Introduction to collection: confronting the challenges of health research in humanitarian crises

Physiological and genomic signatures of war and displacement: A comprehensive literature review and future directions

There are now 108.4 million forcibly displaced people worldwide, many of whom endure adversities that result in trauma, toxic stress, and potentially, altered epigenetic development. This paper provides a comprehensive review of current literature on the biological signatures of war and forced migration among refugee populations. To consolidate evidence and identify key concerns and avenues for future research, we reviewed 36 publications and one article under review, published since 2000, most of which focused on refugees relocated in Europe and the Middle East. This body of work - including cross-sectional, observational, and experimental studies - reveals heterogenous findings regarding human biological responses to war-related adversities and their associations with health outcomes. We conclude with four main observations, regarding why genomic and physiological biomarkers are valuable, what study designs advance understanding of causality and health-promoting interventions, how to prepare for ethical challenges, and why theoretical frameworks and research procedures need more detailed consideration in scientific publications.

Volunteer programs, empowerment, and life satisfaction in Jordan: mapping local knowledge and systems change to inform public policy and science diplomacy

Introduction

Volunteering in the community is thought to provide unique benefits to people who experience limited engagement in society. In the global South, volunteer programs are often framed as empowering women and benefiting the poor, without empirical evidence or systematic investigation of what this means from a local perspective. For this reason, it is critical to represent stakeholder knowledge, understand how change happens systemically, and reduce cultural bias in scientific inquiry and public policy. As such, efforts to respect diverse narratives and problem-solving approaches are key to science diplomacy - they help us understand cultural relevance, program efficacy, and for whom a program is considered transformative.

Methods and results

This study shows how Syrian refugee and Jordanian women, living in resource-poor families, articulated (i) concepts of empowerment and life satisfaction and (ii) the benefits of engaging in community-based volunteering programs. Through engaging in a participatory methodology known as Fuzzy Cognitive Mapping, women generated visual representations of these constructs and cause-and-effect reasoning. They identified several dimensions of empowerment (e.g., cultural, financial, and psychological empowerment) and several meanings of life satisfaction (e.g. adaptation, acceptance, and contentment). They also mapped connections between variables, identifying those that might catalyze change. We were specifically interested in evaluating understandings of We Love Reading, a program that trains volunteers to become changemakers in their local community. In simulations, we modelled how employment, education, money, and volunteering would drive system change, with notable results on cultural empowerment.

Discussion

Through visual maps and scenarios of change, the study demonstrates a participatory approach to localizing knowledge and evaluating programs. This is key to improving scientific enquiry and public policy.

The Role of Water, Sanitation and Hygiene (WaSH) Interventions on Health and Behavioral Outcomes during Humanitarian Crisis: A Systematic Review and Meta-Analysis

Background

In humanitarian crises, water, sanitation and hygiene interventions are critical for the survival of people. However, strong evidence-based information is still limited. In order to describe the quantity and quality of current evidence, we conducted an evidence gap map provides a visual overview, highlighting areas lacking evidence.

Methods

According to developed inclusion and exclusion criteria, a systematic literature search was conducted to find related systematic reviews and meta-analyses. The databases, including PubMed, Web of Science, SCOPUS and Cochrane were searched using search strings from 2000 until 2021. Characteristics of the included reviews were extracted and summarized. Two persons evaluated methodological quality independently using the AMSTAR tool. Invite a third person to solve any discrepancies.

Results

This study revealed seven systematic reviews, including one meta-analysis. One study was of high quality, four of medium, and two of low quality. A total of 272 primary studies were included with a median value of 38.8 (range, 6-106) which deeply analyzed for data extraction. Cross-sectional, case-control, and qualitative case studies were the most used study designs. Diarrheal diseases were the most reported outcomes representing 46% of the impact evaluations. Cholera outbreaks account for 43% of a crisis context. The research gaps were insufficient reporting of some interventions with related outcomes and the geographical distribution of current evidence.

Conclusion

There is a limitation in current evidence represented by a lack of high-quality and experimental studies investigate the impact of water, sanitation and hygiene (WaSH) interventions on health and behavioral outcomes in humanitarian sittings.

Pathways to resilience and pathways to flourishing: Examining the added-value of multisystem research and intervention in contexts of war and forced displacement

This paper examines the added-value that multisystem approaches bring to research and intervention in contexts of war and forced displacement. I highlight what is useful and truly innovative about systems-level work, aware that providing data-related evidence is only part of the story when connecting research to policy and practice. I discuss four types of added-value: these are conceptual, instrumental, capacity-building, and connectivity impacts that, respectively, aim to change current knowledge, improve implementation, build research skills, and strengthen network connectivity. Specifically, systems-based research can help transform the key frames of humanitarian work, fostering the more integrated and distributive models of professional assistance known as resilience and network humanitarianism. I argue that systems-level approaches on resilience and flourishing in war-affected and refugee populations help to articulate new mindsets, methodologies, partnerships, and ways of working relevant for humanitarian research, policy and practice. I focus attention on interdisciplinary, interventionist, prospective, transgenerational, and network-building initiatives. My specific examples cover the family context of mental health and trauma memory in Afghanistan, as well as program evaluation with Syrian refugees in Jordan, connecting stress biology to human experience, and social networks to psychological empowerment. The paper suggests future directions to support more effective and impactful systems-level work in protracted humanitarian crises.

The Integration of Social Science for Community Engagement in the Humanitarian Fields of Conflicts and Disasters: A Scoping Review

Community engagement (CE) is essential to humanitarian assistance, and the social sciences have been credited in recent epidemics and disease outbreaks as having played a crucial, supportive role. Broadening this attention to other humanitarian fields, this scoping review asks what lessons learned can be found in grey and peer-reviewed literature on the integration of the social sciences in CE for conflicts and disasters. Using an analytical framework developed through a UNICEF-led project called Social Science for Community Engagement (SS4CE) in Humanitarian Action, we identified 1093 peer reviewed publications and 315 grey literature reports of possible relevance. The results show that only a small minority-18 publications and 4 reports-tangibly comment on the relevance of social sciences, mostly only in passing and implicitly. While social science techniques are used and the importance of understanding a community's cultural, linguistic, and religious context is emphasized, further discussion on the integration of transdisciplinary and multidisciplinary social sciences is absent. Furthermore, CE is mostly seen as an instrumental ('means to an end') involvement, for example to collect data in emergency situations and receive feedback on interventions, but not as a critical and transformative intervention. We conclude that unlike the attention given to social sciences in disease outbreaks, there is a knowledge gap and an accordingly proper planning and implementation gap regarding the potentiality of social science to improve CE across all humanitarian contexts of disasters and conflicts.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Process evaluations of mental health and psychosocial support interventions for populations affected by humanitarian crises

BACKGROUND

Randomised controlled trials (RCTs) have been increasingly used to test the effectiveness of mental health and psychosocial support(MHPSS) interventions for populations affected by humanitarian crises. Process evaluations are often integrated within RCTs of psychological interventions to investigate the implementation of the intervention, the impact of context, and possible mechanisms of action. We aimed to explore limitations and strengths of how process evaluations are currently conceptualised and implemented within MHPSS RCTs specifically.

METHODS

In April-June 2021 we conducted semi-structured interviews with 24 researchers involved in RCTs of MHPSS interventions in 23 different countries. Participants were selected based on systematic reviews of MHPSS interventions, funders' databases, and personal networks. Data were analysed using codebook thematic analysis.

RESULTS

The conduct of process evaluations was characterized by high heterogeneity in perceived function, implementation outcomes assessed, and methods used. While process evaluations were overwhelmingly considered as an important component of an RCT, there were different opinions on their perceived quality. This could be explained by the varying prioritization of effectiveness data over implementation data, confusion around the nature of process evaluations, and challenges in the collection and analysis of process data in humanitarian settings. Various practical recommendations were made by participants to improve future process evaluations in relation to: (i) study design (e.g., embedding process evaluations in study protocol and overall study objectives); (ii) methods (e.g., use of mixed methods); and (iii) increased financial and human resources dedicated to process evaluations.

CONCLUSION

The current state of process evaluations in MHPSS RCTs is heterogeneous. The quality of process evaluations should be improved to strengthen implementation science of the growing number of evidence-informed MHPSS interventions.

Case Series: Managing Severe Mental Illness in Disaster Situation: the Croatian Experience After 2020 Earthquake

On the 29th of December 2020, amidst the COVID-19 pandemic, Petrinja in the Croatian Sisak-Moslavina County experienced a strong earthquake, resulting in a severe disruption in mental health service delivery. Specialized care community mental health teams were introduced days within the event with the aim to bridge the gap in psychiatric care that was severely disturbed in the region affected by the earthquake. Through a case series of patients with SMI, we describe how care was quickly deployed and delivered after a natural disaster and during a pandemic resulting in their functional recovery. Community mental health teams have the potential to provide feasible, comprehensive, and accessible mental health services, and their continued implementation in the post-disaster period in Croatia could be beneficial for care management of people with severe mental illness.