), and their experiences with regard to how these rights were respected in their schools. The aim of the study was to examine and evaluate validity and reliability of the survey used with a sample of 838 Chinese students from two high schools, one urban, and one rural. Overall, the survey exhibits certain degrees of validity and reliability and is appropriate for measuring children’s perceptions on freedom of expression. The study pointed to a number of areas where the survey could be improved. Implications for future research were discussed.

Customer Need Identification Methods in New Product Development: What Works “Best”?

Although new product development is associated with high failure rates, it is still the most natural measure for firms to grow and by that expand their market position. Therefore, firms need to optimally align product functions to the needs of their target customer. By conducting an online survey with 179 participants, this paper identifies the most commonly applied need identification techniques. We can show that analyzing internal data and external reports today is the most commonly used method, at least in the German-speaking world. Still, interacting with customers via different approaches is perceived as the most beneficial approach, at the same time being very resource-demanding. In contrast to most scientific studies analyzing this topic, we furthermore identify reasons for refusing certain methods, e.g. because of lack of knowledge and resources or severe resistance within the organizations. Additionally, we derive academic and practical information from the input of the survey data for an improved application in the future.

A review of measures of women's empowerment and related gender constructs in family planning and maternal health program evaluations in low- and middle-income countries

BACKGROUND

Evidence suggests that gender-integrated interventions, which actively seek to identify and integrate activities that address the role of gender norms and dynamics, improve family planning (FP) and maternal health (MH). To understand the link between the gender components of interventions and FP and MH outcomes, it is critical to examine the gender measures used in evaluations.

METHODS

We conducted a systematic review of evaluations of gender-integrated FP and MH interventions in low- and middle-income countries. We examine characteristics of the interventions and their evaluations, and summarize women's empowerment and related gender measures.

RESULTS

Out of 16 evaluation articles, five reported the theoretical or conceptual model that guided the intervention. Twelve described how gender was quantitatively measured and identified 13 women's empowerment and related gender constructs. Gender scales or indexes were used in five evaluations, three of which noted that their scales had been validated. Less than one third of articles reported examining the effect of gender on FP or MH.

CONCLUSIONS

Evaluations of gender-integrated FP and MH interventions do not consistently describe how gender influences FP and MH outcomes or include validated gender measures within their studies. As a result, examining the pathways through which interventions empower women and the manner in which women's empowerment leads to changes in FP and MH outcomes remains a challenge. Valid measures of commonly reported women's empowerment and gender constructs, such as gender-equitable attitudes and women's decision-making power, must be adapted and used within evaluations to examine how empowerment and improvements in gender-related factors can produce positive FP and MH outcomes.

"Can I Ask That?": Perspectives on Perinatal Care After Resettlement Among Karen Refugee Women, Medical Providers, and Community-Based Doulas

This study characterized the perspectives of Karen refugee women in Buffalo, NY, their medical providers, and Karen interpreters/doulas on perinatal care for Karen women in resettlement. In-depth qualitative interviews with Karen women (14), Karen doulas/interpreters and key informants (8), and medical providers (6) were informed by the social contextual model and focused on women's questions about and opinions of perinatal care in Buffalo and on providers' experiences caring for Karen patients. Karen women expressed gratitude for and understanding of perinatal care in Buffalo, and providers described Karen patients as agreeable but shy. Karen doulas offered an alternative view that exposed women's many questions and concerns, and described how doula training empowered them as patients' advocates. Low self-efficacy, trauma histories, and cultural expectations may contribute to Karen women's seeming agreeability. Doulas/interpreters possess insider knowledge of women's concerns and facilitate communication between patients and the care team.

Socioeconomic factors associated with severe acute malnutrition in Jamaica

OBJECTIVES

Severe acute malnutrition (SAM) is an important risk factor for illness and death globally, contributing to more than half of deaths in children worldwide. We hypothesized that SAM is positively correlated to poverty, low educational attainment, major crime and higher mean soil concentrations of lead, cadmium and arsenic.

METHODS

We reviewed admission records of infants admitted with a diagnosis of SAM over 14 years (2000-2013) in Jamaica. Poverty index, educational attainment, major crime and environmental heavy metal exposure were represented in a Geographic Information System (GIS). Cases of SAM were grouped by community and the number of cases per community/year correlated to socioeconomic variables and geochemistry data for the relevant year.

RESULTS

375 cases of SAM were mapped across 204 urban and rural communities in Jamaica. The mean age at admission was 9 months (range 1-45 months) and 57% were male. SAM had a positive correlation with major crime (r = 0.53; P < 0.001), but not with educational attainment or the poverty index. For every one unit increase in the number of crimes reported, the rate of occurrence of SAM cases increased by 1.01% [Incidence rate ratio (IRR) = 1.01 (95% CI = 1.006-1.014); P P<0.001]. The geochemistry data yielded no correlation between levels of heavy metals and the prevalence of malnutrition.

CONCLUSION

Major crime has an independent positive association with severe acute malnutrition in Jamaican infants. This could suggest that SAM and major crime might have similar sociological origins or that criminality at the community level may be indicative of reduced income opportunities with the attendant increase in poor nutrition in the home.

A systematic review of Karen refugee health

Purpose

– The purpose of this paper is to provide a comprehensive perspective of the documented physical and mental health issues Karen refugees from Burma face as a result of war and refugee trauma, and migration. The review will address the question: What is the impact of trauma and migration on the physical and mental health of Karen refugees?

Design/methodology/approach

– A total of 18 articles were systematically selected for inclusion in the final review. The focal content for included articles includes qualitative and quantitative research representative of the health and migration experiences of Karen refugees.

Findings

– The findings of this review demonstrate significance for health providers from a public health standpoint as programs and services are targeted to meet the specific health needs of the Karen community. It also highlights the contribution of the Karen forced migration experience to the complexity of individual and community health needs, particularly as a result of the protracted conflict.

Originality/value

– This critical appraisal of the body of literature describing the health experiences of Karen refugees from Burma, with a particular focus on outcomes relevant to resettlement, demonstrates value as programs are developed with an integrated refugee perspective.

Militarization, human rights violations and community responses as determinants of health in southeastern Myanmar: results of a cluster survey

Background

The Myanmar army and ethnic armed groups agreed to a preliminary ceasefire in 2012, but a heavy military presence remains in southeastern Myanmar. Qualitative data suggested this militarization can result in human rights abuses in the absence of armed engagements between the parties, and that rural ethnic civilians use a variety of self-protection strategies to avoid these abuses or reduce their negative impacts. We used data from a household survey to determine prevalence of select self-protection activities and to examine exposure to armed groups, human rights violations and self-protection activities as determinants of health in southeastern Myanmar.

Methods and findings

Data collected from 463 households via a two-stage cluster survey of conflict-affected areas in eastern Myanmar in January 2012, were analyzed using logistic regression models to identify associations between exposure to state and non-state armed groups, village self-protection, human rights abuses and health outcomes. Close proximity to a military base was associated with human rights abuses (PRR 1.30, 95 % CI: 1.14-1.48), inadequate food production (PRR 1.08, 95 % CI: 1.03-1.13), inability to access health care (PRR 1.29, 95 % CI: 1.04-1.60) and diarrhea (PRR 1.15, 95 % CI: 1.05-1.27. Direct exposure to armed groups was associated with household hunger (PRR1.71, 95 % CI: 1.30-2.23). Among households that reported no human rights abuses, risk of household hunger (PRR 5.64, 95 % CI: 1.88-16.91), inadequate food production (PRR 1.95, 95 % CI: 1.11-3.41) and diarrhea (PRR 2.53, 95 % CI: 1.45-4.42) increased when neighbors’ households reported experiencing human rights abuses. Households in villages that reported negotiating with the Myanmar army had lower risk of human rights violations (PRR 0.91, 95 % CI: 0.85-0.98), household hunger (PRR 0.85, 95 % CI: 0.74-0.96), inadequate food production (PRR 0.93, 95 % CI:0.89-0.98) and diarrhea (PRR 0.89, 95 % CI:0.82-0.97). Stratified analysis suggests that self-protection strategies may modify the effect of exposure to armed groups on risk of human rights violations and some health outcomes.

Conclusion

Militarization may negatively affect health in southeastern Myanmar, and village self-protection activities may reduce these impacts. As southeastern Myanmar opens to international health and development interventions, implementing agencies should consider militarization as a determinant of health and design interventions that can mediate its effects. Such interventions should take into account existing self-protection strategies, seek to provide support where possible and, at all times, take care not to unintentionally undermine them.

Electronic supplementary material

The online version of this article (doi:10.1186/s13031-015-0059-0) contains supplementary material, which is available to authorized users.

Malaria ecology along the Thailand-Myanmar border

Background

Malaria in Southeast Asia frequently clusters along international borders. For example, while most of Thailand is malaria free, the border region shared with Myanmar continues to have endemic malaria. This spatial pattern is the result of complex interactions between landscape, humans, mosquito vectors, and malaria parasites. An understanding of these complex ecological and socio-cultural interactions is important for designing and implementing malaria elimination efforts in the region. This article offers an ecological perspective on the malaria situation along the Thailand–Myanmar border.

Discussion

This border region is long (2000 km), mountainous, and the environment ranges from thick forests to growing urban settlements and wet-rice fields. It is also a biologically diverse region. All five species of malaria known to naturally infect humans are present. At least three mosquito vector species complexes, with widely varying behavioural characteristics, exist in the area. The region is also a hub for ethnic diversity, being home to over ten different ethnolinguistic groups, several of which have been engaged in conflict with the Myanmar government now for over half a century. Given the biological and ethnic diversity, as well as the complex socio-political context, malaria control and elimination in the region is challenging.

Conclusion

Despite these complexities, multipronged approaches including collaborations with multiple local organizations, quick access to diagnosis and treatment, prevention of mosquito bites, radical cure of parasites, and mass drug administration appear to be drastically decreasing Plasmodium falciparum infections. Such approaches remain crucial as the region moves toward elimination of P. falciparum and potentially Plasmodium vivax.

Health and Human Rights in Karen State, Eastern Myanmar

BACKGROUND

Decades of conflict in eastern Myanmar have resulted in high prevalence of human rights violations and poor health outcomes. While recent ceasefire agreements have reduced conflict in this area, it is unknown whether this has resulted in concomitant reductions in human rights violations.

METHODS AND FINDINGS

We conducted a two-stage cluster survey of 686 households in eastern Myanmar to assess health status, access to healthcare, food security, exposure to human rights violations and identification of alleged perpetrators over the 12 months prior to January 2012, a period of near-absence of conflict in this region. Household hunger (FANTA-2 scale) was moderate/high in 91 (13.2%) households, while the proportion of households reporting food shortages in each month of 2011 ranged from 19.9% in December to 47.0% in September, with food insecurity peaking just prior to the harvest. Diarrhea prevalence in children was 14.2% and in everyone it was 5.8%. Forced labor was the most common human rights violation (185 households, 24.9%), and 210 households (30.6%) reported experiencing one or more human rights violations in 2011. Multiple logistic regression analysis identified associations between human rights violations and poor health outcomes.

CONCLUSION

Human rights violations and their health consequences persist despite reduced intensity of conflict in eastern Myanmar. Ceasefire agreements should include language that protects human rights, and reconciliation efforts should address the health consequences of decades of human rights violations.

Health and human rights in eastern Myanmar after the political transition: a population-based assessment using multistaged household cluster sampling

Background

Myanmar transitioned to a nominally civilian parliamentary government in March 2011. Qualitative reports suggest that exposure to violence and displacement has declined while international assistance for health services has increased. An assessment of the impact of these changes on the health and human rights situation has not been published.

Methods and Findings

Five community-based organizations conducted household surveys using two-stage cluster sampling in five states in eastern Myanmar from July 2013-September 2013. Data was collected from 6, 178 households on demographics, mortality, health outcomes, water and sanitation, food security and nutrition, malaria, and human rights violations (HRV). Among children aged 6-59 months screened, the prevalence of global acute malnutrition (representing moderate or severe malnutrition) was 11.3% (8.0 – 14.7). A total of 250 deaths occurred during the year prior to the survey. Infant deaths accounted for 64 of these (IMR 94.2; 95% CI 66.5-133.5) and there were 94 child deaths (U5MR 141.9; 95% CI 94.8-189.0). 10.7% of households (95% CI 7.0-14.5) experienced at least one HRV in the past year, while four percent reported 2 or more HRVs. Household exposure to one or more HRVs was associated with moderate-severe malnutrition among children (14.9 vs. 6.8%; prevalence ratio 2.2, 95% CI 1.2-4.2). Household exposure to HRVs was associated with self-reported fair or poor health status among respondents (PR 1.3; 95% CI 1.1 – 1.5).

Conclusion

This large survey of health and human rights demonstrates that two years after political transition, vulnerable populations of eastern Myanmar are less likely to experience human rights violations compared to previous surveys. However, access to health services remains constrained, and risk of disease and death remains higher than the country as a whole. Efforts to address these poor health indicators should prioritize support for populations that remain outside the scope of most formal government and donor programs.

War trauma and torture experiences reported during public health screening of newly resettled Karen refugees: a qualitative study

Background

Karen refugees have suffered traumatic experiences that affect their physical and mental health in resettlement. The United States Centers for Disease Control and Prevention recommends assessing traumatic histories and mental health symptoms during initial public health screening. This article reports the traumatic experiences that Karen refugees were able to describe during a short screening and contributes knowledge to existing human rights documentation systems.

Methods

Four semi-structured and open-ended items asked about lifetime experiences of war trauma and torture. Interviews were completed with adult, Karen refugees during their initial public health screening. Experiences of war trauma and torture were coded using the extensive Human Rights Information and Documentation (HURIDOCS) Micro-thesauri coding system. Additional codes were created to describe experiences not captured by existing codes.

Results

Over 85% of 179 Karen people interviewed experienced life-threatening war trauma. All participants who reported war trauma or torture stories were able to describe at least one event. New war trauma codes proposed include: widespread community fear, systematic destruction/burning of house or village, exposure to dead bodies, orphaned in the context of war, injury caused by a landmine, fear of Thai police or deportation from Thailand, and harm or killings in the context of war. New torture codes include: forced portering; forced to be a human landmine sweep; forced to be a soldier, including child soldier; forced contact with a dead body; and removal of the eyes.

Conclusion

Karen refugees were able to report traumatic experiences in the context of a brief health screening. The findings confirm existing reports of human rights violations against Karen people and suggest that additional codes be added to the HURIDOCS Micro-thesauri system that is used by torture treatment centers. Understanding the nature of traumatic experiences of this group is important for health providers working with resettled Karen refugees in their countries of resettlement. Health providers may need specialized training to understand the traumatic histories of this new refugee group, learn how to initiate conversations about trauma and its impact on health, and make appropriate mental health referrals in the context of a brief public health screening.

Trauma training course: innovative teaching models and methods for training health workers in active conflict zones of Eastern Myanmar

Background

Myanmar has struggled through decades of internal conflict, which has negatively impacted the country’s health outcomes. Recent government changes have brought hope and reduced conflict. The ethnic minority groups have suffered the brunt of the health consequences and reside in regions that lack health infrastructure, resources, and providers. Due to the chronic lack of healthcare providers within conflict areas, health workers (HWs) have been trained in an effort to fill the void. Research has shown that these non-physician clinicians positively impact health outcomes in developing countries. These HWs are supported by community-based organizations in collaboration with foreign non-governmental organizations. Started in 2000, the trauma training course was developed to meet the educational needs of these HWs.

Methods

Essential procedures for HWs in conflict zones were identified, and teaching methods were adapted to develop models that were simple, reproducible, cost effective, and able to facilitate effective learning within the limitations of these challenging environments. This paper presents simulation models developed to teach trauma injury evaluation and management in resource-limited settings to HWs.

Results

Material and construction of the models described include breathing, chest, cricothyroidotomy, circulation, wound repair, fracture/dislocation, splinting, fasciotomy/amputation, and an animal model. In 2013, a pre/post test and post-training evaluation were completed, which demonstrated an increase in understanding of the material and satisfaction with the training.

Conclusions

The simulation models described engage the HWs in clinical skills practice specific to injury management, which builds upon the HWs existing knowledge and facilitates an increased understanding of life-saving procedures. Through observation of the HW performance and HW feedback, these simulation models have increased the understanding of trauma management. Limitations include lack of a graduated learning system for the HWs, logistics, and time constraints. Despite the barriers faced, we feel that this is a necessary program that has reduced morbidity and mortality due to traumatic injury in the geographic areas that the HWs serve. With the changing political environment in Myanmar and the development of peace agreements between the government and the ethnic minority groups, these HWs can be integrated into Myanmar’s evolving health system.

New politics, an opportunity for maternal health advancement in eastern myanmar: an integrative review

Myanmar (formerly Burma) is a southeast Asian country, with a long history of military dictatorship, human rights violations, and poor health indicators. The health situation is particularly dire among pregnant women in the ethnic minorities of the eastern provinces (Kachin, Shan, Mon, Karen and Karenni regions). This integrative review investigates the current status of maternal mortality in eastern Myanmar in the context of armed conflict between various separatist groups and the military regime. The review examines the underlying factors contributing to high maternal mortality in eastern Myanmar and assesses gaps in the existing research, suggesting areas for further research and policy response. Uncovered were a number of underlying factors uniquely contributing to maternal mortality in eastern Myanmar. These could be grouped into the following analytical themes: ongoing conflict, health system deficits, and political and socioeconomic influences. Abortion was interestingly not identified as an important contributor to maternal mortality. Recent political liberalization may provide space to act upon identified roles and opportunities for the Myanmar Government, the international community, and non-governmental organizations (NGOs) in a manner that positively impacts on maternal healthcare in the eastern regions of Myanmar. This review makes a number of recommendations to this effect.

Malaria baseline survey in four special regions of northern Myanmar near China: a cross-sectional study

BACKGROUND

Epidemiological data in the border area of the northern Myanmar near China are either of little accuracy or sparse of information, due to the poor public health system in these areas, and malaria cases may be severely underestimated. This study aimed to investigate malaria prevalence and health facilities for malaria services, and to provide the baseline information for malaria control in these areas.

METHODS

A cluster, randomized, cross-sectional survey was conducted in four special regions of northern Myanmar, near China: 5,585 people were selected for a malaria prevalence survey and 1,618 households were selected for a mosquito net-owning survey. Meanwhile, a total of 97 health facilities were surveyed on their malaria services. The data were analysed and descriptive statistics were used.

RESULTS

A total of 761 people were found positive through microscopy test, including 290 people for Plasmodium falciparum, 460 for Plasmodium vivax, two for Plasmodium malariae, and nine for mixed infection. The average prevalence of malaria infection was 13.6% (95% CI: 12.7-14.6%). There were significant differences of prevalence of malaria infection among the different regions (P < 0.01); 38.1% (95% CI: 28.3-48.0%) of health facilities had malaria microscope examination service, and 35.1% (95% CI: 25.4-44.7%) of these had malaria treatment services, 23.7% (95% CI: 15.1-32.3%) had malaria outreach services. 28.3% (95% CI: 26.1-30.6%) of households owned one or more long-lasting insecticidal bed nets (LLINs).

CONCLUSION

The prevalence of malaria infection was high in the four special regions of northern Myanmar, near China. Malaria services in health facilities in these areas were weak. ITNs/LLINs owning rate was also low. The cross-border cooperation mechanism should be further strengthened to share the epidemical data about malaria, support technical assistance, and conduct joint malaria control or elimination activities.

Health and human rights in eastern Myanmar prior to political transition: a population-based assessment using multistaged household cluster sampling

Background

Myanmar/Burma has received increased development and humanitarian assistance since the election in November 2010. Monitoring the impact of foreign assistance and economic development on health and human rights requires knowledge of pre-election conditions.

Methods

From October 2008-January 2009, community-based organizations conducted household surveys using three-stage cluster sampling in Shan, Kayin, Bago, Kayah, Mon and Tanintharyi areas of Myanmar. Data was collected from 5,592 heads of household on household demographics, reproductive health, diarrhea, births, deaths, malaria, and acute malnutrition of children 6–59 months and women aged 15–49 years. A human rights focused survey module evaluated human rights violations (HRVs) experienced by household members during the previous year.

Results

Estimated infant and under-five rates were 77 (95% CI 56 to 98) and 139 (95% CI 107 to 171) deaths per 1,000 live births; and the crude mortality rate was 13 (95% CI 11 to 15) deaths per thousand persons. The leading respondent-reported cause of death was malaria, followed by acute respiratory infection and diarrhea, causing 21.2% (95% CI 16.5 to 25.8), 16.6% (95% CI 11.8 to 21.4), and 12.3% (95% CI 8.7 to 15.8), respectively. Over a third of households suffered at least one human rights violation in the preceding year (36.2%; 30.7 to 41.7). Household exposure to forced labor increased risk of death among infants (rate ratio (RR) = 2.2; 95% CI 1.1 to 4.4) and children under five (RR = 2.1; 95% CI 1.3 to 3.6). The proportion of children suffering from moderate to severe acute malnutrition was higher among households that were displaced (prevalence ratio (PR) = 3.3; 95% CI 1.9 to 5.6).

Conclusions

Prior to the 2010 election, populations of eastern Myanmar experienced high rates of disease and death and high rates of HRVs. These population-based data provide a baseline that can be used to monitor national and international efforts to improve the health and human rights situation in the region.

Risk factors associated with slide positivity among febrile patients in a conflict zone of north-eastern Myanmar along the China-Myanmar border

Background

Malaria within the Greater Mekong sub-region is extremely heterogeneous. While China and Thailand have been relatively successful in controlling malaria, Myanmar continues to see high prevalence. Coupled with the recent emergence of artemisinin-resistant malaria along the Thai-Myanmar border, this makes Myanmar an important focus of malaria within the overall region. However, accurate epidemiological data from Myanmar have been lacking, in part because of ongoing and emerging conflicts between the government and various ethnic groups. Here the results are reported from a risk analysis of malaria slide positivity in a conflict zone along the China-Myanmar border.

Methods

Surveys were conducted in 13 clinics and hospitals around Laiza City, Myanmar between April 2011 and October 2012. Demographic, occupational and educational information, as well as malaria infection history, were collected. Logistic models were used to assess risk factors for slide positivity.

Results

Age patterns in Plasmodium vivax infections were younger than those with Plasmodium falciparum. Furthermore, males were more likely than females to have falciparum infections. Patients who reported having been infected with malaria during the previous year were much more likely to have a current vivax infection. During the second year of the study, falciparum infections among soldiers increased signficiantly.

Conclusions

These results fill some knowledge gaps with regard to risk factors associated with malaria slide positivity in this conflict region of north-eastern Myanmar. Since epidemiological studies in this region have been rare or non-existent, studies such as the current are crucial for understanding the dynamic nature of malaria in this extremely heterogeneous epidemiological landscape.

Trauma and mental health of medics in eastern Myanmar's conflict zones: a cross-sectional and mixed methods investigation

BACKGROUND

In conflict and disaster settings, medical personnel are exposed to psychological stressors that threaten their wellbeing and increase their risk of developing burnout, depression, anxiety, and PTSD. As lay medics frequently function as the primary health providers in these situations, their mental health is crucial to the delivery of services to afflicted populations. This study examines a population of community health workers in Karen State, eastern Myanmar to explore the manifestations of health providers' psychological distress in a low-resource conflict environment.

METHODS

Mental health screening surveys were administered to 74 medics, incorporating the 12-item general health questionnaire (GHQ-12) and the posttraumatic checklist for civilians (PCL-C). Semi-structured qualitative interviews were conducted with 30 medics to investigate local idioms of distress, sources of distress, and the support and management of medics' stressors.

RESULTS

The GHQ-12 mean was 10.7 (SD 5.0, range 0-23) and PCL-C mean was 36.2 (SD 9.7, range 17-69). There was fair internal consistency for the GHQ-12 and PCL-C (Cronbach's alpha coeffecients 0.74 and 0.80, respectively) and significant correlation between the two scales (Pearson's R-correlation 0.47, P<0.001). Qualitative results revealed abundant evidence of stressors, including perceived inadequacy of skills, transportation barriers, lack of medical resources, isolation from family communities, threats of military violence including landmine injury, and early life trauma resulting from conflict and displacement. Medics also discussed mechanisms to manage stressors, including peer support, group-based and individual forms of coping.

CONCLUSIONS

The results suggest significant sources and manifestations of mental distress among this under-studied population. The discrepancy between qualitative evidence of abundant stressors and the comparatively low symptom scores may suggest marked mental resilience among subjects. The observed symptom score means in contrast with the qualitative evidence of abundant stressors may suggest the development of marked mental resilience among subjects. Alternatively, the discrepancy may reflect the inadequacy of standard screening tools not validated for this population and potential cultural inappropriateness of established diagnostic frameworks. The importance of peer-group support as a protective factor suggests that interventions might best serve healthworkers in conflict areas by emphasizing community- and team-based strategies.

Mental health status among Burmese adolescent students living in boarding houses in Thailand: a cross-sectional study

BACKGROUND

In Tak province of Thailand, a number of adolescent students who migrated from Burma have resided in the boarding houses of migrant schools. This study investigated mental health status and its relationship with perceived social support among such students.

METHODS

This cross-sectional study surveyed 428 students, aged 12-18 years, who lived in boarding houses. The Hopkins Symptom Checklist (HSCL)-37 A, Stressful Life Events (SLE) and Reactions of Adolescents to Traumatic Stress (RATS) questionnaires were used to assess participants' mental health status and experience of traumatic events. The Medical Outcome Study (MOS) Social Support Survey Scale was used to measure their perceived level of social support. Descriptive analysis was conducted to examine the distribution of sociodemographic characteristics, trauma experiences, and mental health status. Further, multivariate linear regression analysis was used to examine the association between such characteristics and participants' mental health status.

RESULTS

In total, 771 students were invited to participate in the study and 428 students chose to take part. Of these students, 304 completed the questionnaire. A large proportion (62.8%) indicated that both of their parents lived in Myanmar, while only 11.8% answered that both of their parents lived in Thailand. The mean total number of traumatic events experienced was 5.7 (standard deviation [SD] 2.9), mean total score on the HSCL-37A was 63.1 (SD 11.4), and mean total score on the RATS was 41.4 (SD 9.9). Multivariate linear regression analysis revealed that higher number of traumatic events was associated with more mental health problems.

CONCLUSIONS

Many students residing in boarding houses suffered from poor mental health in Thailand's Tak province. The number of traumatic experiences reported was higher than expected. Furthermore, these traumatic experiences were associated with poorer mental health status. Rather than making a generalized assumption on the mental health status of migrants or refugees, more detailed observation is necessary to elucidate the unique nature and vulnerabilities of this mobile population.

Molecular surveillance for drug-resistant Plasmodium falciparum in clinical and subclinical populations from three border regions of Burma/Myanmar: cross-sectional data and a systematic review of resistance studies

BACKGROUND

Confirmation of artemisinin-delayed parasite clearance in Plasmodium falciparum along the Thai-Myanmar border has inspired a global response to contain and monitor drug resistance to avert the disastrous consequences of a potential spread to Africa. However, resistance data from Myanmar are sparse, particularly from high-risk areas where limited health services and decades of displacement create conditions for resistance to spread. Subclinical infections may represent an important reservoir for resistance genes that confer a fitness disadvantage relative to wild-type alleles. This study estimates the prevalence of resistance genotypes in three previously unstudied remote populations in Myanmar and tests the a priori hypothesis that resistance gene prevalence would be higher among isolates collected from subclinical infections than isolates collected from febrile clinical patients. A systematic review of resistance studies is provided for context.

METHODS

Community health workers in Karen and Kachin States and an area spanning the Indo-Myanmar border collected dried blood spots from 988 febrile clinical patients and 4,591 villagers with subclinical infection participating in routine prevalence surveys. Samples positive for P. falciparum 18 s ribosomal RNA by real-time PCR were genotyped for P. falciparum multidrug resistance protein (pfmdr1) copy number and the pfcrt K76T polymorphism using multiplex real-time PCR.

RESULTS

Pfmdr1 copy number increase and the pfcrt K76 polymorphism were determined for 173 and 269 isolates, respectively. Mean pfmdr1 copy number was 1.2 (range: 0.7 to 3.7). Pfmdr1 copy number increase was present in 17.5%, 9.6% and 11.1% of isolates from Karen and Kachin States and the Indo-Myanmar border, respectively. Pfmdr1 amplification was more prevalent in subclinical isolates (20.3%) than clinical isolates (6.4%, odds ratio 3.7, 95% confidence interval 1.1 - 12.5). Pfcrt K76T prevalence ranged from 90-100%.

CONCLUSIONS

Community health workers can contribute to molecular surveillance of drug resistance in remote areas of Myanmar. Marginal and displaced populations under-represented among previous resistance investigations can and should be included in resistance surveillance efforts, particularly once genetic markers of artemisinin-delayed parasite clearance are identified. Subclinical infections may contribute to the epidemiology of drug resistance, but determination of gene amplification from desiccated filter samples requires further validation when DNA concentration is low.

Human rights research and ethics review: protecting individuals or protecting the state?

Joseph Amon and colleagues discuss the challenges of conducting human rights research in settings where local research ethics committees may favor the interests of the state over the interests of research participants.

War, forced displacement and growth in Laotian adults

BACKGROUND

Evidence from several populations suggests that war negatively impacts civilian nutrition, physical growth and overall health. This effect is often enduring or permanent, particularly if experienced early in life.

AIM

To assess whether the number of lifetime displacement experiences and being displaced in infancy were associated with adult height, sitting height, leg length and the sitting height ratio.

SUBJECTS AND METHODS

Retrospective questionnaires on displacement and resettlement experiences and anthropometric data were collected from a sample of Laotian adult refugees (ethnic Hmong and Lao; n = 365). All were born in Laos or Thailand and had resettled in French Guiana or the US. Many had been displaced several times by military conflict in Laos.

RESULTS

In bivariate analyses, being displaced in infancy and the number of lifetime displacement experiences one had were negatively associated with final adult height and leg length in both sexes. The association was stronger in females, particularly Hmong females. There was no significant association between total displacement experiences and the sitting height ratio. In multiple regression analyses, linear growth in males was negatively associated with being displaced in infancy; in females, the number of lifetime displacement experiences was a significant predictor.

CONCLUSION

Forced displacement from war appears to have a lasting effect on final adult height, sitting height and leg length, although not necessarily on the sitting height ratio in this sample.

Health and human rights in Chin State, Western Burma: a population-based assessment using multistaged household cluster sampling

BACKGROUND

The Chin State of Burma (also known as Myanmar) is an isolated ethnic minority area with poor health outcomes and reports of food insecurity and human rights violations. We report on a population-based assessment of health and human rights in Chin State. We sought to quantify reported human rights violations in Chin State and associations between these reported violations and health status at the household level.

METHODS AND FINDINGS

Multistaged household cluster sampling was done. Heads of household were interviewed on demographics, access to health care, health status, food insecurity, forced displacement, forced labor, and other human rights violations during the preceding 12 months. Ratios of the prevalence of household hunger comparing exposed and unexposed to each reported violation were estimated using binomial regression, and 95% confidence intervals (CIs) were constructed. Multivariate models were done to adjust for possible confounders. Overall, 91.9% of households (95% CI 89.7%-94.1%) reported forced labor in the past 12 months. Forty-three percent of households met FANTA-2 (Food and Nutrition Technical Assistance II project) definitions for moderate to severe household hunger. Common violations reported were food theft, livestock theft or killing, forced displacement, beatings and torture, detentions, disappearances, and religious and ethnic persecution. Self reporting of multiple rights abuses was independently associated with household hunger.

CONCLUSIONS

Our findings indicate widespread self-reports of human rights violations. The nature and extent of these violations may warrant investigation by the United Nations or International Criminal Court. Please see later in the article for the Editors' Summary.

Impact of community-based maternal health workers on coverage of essential maternal health interventions among internally displaced communities in eastern Burma: the MOM project

BACKGROUND

Access to essential maternal and reproductive health care is poor throughout Burma, but is particularly lacking among internally displaced communities in the eastern border regions. In such settings, innovative strategies for accessing vulnerable populations and delivering basic public health interventions are urgently needed.

METHODS

Four ethnic health organizations from the Shan, Mon, Karen, and Karenni regions collaborated on a pilot project between 2005 and 2008 to examine the feasibility of an innovative three-tiered network of community-based providers for delivery of maternal health interventions in the complex emergency setting of eastern Burma. Two-stage cluster-sampling surveys among ever-married women of reproductive age (15-45 y) conducted before and after program implementation enabled evaluation of changes in coverage of essential antenatal care interventions, attendance at birth by those trained to manage complications, postnatal care, and family planning services.

RESULTS

Among 2,889 and 2,442 women of reproductive age in 2006 and 2008, respectively, population characteristics (age, marital status, ethnic distribution, literacy) were similar. Compared to baseline, women whose most recent pregnancy occurred during the implementation period were substantially more likely to receive antenatal care (71.8% versus 39.3%, prevalence rate ratio [PRR] = 1.83 [95% confidence interval (CI) 1.64-2.04]) and specific interventions such as urine testing (42.4% versus 15.7%, PRR = 2.69 [95% CI 2.69-3.54]), malaria screening (55.9% versus 21.9%, PRR = 2.88 [95% CI 2.15-3.85]), and deworming (58.2% versus 4.1%, PRR = 14.18 [95% CI 10.76-18.71]. Postnatal care visits within 7 d doubled. Use of modern methods to avoid pregnancy increased from 23.9% to 45.0% (PRR = 1.88 [95% CI 1.63-2.17]), and unmet need for contraception was reduced from 61.7% to 40.5%, a relative reduction of 35% (95% CI 28%-40%). Attendance at birth by those trained to deliver elements of emergency obstetric care increased almost 10-fold, from 5.1% to 48.7% (PRR = 9.55 [95% CI 7.21-12.64]).

CONCLUSIONS

Coverage of maternal health interventions and higher-level care at birth was substantially higher during the project period. The MOM Project's focus on task-shifting, capacity building, and empowerment at the community level might serve as a model approach for similarly constrained settings.

Household exposure to violence and human rights violations in western Bangladesh (I): prevalence, risk factors and consequences

BACKGROUND

The ruling parties in Bangladesh have systematically used violence against political opponents and criminals. It is essential to 1) determine the magnitude and burden of organised crime and political violence (OPV) and human rights violations in the affected community, and to 2) identify the risk factors and key indicators for developing effective health intervention and prevention measures.

METHODS

The population-based study consisted of two parts: a household survey and OPV screening at mobile clinics (presented in Part II). A cross-sectional, multistage cluster household survey was conducted in the Meherpur district in February-March 2008; 22 clusters with a sample size of 1,101 households (population of 4,870) were selected.

RESULTS

Around 83% of households reported being exposed to at least two categories of OPV or human rights violations: 29% reported that the family members had been arrested or detained; 31% reported torture or other cruel, inhuman or degrading treatment or punishment. Crude mortality rate was 17.9/1,000 and under 5 mortality rate was 75/1,000. The annual injury rate was 36%, lifetime experience of violence-related injury was 50%, and pain experience within 2 weeks was reported by 57%. Over 80% of the population over 35 years old complained of pain. High prevalence of injury, lifetime experience of OPV-related injury and pain complaints are related to the level of exposure to OPV and human rights violations. A financial burden was imposed on families with an injured person. A geographical variation was revealed regarding reports of torture and lifetime experience of violence-related injury. A combination of individual, relational, community and societal factors, including variables such as political party affiliation, conflict with other families, household income and residential area, affected the risk of victimisation in the household. The odds ratio for reporting extrajudicial execution of a family member was 9.22 for Awami League supporters, 9.15 for Bangladesh Nationalist Party supporters; and 3.97 for Jamaat-e-Islami Party supporters compared with families with no political involvement.

CONCLUSION

The level of violence and human rights violations is high. The affected population suffers from violence-related injuries and traumas, which could be a factor contributing to poverty. Victimisation is not random.

Internally displaced human resources for health: villager health worker partnerships to scale up a malaria control programme in active conflict areas of eastern Burma

Approaches to expand malaria control interventions in areas of active conflict are urgently needed. Despite international agreement regarding the imperative to control malaria in eastern Burma, there are currently no large-scale international malaria programmes operating in areas of active conflict. A local ethnic health department demonstrated that village health workers are capable of implementing malaria control interventions among internally displaced persons (IDPs). This paper describes how these internally displaced villagers facilitated rapid expansion of the programme. Clinic health workers received training in malaria diagnosis and treatment, vector control and education at training sites along the border. After returning to programme areas inside Burma, they trained villagers to perform an increasingly comprehensive set of interventions. This iterative training strategy to increase human resources for health permitted the programme to expand from 3000 IDPs in 2003 to nearly 40,000 in 2008. It was concluded that IDPs are capable of delivering essential malaria control interventions in areas of active conflict in eastern Burma. In addition, health workers in this area have the capacity to train community members to take on implementation of such interventions. This iterative strategy may provide a model to improve access to care in this population and in other conflict settings.

Multi-level partnerships to promote health services among internally displaced in eastern Burma

Ethnic populations in eastern Burma are the target of military policies that result in forced labour, destruction of food supplies, and massive forced displacement. Despite international assistance to Burmese refugees along the Thai-Burma border, traditional humanitarian models have failed to reach these internally displaced persons (IDPs) within Burma. Nevertheless, through the cultivation of a model (cross border local-global partnerships) 300,000 IDPs in eastern Burma now receive critical health services where, otherwise, there would be none. We describe key elements of the partnership model's genesis in eastern Burma. The role of the local partner, Backpack Health Worker Team (BPHWT), is highlighted for its indigenous access to the IDP populations and its maintenance of programmatic autonomy. These local elements are potentiated by international support for technical assistance, training, resources, and advocacy. International policy and investment should prioritize support of locally-driven health initiatives that utilize local-global partnerships to reach not only IDPs but also other war-torn or traditionally inaccessible populations worldwide.

Essential trauma management training: addressing service delivery needs in active conflict zones in eastern Myanmar

INTRODUCTION

Access to governmental and international nongovernmental sources of health care within eastern Myanmar's conflict regions is virtually nonexistent. Historically, under these circumstances effective care for the victims of trauma, particularly landmine injuries, has been severely deficient. Recognizing this, community-based organizations (CBOs) providing health care in these regions sought to scale up the capacity of indigenous health workers to provide trauma care.

CASE DESCRIPTION

The Trauma Management Program (TMP) was developed by CBOs in cooperation with a United States-based health care NGO. The goal of the TMP is to improve the capacity of local health workers to deliver effective trauma care. From 2000 to the present, international and local health care educators have conducted regular workshops to train indigenous health workers in the management of landmine injuries, penetrating and blunt trauma, shock, wound and infection care, and orthopedics. Health workers have been regularly resupplied with the surgical instruments, supplies and medications needed to provide the care learnt through TMP training workshops.

DISCUSSION AND EVALUATION

Since 2000, approximately 300 health workers have received training through the TMP, as part of a CBO-run health system providing care for approximately 250,000 internally displaced persons (IDPs) and war-affected residents. Based on interviews with health workers, trauma registry inputs and photo/video documentation, protocols and procedures taught during training workshops have been implemented effectively in the field. Between June 2005 and June 2007, more than 200 patients were recorded in the trauma patient registry. The majority were victims of weapons-related trauma.

CONCLUSION

This report illustrates a method to increase the capacity of indigenous health workers to manage traumatic injuries. These health workers are able to provide trauma care for otherwise inaccessible populations in remote and conflicted regions. The principles learnt during the implementation of the TMP might be applied in similar settings.

Community-based delivery of maternal care in conflict-affected areas of eastern Burma: perspectives from lay maternal health workers

In settings where active conflict, resource scarcity, and logistical constraints prevail, provision of maternal health services within health centers and hospitals is unfeasible and alternative community-based strategies are needed. In eastern Burma, such conditions necessitated implementation of the "Mobile Obstetric Maternal Health Worker" (MOM) project, which has employed a community-based approach to increase access to essential maternal health services including emergency obstetric care. Lay Maternal Health Workers (MHWs) are central to the MOM service delivery model and, because they are accessible to both the communities inside Burma and to outside project managers, they serve as key informants for the project. Their insights can facilitate program and policy efforts to overcome critical delays and insufficient management of maternal complications linked to maternal mortality. Focus group discussions (n=9), in-depth interviews (n=18), and detailed case studies (n=14) were collected from MHWs during centralized project management meetings in February and October of 2007. Five case studies are presented to characterize and interpret the realities of reproductive health work in a conflict-affected setting. Findings highlight the process of building supportive networks and staff ownership of the MOM project, accessing and gaining community trust and participation to achieve timely delivery of care, and overcoming challenges to manage and appropriately deliver essential health services. They suggest that some emergency obstetric care services that are conventionally delivered only within healthcare settings might be feasible in community or home-based settings when alternatives are not available. This paper provides an opportunity to hear directly from community-based workers in a conflict setting, perspectives seldom documented in the scientific literature. A rights-based approach to service delivery and its suitability in settings where human rights violations are widespread is highlighted.

Access to essential maternal health interventions and human rights violations among vulnerable communities in eastern Burma

BACKGROUND

Health indicators are poor and human rights violations are widespread in eastern Burma. Reproductive and maternal health indicators have not been measured in this setting but are necessary as part of an evaluation of a multi-ethnic pilot project exploring strategies to increase access to essential maternal health interventions. The goal of this study is to estimate coverage of maternal health services prior to this project and associations between exposure to human rights violations and access to such services.

METHODS AND FINDINGS

Selected communities in the Shan, Mon, Karen, and Karenni regions of eastern Burma that were accessible to community-based organizations operating from Thailand were surveyed to estimate coverage of reproductive, maternal, and family planning services, and to assess exposure to household-level human rights violations within the pilot-project target population. Two-stage cluster sampling surveys among ever-married women of reproductive age (15-45 y) documented access to essential antenatal care interventions, skilled attendance at birth, postnatal care, and family planning services. Mid-upper arm circumference, hemoglobin by color scale, and Plasmodium falciparum parasitemia by rapid diagnostic dipstick were measured. Exposure to human rights violations in the prior 12 mo was recorded. Between September 2006 and January 2007, 2,914 surveys were conducted. Eighty-eight percent of women reported a home delivery for their last pregnancy (within previous 5 y). Skilled attendance at birth (5.1%), any (39.3%) or > or = 4 (16.7%) antenatal visits, use of an insecticide-treated bed net (21.6%), and receipt of iron supplements (11.8%) were low. At the time of the survey, more than 60% of women had hemoglobin level estimates < or = 11.0 g/dl and 7.2% were Pf positive. Unmet need for contraceptives exceeded 60%. Violations of rights were widely reported: 32.1% of Karenni households reported forced labor and 10% of Karen households had been forced to move. Among Karen households, odds of anemia were 1.51 (95% confidence interval [CI] 0.95-2.40) times higher among women reporting forced displacement, and 7.47 (95% CI 2.21-25.3) higher among those exposed to food security violations. The odds of receiving no antenatal care services were 5.94 (95% CI 2.23-15.8) times higher among those forcibly displaced.

CONCLUSIONS

Coverage of basic maternal health interventions is woefully inadequate in these selected populations and substantially lower than even the national estimates for Burma, among the lowest in the region. Considerable political, financial, and human resources are necessary to improve access to maternal health care in these communities.

Accessing maternal health services in eastern Burma

Macaya Douoguih discusses a retrospective household survey that characterized the relationships between access to care, health status, and human rights violations in eastern Burma.

The dirty war index: a public health and human rights tool for examining and monitoring armed conflict outcomes

Madelyn Hsiao-Rei Hicks and Michael Spagat introduce the "Dirty War Index," a public health tool that identifies rates of undesirable or prohibited war outcomes inflicted on populations during armed conflict.