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

Does multidisciplinary rehabilitation of tortured refugees represent 'value-for-money'? A follow-up of a Danish case-study

BACKGROUND

The recent surge of asylum seekers in the European Union (EU) is raising questions about the EU's ability to integrate newcomers into the economy and into society; particularly those who need specialized services for the treatment of severe trauma. This study investigated whether rehabilitating traumatised refugees represents 'value-for-money' (VfM) in terms of intervention cost per health gain and in a long-term and societal perspective.

METHODS

The economic evaluation comprised a cost-utility analysis (CUA) and a partial cost-benefit analysis (CBA). The CUA incorporated data on Quality Adjusted Life Years (QALY) for 45 patients who were treated at the Rehabilitation and Research Centre for Torture Victims, Copenhagen, Denmark, in 2001-2004 and followed for up to 2 years, to determine the incremental cost effectiveness ratio (ICER). For the CBA, data was collected for 44 patients who completed treatment between 2001 and 2004 and 44 matched controls on the waiting list, for the patients' primary health care utilisation, and personal and family labour income from 2001 to 2014. This was analysed to evaluate the Net Social Benefit (NSB) of the programme.

RESULTS

The average cost of treatment was found to be about 32,000 USD per patient (2016 prices) with an average gain in QALY of 0.82. The treatment was cost effective according to the ICER threshold suggested by the National Institute of Health and Care Excellence (UK). At the individual level, the NSB remained negative throughout the study period. However, at the family income level the intervention proved to have been beneficial after 3 years.

CONCLUSION

The implication of the study is, that providing rehabilitation to severely traumatised refugee families can be an economically viable strategy, considering the economic effects observed at the family level.

Global health: injuries and violence

Injury and violence rank among the leading causes of death worldwide, with more than 5 million deaths annually, representing a significant portion of the global burden of disease. This article examines how injury and violence relate to global health using recent global burden of disease data and selected key studies and databases, and further explores risk factors and intervention initiatives that address unintentional and intentional injuries. The article serves as a call to action to enhance understanding of the growing burden of injury and violence, especially in low-income and middle-income countries, where more than 90% of injuries occur.

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.

Survivors of war in the Northern Kosovo (II): baseline clinical and functional assessment and lasting effects on the health of a vulnerable population

BACKGROUND

This study documents torture and injury experience and investigates emotional well-being of victims of massive violence identified during a household survey in Mitrovicë district in Kosovo. Their physical health indicators such as body mass index (BMI), handgrip strength and standing balance were also measured. A further aim is to suggest approaches for developing and monitoring rehabilitation programmes.

METHODS

A detailed assessment was carried out on 63 male and 62 female victims. Interviews and physical examination provided information about traumatic exposure, injuries, and intensity and frequency of pain. Emotional well-being was assessed using the "WHO-5 Well-Being" score. Height, weight, handgrip strength and standing balance performance were measured.

RESULTS

Around 50% of victims had experienced at least two types of torture methods and reported at least two injury locations; 70% had moderate or severe pain and 92% reported constant or periodic pain within the previous two weeks. Only 10% of the victims were in paid employment. Nearly 90% of victims had experienced at least four types of emotional disturbances within the previous two weeks, and many had low scores for emotional well-being. This was found to be associated with severe pain, higher exposure to violence and human rights violations and with a low educational level, unemployment and the absence of political or social involvement.Over two thirds of victims were overweight or obese. They showed marked decline in handgrip strength and only 19 victims managed to maintain standing balance. Those who were employed or had a higher education level, who did not take anti-depressant or anxiety drugs and had better emotional well-being or no pain complaints showed better handgrip strength and standing balance.

CONCLUSIONS

The victims reported a high prevalence of severe pain and emotional disturbance. They showed high BMI and a reduced level of physical fitness. Education, employment, political and social participation were associated with emotional well-being. Interventions to promote physical activity and social participation are recommended. The results indicate that the rapid assessment procedure used here offers an adequate tool for collecting data for the monitoring of health interventions among the most vulnerable groups of a population exposed to violence.

Survivors of the war in the Northern Kosovo: violence exposure, risk factors and public health effects of an ethnic conflict

BACKGROUND

The aim of this population-based study was to assess the long-lasting effects of ethnic conflict on health and well-being (with a focus on injury and persistent pain) at family and community level. We have also investigated possible risk factors for victimisation during the conflict and factors contributing to healing.

METHODS

We conducted a district-level cross-sectional cluster survey of 1,115 households with a population of 6,845. Interviews were carried out in Mitrovicë district in Northern Kosovo from September to October 2008, using standardised questionnaire to collect lifetime violence exposure, lifestyle factors and health information on individual and household.

RESULTS

Ethnic Albanians made up 95% of the sample population. Crude mortality and under-five mortality rate was not high in 2008. Over 90% of families had been exposed to at least two categories of violence and human rights violations, and 493 individuals from 341 families reported torture experiences. During the two weeks before the survey, 20% of individuals had suffered physical or mental pain. There were differences in pain complaints according to gender and age, and whether people had been injured within 12 months, had lifetime exposure to violence-related injury, or had been tortured. Patterns of social and political participation in a family could affect the proportion of family members complaining of pain. The proportion of family members with pain complaints was related to a decline in the household income (coef = 9.31, 95% CI = 6.16-12.46, P < 0.001) and the fact of borrowing money (coef = 6.11, 95% CI = 2.91-9.30, P < 0.001) because of an injured person in the household. Families that were affiliated with the Kosovo Liberation Army, or had participated in a protest before or during the war, were likely to be targeted by Serbian paramilitary and law enforcement agencies.

CONCLUSIONS

Mitrovicë district is currently characterised by a low level of violence, but the effects of ethnic conflict on health and well-being have not gone. The level of lifetime exposure to violence, the proportion of family members reporting pain and lifetime violence-related injury, and family's financial burden were found to be inter-correlated. The sample confined to one ethnic group in one district limits the generalizability of the findings.

Household exposure to violence and human rights violations in western Bangladesh (II): history of torture and other traumatic experience of violence and functional assessment of victims

BACKGROUND

Organised crime and political violence (OPV) and human rights violations have marred Bangladesh history since 1971. Little is known about the consequences for the oppressed population. This study describes the patterns of OPV and human rights violations in a disturbed area of Bangladesh and assesses the physical, emotional and social functioning of victims.

METHODS

A total of 236 of selected participants in a household survey in Meherpur district were recruited for a detailed study. Interviews and physical examinations were used to obtain information about history of torture and other cruel, inhuman or degrading treatment or punishment (TCIDTP), and about injuries, pain frequency and intensity. Handgrip strength and standing balance performance were measured. The "WHO-5 Well-being" scale was used to assess the subjective emotional well-being of study participants.

RESULTS

The majority of the reported cases of TCIDTP occurred in 2000-2008, 51% of incidents occurred during winter; 32.0% between 20:00 and midnight. Police involvement was reported in 75% of cases. Incidents took place at victims' homes (46.7%), or at the police station, military camp, in custody or in prison (21.9%). Participants experienced 1-10 TCIDTP methods and reported 0-6 injury locations on their bodies; 77.5% reported having at least two injuries. Less than half of the participants were able to stand on one leg for 30 seconds. Only 7.5% of males aged 25-44 had handgrip strength in both hands exceeding average values for healthy people at the same age. Over 85% of participants scored low (<13) on the 25-point "WHO-5 Well-being" scale. The number of years since the TCIDTP event, pain frequency, the need to quit a job to take care of an injured family member, political involvement, personal conflicts and the fear of neighbourhood violence strongly affected emotional well-being. Good emotional well-being correlated with increased political and social participation.

CONCLUSION

A detailed picture of characteristics of the victimisation is presented. The participants showed poor emotional well-being and reduced physical capacity. The results indicated that the simple and rapid method of assessment used here is a promising tool that could be used to monitor the quality and outcome of rehabilitation.