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Schmid B, Njeim C, Vijayasingham L, Sanga LA, Naimi RK, Fouad FM, Akik C, Zmeter C, Perone SA, Larsen LB, Roswall J, Ansbro É, Perel P. Implementing (and evaluating) peer support with people living with noncommunicable diseases in humanitarian settings. J Migr Health 2024; 9:100229. [PMID: 38633280 PMCID: PMC11021823 DOI: 10.1016/j.jmh.2024.100229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
In line with the peer reviewers comments, the authors have added highlights in stead of an abstract. It was felt that it was better able to capture the findings and is more in line with the paper's target audience.
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Affiliation(s)
- Benjamin Schmid
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Lavanya Vijayasingham
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Leah Anku Sanga
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | | | - Carla Zmeter
- International Committee of the Red Cross, Beirut, Lebanon
| | - Sigiriya Aebischer Perone
- International Committee of the Red Cross, Geneva, Switzerland
- Geneva University Hospitals, Geneva, Switzerland
| | | | | | - Éimhín Ansbro
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Pablo Perel
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Willis R, Akik C, El-Dirani Z, Truppa C, Zmeter C, Fleri F, Perone SA, Paci R, Frederiksen S, Haidar CA, Hamadeh RS, Fouad FM, Perel P, Roberts B, Ansbro É. Patient experiences of diabetes and hypertension care during an evolving humanitarian crisis in Lebanon: A qualitative study. PLOS Glob Public Health 2023; 3:e0001383. [PMID: 38055706 DOI: 10.1371/journal.pgph.0001383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/19/2023] [Indexed: 12/08/2023]
Abstract
Humanitarian health care models increasingly incorporate care for non-communicable diseases (NCDs). Current research evidence focuses on burden of disease, service provision and access to care, and less is known about patient's experience of the continuum of care in humanitarian settings. To address this gap, this study explored experiences of displaced Syrian and vulnerable Lebanese patients receiving care for hypertension and/or diabetes at four health facilities supported by humanitarian organisations in Lebanon. We conducted in-depth, semi-structured qualitative interviews with a purposive sample of patients (n = 18) and their informal caregivers (n = 10). Data were analysed thematically using both deductive and inductive approaches. Both Syrian and Lebanese patients reported interrupted pathways of care. We identified three typologies of patient experience at the time of interview; (1) managing adequately from the patient's perspective; (2) fragile management and (3) unable to manage their condition(s) adequately, with the majority falling into typologies 2 and 3. Patients and their families recognised the importance of maintaining continuity of care and self-management, but experienced substantial challenges due to changing availability and cost of medications and services, and decreasing economic resources during a period of national crises. Family support underpinned patient's response to challenges. Navigating the changing care landscape was a significant burden for patients and their families. Interactions were identified between mental health and NCD management. This study suggests that patients experienced disrupted, non-linear pathways in maintaining care for hypertension and diabetes in a humanitarian setting, and family support networks were key in absorbing treatment burden and sustaining NCD management. Recommendations are made to reduce treatment burden for patients and their families and to support sustainable condition management.
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Affiliation(s)
- Ruth Willis
- Faculty of Public Health and Policy, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chaza Akik
- Faculty of Health Sciences, Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
| | - Zeinab El-Dirani
- Faculty of Health Sciences, Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
| | - Claudia Truppa
- International Committee of the Red Cross, Beirut, Lebanon
| | - Carla Zmeter
- International Committee of the Red Cross, Beirut, Lebanon
| | - Fabrizio Fleri
- International Committee of the Red Cross, Beirut, Lebanon
| | - Sigiriya Aebischer Perone
- International Committee of the Red Cross, Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | | | | | | | - Randa S Hamadeh
- Primary Healthcare and Social Health Department, Ministry of Public Health, Lebanon
| | - Fouad M Fouad
- Faculty of Health Sciences, Department of Epidemiology and Population Health, American University of Beirut, Lebanon
| | - Pablo Perel
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Bayard Roberts
- Faculty of Public Health and Policy, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Éimhín Ansbro
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Ismail SA, Tomoaia-Cotisel A, Noubani A, Fouad FM, Bell S, Borghi J, Blanchet K. Resilience in childhood vaccination: analysing delivery system responses to shocks in Lebanon. BMJ Glob Health 2023; 8:e012399. [PMID: 37931939 PMCID: PMC10632819 DOI: 10.1136/bmjgh-2023-012399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 09/09/2023] [Indexed: 11/08/2023] Open
Abstract
INTRODUCTION Despite rapidly growing academic and policy interest in health system resilience, the empirical literature on this topic remains small and focused on macrolevel effects arising from single shocks. To better understand health system responses to multiple shocks, we conducted an in-depth case study using qualitative system dynamics. We focused on routine childhood vaccination delivery in Lebanon in the context of at least three shocks overlapping to varying degrees in space and time: large-scale refugee arrivals from neighbouring Syria; COVID-19; and an economic crisis. METHODS Semistructured interviews were performed with 38 stakeholders working at different levels in the system. Interview transcripts were analysed using purposive text analysis to generate individual stakeholder causal loop diagrams (CLDs) mapping out relationships between system variables contributing to changes in coverage for routine antigens over time. These were then combined using a stepwise process to produce an aggregated CLD. The aggregated CLD was validated using a reserve set of interview transcripts. RESULTS Various system responses to shocks were identified, including demand promotion measures such as scaling-up community engagement activities and policy changes to reduce the cost of vaccination to service users, and supply side responses including donor funding mobilisation, diversification of service delivery models and cold chain strengthening. Some systemic changes were introduced-particularly in response to refugee arrivals-including task-shifting to nurse-led vaccine administration. Potentially transformative change was seen in the integration of private sector clinics to support vaccination delivery and depended on both demand side and supply side changes. Some resilience-promoting measures introduced following earlier shocks paradoxically increased vulnerability to later ones. CONCLUSION Flexibility in financing and human resource allocation appear key for system resilience regardless of the shock. System dynamics offers a promising method for ex ante modelling of ostensibly resilience-strengthening interventions under different shock scenarios, to identify-and safeguard against-unintended consequences.
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Affiliation(s)
- Sharif A Ismail
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Aya Noubani
- Institute for Global Health and Development, Queen Margaret University, Musselburgh, UK
| | - Fouad M Fouad
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Sadie Bell
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Karl Blanchet
- Geneva Center of Humanitarian Studies, University of Geneva, Geneva, Switzerland
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Shamieh O, Kutluk T, Fouad FM, Sullivan R, Mansour A. Editorial: Cancer care in areas of conflict. Front Oncol 2023; 13:1301552. [PMID: 38023225 PMCID: PMC10646180 DOI: 10.3389/fonc.2023.1301552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Omar Shamieh
- Center for Palliative & Cancer Care in Conflict (CPCCC), King Hussein Cancer Centre (KHCC), Amman, Jordan
- Department of Palliative Care, King Hussein Cancer Centre (KHCC), Amman, Jordan
- Faculty of Medicine, the University of Jordan, Amman, Jordan
| | - Tezer Kutluk
- Department of Pediatric Oncology, Hacettepe University Faculty of Medicine and Cancer Institute, Ankara, Türkiye
| | - Fouad M. Fouad
- Department of Epidemiology & Population Health, the American University of Beirut, Beirut, Lebanon
| | - Richard Sullivan
- Institute of Cancer Policy & Conflict & Health Research Group, King’s College London, London, United Kingdom
| | - Asem Mansour
- Center for Palliative & Cancer Care in Conflict (CPCCC), King Hussein Cancer Centre (KHCC), Amman, Jordan
- Department of Radiology, King Hussein Cancer Centre (KHCC), Amman, Jordan
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Abboud S, Seal DW, Pachankis JE, Khoshnood K, Khouri D, Fouad FM, Heimer R. Experiences of stigma, mental health, and coping strategies in Lebanon among Lebanese and displaced Syrian men who have sex with men: A qualitative study. Soc Sci Med 2023; 335:116248. [PMID: 37742387 DOI: 10.1016/j.socscimed.2023.116248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND In Lebanon, men who have sex with men (MSM) face high rates of stigma, discrimination, and violence. Minority stress, or the unique stressors related to anti-MSM stigma and discrimination, negatively impacts the mental health of MSM. These stressors are heightened for those with intersectional minority identities such as displaced Syrian MSM in Lebanon. METHODS In this qualitative study conducted in 2020-21, part of a larger study focused on the mental and sexual health risks among MSM, we collected qualitative data from Lebanese and displaced Syrian MSM living in Lebanon and analyzed reports of their experiences with stigma, mental health, and coping strategies. We conducted semi-structured, in-depth interviews with 12 displaced Syrian MSM and 13 Lebanese MSM. RESULTS Our findings highlight how MSM in Lebanon navigate stigma and the mental health risks that result. Common stressors among Lebanese and displaced Syrian MSM were related to finances, sexual orientation discrimination, and social isolation. Comparing the two groups, we found that stressors specific to displaced Syrian MSM were related to adverse childhood experiences, recent exposure to the Syrian war, displacement, and discrimination in Lebanon based on their intersectional identities as MSM and Syrians. For Lebanese participants, the most common stigma coping strategies were avoidance, drinking alcohol, using drugs, or having sex. As for displaced Syrian MSM, the most common stigma coping strategy was seeking the freely available mental health services offered to them through non-governmental organizations. CONCLUSION Our findings suggest that increased targeted mental health and social support interventions, informed by the unique experiences of Lebanese and displaced Syrian MSM, are highly needed to improve the coping and mental health resources of all MSM in Lebanon.
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Affiliation(s)
- Sarah Abboud
- University of Illinois Chicago College of Nursing, 845 S. Damen Ave, Chicago, IL, 60612, USA
| | - David W Seal
- Tulane University School of Public Health & Tropical Medicine, 1440 Canal St, New Orleans, LA, 70112, USA.
| | - John E Pachankis
- Yale School of Public Health, Department of Epidemiology of Microbial Diseases, 60 College St, New Haven, CT, 06510, USA
| | - Kaveh Khoshnood
- Yale School of Public Health, Department of Epidemiology of Microbial Diseases, 60 College St, New Haven, CT, 06510, USA
| | - Danielle Khouri
- American University of Beirut, Faculty of Health Sciences, Bliss Street, Beirut, Lebanon
| | - Fouad M Fouad
- American University of Beirut, Faculty of Health Sciences, Bliss Street, Beirut, Lebanon
| | - Robert Heimer
- Yale School of Public Health, Department of Epidemiology of Microbial Diseases, 60 College St, New Haven, CT, 06510, USA
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Jabbour S, Abbara A, Ekzayez A, Fouad FM, Katoub M, Nasser R. The catastrophic response to the earthquake in Syria: the need for corrective actions and accountability. Lancet 2023; 401:802-805. [PMID: 36893775 DOI: 10.1016/s0140-6736(23)00440-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 03/08/2023]
Affiliation(s)
- Samer Jabbour
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
| | - Aula Abbara
- Syria Public Health Network, London, UK; Imperial College London, London, UK
| | - Abdulkarim Ekzayez
- Syria Public Health Network, London, UK; King's College London, London, UK
| | - Fouad M Fouad
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon; Syria Public Health Network, London, UK; King's College London, London, UK
| | - Mohamad Katoub
- IMPACT, Civil Society Research and Development, Berlin, Germany
| | - Rabie Nasser
- Syrian Centre for Policy Research, Vienna, Austria
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Kaloti R, Fouad FM. Between life & death: Political economy of breast cancer care for refugee populations in Lebanon. J Cancer Policy 2023; 35:100377. [PMID: 36529449 DOI: 10.1016/j.jcpo.2022.100377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/25/2022] [Accepted: 11/27/2022] [Indexed: 12/23/2022]
Abstract
Refugees and displaced groups have been shown to face increased risk of developing advanced cancer stages. This has been shown to be evident in Lebanon, whereby refugees are detected at later stages when compared to the Lebanese population. Lebanon is one of the biggest host (per capita) of refugees worldwide, and suffers from difficult political situation, compounded by an economic crisis, the COVID-19 pandemic and a blast which hit the capital Beirut in 2020. The main determinants of poor health outcomes among migrant populations in Lebanon include a fragmented and inequitable healthcare system and legal constraints to healthcare accessibility. The health care system is largely privatised with multiple health systems operating simultaneously for different nationalities. The current multi-crisis situation has exacerbated the fragility of the health system and its ability to cope with increasing needs. On the other hand, legal constraints for refugees to obtain residency in Lebanon has also contributed to insufficient access to health care and poor health outcomes among this population. Health system reforms, improved emergency preparedness and response measures, and an ease on legal and political restrictions for the refugee populations in Lebanon are considered key policy recommendations to ensure refugees right to health in Lebanon.
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Fouad FM, Hashoush M, Diab JL, Nabulsi D, Bahr S, Ibrahim S, Farhat T, Kobeissi L. Perceived facilitators and barriers to the provision of sexual and reproductive health services in response to the Syrian refugee crisis in Lebanon. Womens Health (Lond) 2023; 19:17455057231171486. [PMID: 37209110 PMCID: PMC10201148 DOI: 10.1177/17455057231171486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND The Syrian crisis has resulted in one of the worst humanitarian disasters in modern history. Inadequate access to and use of sexual and reproductive health services is a prevailing issue among adolescent girls and young refugee women in humanitarian settings. OBJECTIVES This article aimed to explore and describe the perceived extent of implementation of the different objectives and activities outlined within the minimum initial service package for reproductive health in crisis services in Lebanon, from the perspectives of a diverse set of stakeholders from leading organizations (public, private, primary health centers, nongovernmental organizations) that were directly engaged with the Syrian refugee crisis response. DESIGN This study is a cross-sectional survey conducted using a standardized and validated questionnaire. METHODS Centers that provided sexual and reproductive health services to Syrian refugees in Lebanon were mapped. The study was based on a purposive sampling approach, retrieving 52 eligible organizations to cover most areas in the country. A total of 43 centers accepted to take part in the study. The head of the center was then asked to identify one person in their center who holds adequate knowledge of the explained objectives of the survey. Accordingly, the identified person was asked to fill out the survey. RESULTS A considerable portion of the respondents had limited knowledge about the specific minimum initial service package objectives and related sexual and reproductive health services. The study found the presence of a leading reproductive health agency, the Lebanese MoPH, as an essential facilitating factor for sexual and reproductive health service provision in Lebanon and has helped in overseeing the overall sexual and reproductive health coordination response for Syrian refugees (76.74% of all respondents). The identified challenges impeding adequate sexual and reproductive health services provision for Syrian refugees included (1) insufficient supplies (46.51%); (2) insufficient funds (39.53%); and (3) shortage of staff (39.53%). CONCLUSION The recommendations for improved sexual and reproductive health service provision include the need for (1) enforcing the lead minimum initial service package agency for adequate and effective coordination, reporting, and accountability and (2) increasing funding for training staff and healthcare workers, as well as improving the overall quality of services available with the inclusion of family planning services, purchasing the necessary commodities, supplies and equipment, and covering fees associated with the different sexual and reproductive health services.
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Affiliation(s)
- Fouad M Fouad
- Refugee Health Program, Global Health
Institute, American University of Beirut, Beirut, Lebanon
- Faculty of Health Sciences, American
University of Beirut, Beirut, Lebanon
| | - Mahmoud Hashoush
- Refugee Health Program, Global Health
Institute, American University of Beirut, Beirut, Lebanon
| | - Jasmin Lilian Diab
- Refugee Health Program, Global Health
Institute, American University of Beirut, Beirut, Lebanon
| | - Dana Nabulsi
- Refugee Health Program, Global Health
Institute, American University of Beirut, Beirut, Lebanon
| | - Sarah Bahr
- Refugee Health Program, Global Health
Institute, American University of Beirut, Beirut, Lebanon
| | - Sarah Ibrahim
- Refugee Health Program, Global Health
Institute, American University of Beirut, Beirut, Lebanon
| | - Theresa Farhat
- Refugee Health Program, Global Health
Institute, American University of Beirut, Beirut, Lebanon
| | - Loulou Kobeissi
- Department of Sexual and Reproductive
Health and Research (SRH), World Health Organization (WHO), Geneva,
Switzerland
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Orr LV, Crawford FW, Khoshnood K, Khouri D, Fouad FM, Seal DW, Heimer R. Sociodemographic characteristics and HIV risk behaviors of native-born and displaced Syrian men and transgender women who have sex with men in Lebanon. AIDS Behav 2022; 26:4004-4011. [PMID: 35672550 DOI: 10.1007/s10461-022-03726-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 11/28/2022]
Abstract
HIV rates among men and transgender women who have sex with men (MTWSM) in Lebanon are consistent with a concentrated epidemic. Geopolitical and social circumstances leave these communities vulnerable to HIV spread. To document this risk encountered by Lebanese native and displaced Syrian MTWSM, participants, recruited by respondent driven sampling beginning with Syrian seeds, completed a survey with questions covering sociodemographic, behavioral, medical, and stigma, followed by opt-out HIV testing. Analyses included descriptive statistics and linear regression to differentiate between native Lebanese and Syrians who migrated after the onset of the civil war to identify correlations among sociodemographic factors, stigma, and risk behavior as a function of country of birth. Experienced and internalized stigmas were higher in the Syrian born MTWSM and correlated with elements of HIV risk. Combatting the intersectional stigmas of Syrian MTWSM in Lebanon would be most beneficial in mitigating HIV risk for these individuals.
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Affiliation(s)
- Lilla V Orr
- Immigration Policy Lab, Stanford University, Stanford, CA, United States
| | - Forrest W Crawford
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, United States
| | - Kaveh Khoshnood
- Department of the Epidemiology of Microbial Diseases, Yale School of Public Health, 06520-8034, New Haven, CT, USA
| | - Danielle Khouri
- Department of Epidemiology & Population Health, American University of Beirut (AUB), Beirut, Lebanon
| | - Fouad M Fouad
- Department of Epidemiology & Population Health, American University of Beirut (AUB), Beirut, Lebanon
| | - David W Seal
- Global Community Health and Behavioral Sciences, Tulane University School of Public Health & Tropical Medicine, New Orleans, LA, United States
| | - Robert Heimer
- Department of the Epidemiology of Microbial Diseases, Yale School of Public Health, 06520-8034, New Haven, CT, USA.
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Ismail SA, Lam ST, Bell S, Fouad FM, Blanchet K, Borghi J. Strengthening vaccination delivery system resilience in the context of protracted humanitarian crisis: a realist-informed systematic review. BMC Health Serv Res 2022; 22:1277. [DOI: 10.1186/s12913-022-08653-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 10/09/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Childhood vaccination is among the most effective public health interventions available for the prevention of communicable disease, but coverage in many humanitarian settings is sub-optimal. This systematic review critically evaluated peer-review and grey literature evidence on the effectiveness of system-level interventions for improving vaccination coverage in protracted crises, focusing on how they work, and for whom, to better inform preparedness and response for future crises.
Methods
Realist-informed systematic review of peer-reviewed and grey literature. Keyword-structured searches were performed in MEDLINE, EMBASE and Global Health, CINAHL, the Cochrane Collaboration and WHOLIS, and grey literature searches performed through the websites of UNICEF, the Global Polio Eradication Initiative (GPEI) and Technical Network for Strengthening Immunization Services. Results were independently double-screened for inclusion on title and abstract, and full text. Data were extracted using a pre-developed template, capturing information on the operating contexts in which interventions were implemented, intervention mechanisms, and vaccination-related outcomes. Study quality was assessed using the MMAT tool. Findings were narratively synthesised.
Results
50 studies were included, most describing interventions applied in conflict or near-post conflict settings in sub-Saharan Africa, and complex humanitarian emergencies. Vaccination campaigns were the most commonly addressed adaptive mechanism (n = 17). Almost all campaigns operated using multi-modal approaches combining service delivery through multiple pathways (fixed and roving), health worker recruitment and training and community engagement to address both vaccination supply and demand. Creation of collaterals through service integration showed generally positive evidence of impact on routine vaccination uptake by bringing services closer to target populations and leveraging trust that had already been built with communities. Robust community engagement emerged as a key unifying mechanism for outcome improvement across almost all of the intervention classes, in building awareness and trust among crisis-affected populations. Some potentially transformative mechanisms for strengthening resilience in vaccination delivery were identified, but evidence for these remains limited.
Conclusion
A number of interventions to support adaptations to routine immunisation delivery in the face of protracted crisis are identifiable, as are key unifying mechanisms (multi-level community engagement) apparently irrespective of context, but evidence remains piecemeal. Adapting these approaches for local system resilience-building remains a key challenge.
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Elhage Hassan M, Doumat G, Daher D, Al Tannir AH, Hassan B, Chidiac C, Hariri H, Hatab T, Abou Daher A, Ezzedin O, Fouad FM. Menstrual health and period poverty in Lebanon during economic crisis: A qualitative analysis of the challenges and recommendations. Front Reprod Health 2022; 4:920461. [PMID: 36303680 PMCID: PMC9580731 DOI: 10.3389/frph.2022.920461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/02/2022] [Indexed: 11/17/2022] Open
Abstract
Objective Recently, severe period poverty has had a dramatic spread throughout Lebanon as a result of several crises: the COVID-19 pandemic, the Beirut explosion, and the economic collapse. Period poverty is the lack of access to menstrual hygiene materials, comfortable environments, and adequate education about menstrual health. Due to the great implications of period poverty on Lebanese women's health, our study aims to explore stakeholder's perspective on the Lebanese public health policy regarding menstrual health, the evolving challenges it faces in the context of the current economic collapse, and to suggest recommendations for solutions. Methods Our study is qualitative in nature, where data collection was done via online semi-structured interviews with stakeholders from the public and private sectors of the Lebanese healthcare system in addition to non-governmental organizations (NGOs) and physicians. Data were then analyzed based on themes and subthemes that emerged from the interviews. Results Nine stakeholders were interviewed: five from NGOs, two obstetrics and gynecology physicians, and two public sector representatives. The challenges to menstrual health were subcategorized into previously existing and new ones. The consequences of poor menstrual health were tackled on the mental, physical, and social levels. Stakeholders suggested both short-term and long-term recommendations. Short-term recommendations included decreasing the monetary burden by subsidizing menstrual products or via a coupon system. Long-term recommendations included proper education on multiple levels, cooperation between key players in the private and public sectors, and encouragement of local production to ensure future sustainability. Conclusion Menstrual health is a neglected public health issue in Lebanon, causing detrimental effects on girls and women residing in the country. Proper planning and collaboration between the private and public sectors are required to address this human rights issue.
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Affiliation(s)
| | - George Doumat
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Darine Daher
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | | | - Bashar Hassan
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Charbel Chidiac
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Hussein Hariri
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Taha Hatab
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Alaa Abou Daher
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Omar Ezzedin
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Fouad M. Fouad
- Department of Epidemiology and Population Health, American University of Beirut, Beirut, Lebanon
- *Correspondence: Fouad M. Fouad
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Saleh S, Fouad FM. Political economy of health in fragile and conflict-affected regions in the Middle East and North Africa region. J Glob Health 2022; 12:01003. [PMID: 35959965 PMCID: PMC9373566 DOI: 10.7189/jogh.12.01003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Shadi Saleh
- Global Health Institute, American University of Beirut, Beirut, Lebanon.,Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Fouad M Fouad
- Global Health Institute, American University of Beirut, Beirut, Lebanon.,Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
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Khoshnood K, Smoyer AB, Maviglia F, Kara J, Khouri D, Fouad FM, Heimer R. Stress, Marginalization, and Disruption: A Qualitative Rapid Situational Assessment of Substance Users and HIV Risk in Lebanon. Int J Environ Res Public Health 2022; 19:ijerph19159242. [PMID: 35954600 PMCID: PMC9368310 DOI: 10.3390/ijerph19159242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/22/2022] [Accepted: 07/23/2022] [Indexed: 11/28/2022]
Abstract
Lebanon is a diverse and dynamic nation of six million people that has experienced considerable disruption for the last two decades. The Syrian Civil War, which began in 2011, resulted in the displacement of 1.1 million Syrians to Lebanon. Today, Lebanon is the country with the largest per capita number of refugees in the world. In addition, the country experienced a social, economic, and political crisis in 2019 that destabilized the entire society-circumstances that were further complicated by COVID-19 pandemic. With all of the competing calamities in Lebanon, there has been limited scientific investigation into substance use and the risk of HIV infection among the country's population. To address this gap in knowledge, a qualitative rapid situational assessment (RSA) of substance use and risk of HIV infection in and around Beirut, the nation's capital, was conducted. The goal of this analysis is to describe the demographics and drug use patterns of this population, explore their HIV knowledge and risks, and build knowledge about their perceptions of and access to substance use treatment and other social services.
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Affiliation(s)
- Kaveh Khoshnood
- Center for Interdisciplinary Research on AIDS at Yale, Department of Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, CT 06520, USA; (F.M.); (J.K.); (R.H.)
- Correspondence:
| | - Amy B. Smoyer
- Department of Social Work, Southern Connecticut State University, New Haven, CT 06520, USA;
| | - Francesca Maviglia
- Center for Interdisciplinary Research on AIDS at Yale, Department of Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, CT 06520, USA; (F.M.); (J.K.); (R.H.)
| | - Janine Kara
- Center for Interdisciplinary Research on AIDS at Yale, Department of Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, CT 06520, USA; (F.M.); (J.K.); (R.H.)
| | | | - Fouad M. Fouad
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut 1100, Lebanon;
| | - Robert Heimer
- Center for Interdisciplinary Research on AIDS at Yale, Department of Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, CT 06520, USA; (F.M.); (J.K.); (R.H.)
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Ismail SA, Bell S, Chalabi Z, Fouad FM, Mechler R, Tomoaia-Cotisel A, Blanchet K, Borghi J. Conceptualising and assessing health system resilience to shocks: a cross-disciplinary view. Wellcome Open Res 2022. [DOI: 10.12688/wellcomeopenres.17834.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Health systems worldwide face major challenges in anticipating, planning for and responding to shocks from infectious disease epidemics, armed conflict, climatic and other crises. Although the literature on health system resilience has grown substantially in recent years, major uncertainties remain concerning approaches to resilience conceptualisation and measurement. This narrative review revisits literatures from a range of fields outside health to identify lessons relevant to health systems. Four key insights emerge. Firstly, shocks can only be understood by clarifying how, where and over what timescale they interact with a system of interest, and the dynamic effects they produce within it. Shock effects are contingent on historical path-dependencies, and on the presence of factors or system pathways (e.g. financing models, health workforce capabilities or supply chain designs) that may amplify or dampen impact in unexpected ways. Secondly, shocks often produce cascading effects across multiple scales, whereas the focus of much of the health resilience literature has been on macro-level, national systems. In reality, health systems bring together interconnected sub-systems across sectors and geographies, with different components, behaviours and sometimes even objectives – all influencing how a system responds to a shock. Thirdly, transformability is an integral feature of resilient social systems: cross-scale interactions help explain how systems can show both resilience and transformational capability at the same time. We illustrate these first three findings by extending the socioecological concept of adaptive cycles in social systems to health, using the example of maternal and child health service delivery. Finally, we argue that dynamic modelling approaches, under-utilised in research on health system resilience to date, have significant promise for identification of shock-moderating or shock-amplifying pathways, for understanding effects at multiple levels and ultimately for building resilience.
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Fouad FM, Soares L, Diab JL, Abouzeid A. The political economy of health in conflict: Lessons learned from three states in the Eastern Mediterranean Region during COVID-19. J Glob Health 2022; 12:07001. [PMID: 35198151 PMCID: PMC8836263 DOI: 10.7189/jogh.12.07001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background The Eastern Mediterranean Region continues to face a severe scale of emergencies as a direct result of conflict and political instability in a number of countries. As of 2020, nine countries out of 22 countries in the region affected by protracted and ongoing wars and conflict, left more than 62 million people in dire need of access to quality health care and adequate response measures. COVID-19 exacerbates the humanitarian needs of the people especially in countries that suffer from humanitarian crises, and drains the already overstretched health care systems. This study was conducted to derive major takeaways and lessons learned from the COVID-19 response in humanitarian and low resource settings that may assist similar vulnerable and fragile settings in different regions in view of a possible next pandemic. Methods The study involved a desk review, document analysis, and key informant interviews with key stakeholders from the Eastern Mediterranean Region. Results A total of 35 key informant interviews were carried out with health professionals working in humanitarian and low resource settings in the region. This study focuses on the information gathered from Afghanistan, Iraq and Syria. Conclusions A key finding of this study is that each of the nine pillars for COVID response has been implemented differently across the different countries. Although the nine pillars guide the overall response to COVID-19 in the region, they also provide countries with an important starting point and an important implementation tool.
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Affiliation(s)
- Fouad M Fouad
- Refugee Health Program, Global Health Institute, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | | | - Jasmin Lilian Diab
- Institute for Migration Studies, School of Arts and Sciences, Lebanese American University, Beirut, Lebanon
- Department of Social and Education Sciences, Lebanese American University, Beirut, Lebanon
| | - Alaa Abouzeid
- Faculty of Medicine, Cairo University, Cairo, Egypt
- Operational Partnerships, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
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Abbara A, Rayes D, Ekzayez A, Jabbour S, Marzouk M, Alnahhas H, Basha S, Katurji Z, Sullivan R, Fouad FM. The health of internally displaced people in Syria: are current systems fit for purpose? J Migr Health 2022; 6:100126. [PMID: 35942086 PMCID: PMC9356202 DOI: 10.1016/j.jmh.2022.100126] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/22/2022] [Accepted: 07/19/2022] [Indexed: 11/28/2022] Open
Abstract
At 6.7 million, Syria has the largest number of internally displaced people globally. Health of IDPs in Syria is often not disaggregated from that of other populations. IDPs face intersecting vulnerabilities and social determinants which impact health. Syria's fragmented health system results in different system responses for IDPs. The evidence base on IDP health in Syria is weak and requires strengthening.
Introduction: Syria has the largest number of internally displaced people (IDPs) globally with 6.7 million forced from their homes since the uprising erupted in 2011. Most face multiple intersecting vulnerabilities with adverse health impacts. We explore the key health concerns among IDPs, how the various health systems in Syria have responded to the dynamic health needs of IDPs and what modalities have been used by humanitarian actors to address these needs. Methods: We undertook a scoping review of academic and grey literature for available evidence regarding the health of IDPs in Syria. We then organised an online workshop in November 2021 with around 30 participants who represent local, regional, and international organisations and who have relevant expertise. The discussion focused on how the health systems in Syria's various territories have responded to the health needs of IDPs, what this means to the structure and dynamics of these health systems and their intended outcomes and responsiveness. Findings: These emphasised the weak evidence base around IDP health in Syria, particularly in certain geographical areas. Workshop participants explored the applicability of the term IDP in the Syrian context given the fragmented health system and its impact on IDPs, the importance of considering co-determinants (beyond forced displacement) on the health of IDPs and taking a transectoral, community led approach to identify and respond to needs. Conclusion: This manuscript presents some of the current issues with regards to IDP health in Syria, however, there remain numerous unknowns, both for the health of IDP as well as non-IDP populations. We hope that it will be the foundation for further discussions on practical steps relating to research, analysis and interventions which can support health system responses for IDPs in Syria.
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Akik C, Asfahani F, Elghossain T, Mesmar S, Rabkin M, El Sadr W, Fouad FM, Ghattas H. Healthcare system responses to non-communicable diseases’ needs of Syrian refugees: The cases of Jordan and Lebanon. J Migr Health 2022; 6:100136. [PMID: 36148323 PMCID: PMC9486618 DOI: 10.1016/j.jmh.2022.100136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 06/08/2022] [Accepted: 09/13/2022] [Indexed: 12/02/2022] Open
Abstract
Hosting governments were moderately successful in providing health services to Syrian refugees through existing national health systems. Coverage and quality of care remain suboptimal and continuity is often interrupted due to inadequate implementation of national NCD guidelines, major government policy changes and UNHCR policy changes in cost sharing, eligibility, and vulnerability criteria which made the health system difficult to navigate. The latter are related to the lack of financing for NCDs at global level. There is a need for evidence-based guidelines and effective implementation models for continued NCD care in protracted emergency settings. Innovative financing solutions and increased advocacy for funding and prioritization of NCD care for refugees need to be envisioned. Strengthening existing national health systems and striving for equity in achieving universal health coverage for both nationals of host countries and refugees is imperative.
Introduction Since the start of the Syrian conflict in 2011, Jordan and Lebanon have hosted large refugee populations, with a high pre-conflict burden of non-communicable diseases (NCDs). We aimed to explore NCD service provision to Syrian refugees in these two host countries and to identify lessons learned that may inform the global response to the changing health needs of refugees. Methods Between January 2017 and June 2018, we conducted 36 in-depth interviews with stakeholders from Jordan and Lebanon, as well as global stakeholders, to understand the context, the achievements, gaps and priorities in the provision and uptake of NCD prevention, testing and treatment services to Syrian refugees. Findings Both countries succeeded in embedding refugee health care within national health systems, yet coverage and quality of NCD health services offered to Syrian refugees in both contexts were affected by under-funding and consequent policy constraints. Changes in policies relating to cost sharing, eligibility and vulnerability criteria led to difficulties navigating the system and increased out-of-pocket payments for Syrians. Funding shortages were reported as a key barrier to NCD screening, diagnosis and management, including at the primary care level and referral from primary to secondary healthcare, particularly in Lebanon. These barriers were compounded by suboptimal implementation of NCD guidelines and high workloads for healthcare providers resulting from the large numbers of refugees. Conclusions Despite the extraordinary efforts made by host countries, provision and continuity of high quality NCD services at scale remains a tremendous challenge given ongoing funding shortfalls and lack of prioritization of NCD care for refugees. The development of innovative, effective and sustainable solutions is necessary to counter the threat of NCDs.
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Affiliation(s)
- Chaza Akik
- Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Lebanon
| | - Farah Asfahani
- Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Lebanon
| | - Tatiana Elghossain
- Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Lebanon
| | - Sandra Mesmar
- Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Lebanon
| | - Miriam Rabkin
- ICAP, Columbia University Mailman School of Public Health, New York, United States
| | - Wafaa El Sadr
- ICAP, Columbia University Mailman School of Public Health, New York, United States
| | - Fouad M. Fouad
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Lebanon
| | - Hala Ghattas
- Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Lebanon
- Corresponding author.
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Chaaya M, Ghandour LA, Fouad FM, Germani A, Charide R, Shahin Y, Ismail S, Fahd S. Capacity planning for acute hospital inpatient care and adult critical care in England: a descriptive study using hospital administrative data. Lancet 2021. [PMID: 34227954 PMCID: PMC8617324 DOI: 10.1016/s0140-6736(21)02565-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background At the beginning of the COVID-19 pandemic in March and April, 2020, there was a focus on accommodating an anticipated surge of patients with COVID-19 in acute hospitals. We aimed to estimate the potential for freeing up capacity in acute hospitals in England. Methods In this descriptive study, we used admitted patient and adult critical care records from Hospital Episode Statistics (a database containing details of attendances at National Health Service acute hospitals in England) from 2018/19 to estimate historical numbers of inpatients. Each admission was grouped into emergency, maternity, and elective, with elective split by the presence or absence of cancer in the primary diagnosis. We further stratified the population by age and frailty, which we estimated with an index using International Statistical Classification of Diseases and Related Health Problems (tenth revision) codes in diagnosis fields. We used the (then current) National Institute for Health and Care Excellence (NICE) 2020 guidance on critical care pathways as a framework to examine four scenarios that limited access to beds for specific patient groups. This study was approved by the Secretary of State and the Health Research Authority under Regulation 5 of the Health Service (Control of Patient Information) Regulations 2002 to hold confidential data and analyse them for research purposes (CAG ref 15/CAG/0005). We have approval to use these data for research into the quality and safety of health care, from the London–South East Ethics Committee (REC ref 20/LO/0611). Findings Between April 1, 2018, and March 31, 2019, 8 957 521 adults were admitted (7 372 040 [82·3%] emergency, 295 598 [3·3%] elective with cancer, 850 964 [9·5%] elective without cancer, and 438 919 [4·9%] maternity admissions), and 974 038 critical care episodes were recorded. Our analysis suggested that up to 70% of all acute inpatient beds could be released if only maternity, cancer, and emergency patients younger than 65 years were admitted; if non-frail patients aged 65 years and older were also admitted, 41% of beds could be freed up. Similarly, if only maternity, cancer, and emergency patients younger than 65 years were admitted to critical care beds, that might free up to 56% of adult critical care beds; if non-frail patients aged 65 years and older were also admitted, 30% of critical care beds could be freed up. Interpretation Given a crisis in health-care capacity, it seemed appropriate to model some difficult options based on NICE guidelines. We identified scope for freeing up total acute and critical care beds by postponing elective non-cancer admissions as a short-term measure during the first wave of COVID-19 (March to June, 2020) in England. The NICE guidelines were criticised by patient groups and have since been updated (NG191). Administrative data can inform planning for future crises albeit with limitations on estimating individual patient need, and deep social and ethical considerations. Our estimates were incorporated into a modelling tool for hospital provision during the pandemic. Funding Dr Foster Intelligence.
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Affiliation(s)
- Monique Chaaya
- Department of Epidemiology and Population Healthxs, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
| | - Lilian A Ghandour
- Department of Epidemiology and Population Healthxs, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Fouad M Fouad
- Department of Epidemiology and Population Healthxs, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Aline Germani
- Center for Public Health practice, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Rana Charide
- Center for Public Health practice, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Yousef Shahin
- Department of Health, United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) Headquarters, Amman, Jordan
| | - Suha Ismail
- Department of Health, United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) Headquarters, Amman, Jordan
| | - Saleh Fahd
- Department of Health, United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) Headquarters, Amman, Jordan
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Chaaya M, Ghandour LA, Fouad FM, Germani A, Charide R, Shahin Y, Ismail S, Fahd S. Non-communicable diseases among Palestinian refugees from Syria: a cross-sectional study on prevalence, case management, access to and utilisation of UNRWA Health Services. Lancet 2021; 398 Suppl 1:S22. [PMID: 34227954 PMCID: PMC8617324 DOI: 10.1016/s0140-6736(21)01508-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND As of Feb 14, 2014, UNRWA had registered almost 53 000 Palestinian refugees from Syria (PRS) who had fled to Lebanon as the result of the conflict in Syria. Half of the PRS had gone to one of the 12 Palestinian camps, which are overcrowded and of poor infrastructure. Consequently, there is concern for the wellbeing of PRS; in particular, their health status and access to medical care. Little attention has been given to non-communicable diseases (NCDs) in the acute phases of emergencies. Therefore, an assessment of the prevalence of NCDs among PRS, as well as the patterns of use of available health care services by PRS, is warranted. METHODS A cross-sectional study was conducted in April, 2018, with 1100 PRS residing inside and outside refugee camps across all governorates of Lebanon. A listing of all PRS families was the sampling frame. A random sample of families was selected and contacted, and then one adult randomly selected from each family was approached for data collection. Pregnant women and participants who were too ill to participate were excluded. After obtaining informed verbal consent, we did face-to-face interviews to collect data on household details (such as type of settlement, source of income) and sociodemographic information, major NCDs (for the household representative), lifestyle behaviours, and health-care use. We invited all participants to UNRWA clinics for physical and biochemical measurements. The study protocol was approved by the Institutional Review Board of the American University of Beirut. FINDINGS We surveyed 959 PRS (59% male [465], 82% married [785], mean age 43 years [SD 12]). A quarter of those interviewed had at least one NCD; the most prevalent were hypertension (23%; 221 of 959), rheumatic diseases (17%; 166), cardiovascular diseases (CVDs, 13%; 126), diabetes (13%; 124), and chronic respiratory diseases (CRDs) (10%; 100). All these NCDs were more prevalent among PRS inside camps than in those residing outside camps, except for diabetes. Most participants who had been diagnosed with NCDs were adhering to their prescribed medications (90-98%). However, of those reporting CVDs, only 56% (71 of 126) had attended at least one follow-up appointment, and of those reporting rheumatic diseases, only 33% (55 of 166) had attended at least one follow-up appointment. About half of participants reported that they checked their blood pressure (55%; 528 of 959) or blood glucose (45%; 430). 111 of 221 (50%) participants with hypertension monitored their blood pressure, and 78 of 124 (63%) participants with diabetes monitored their blood glucose. 133 participants attended UNRWA clinics for measurements; 40% (54) had obesity (>30 kg/cm2), 10% (13) had elevated blood pressure, 12% (16) had stage 1 hypertension, and 8% (10) had stage 2 hypertension. Most participants had normal glucose (67%; 89 of 133), cholesterol (65%; 87), triglyceride (58%; 77), and glycosylated haemoglobin levels (64; 85). A substantial proportion of participants who were tested had undiagnosed diabetes (14%; 33 of 108 reporting no diabetes), undiagnosed hypertension (23%; 19 of 81), uncontrolled diabetes (79% of participants with diabetes; 19 of 24), or uncontrolled hypertension (64% of participants with hypertension; 29 of 45). INTERPRETATION Further study is needed to understand why the prevalence of NCDs among PRS residing in Palestinian camps is higher than among those living outside, and to understand whether and why access to medicines is a problem, particularly outside camps. The burden of NCDs among PRS is high and their access to services is not optimal; therefore UNRWA should pay special attention to NCD services in this population. UNRWA should invest in efforts to increase awareness of free blood pressure and blood glucose monitoring services in its clinics, and could actively offer free testing in public areas inside camps. Doctors at UNRWA clinics should recommend that patients monitor their disease more frequently and educate them on how to do so. A limitation of the study was the low percentage of participants who attended UNRWA clinics for physical and biochemical measurements. FUNDING UNRWA.
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Affiliation(s)
- Monique Chaaya
- Department of Epidemiology and Population Healthxs, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
| | - Lilian A Ghandour
- Department of Epidemiology and Population Healthxs, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Fouad M Fouad
- Department of Epidemiology and Population Healthxs, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Aline Germani
- Center for Public Health practice, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Rana Charide
- Center for Public Health practice, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Yousef Shahin
- Department of Health, United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) Headquarters, Amman, Jordan
| | - Suha Ismail
- Department of Health, United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) Headquarters, Amman, Jordan
| | - Saleh Fahd
- Department of Health, United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) Headquarters, Amman, Jordan
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Clark K, Pachankis J, Khoshnood K, Bränström R, Seal D, Khoury D, Fouad FM, Barbour R, Heimer R. Stigma, displacement stressors and psychiatric morbidity among displaced Syrian men who have sex with men (MSM) and transgender women: a cross-sectional study in Lebanon. BMJ Open 2021; 11:e046996. [PMID: 33986065 PMCID: PMC8126317 DOI: 10.1136/bmjopen-2020-046996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Displaced Syrians face psychiatric morbidity often resulting from displacement-related stressors (eg, resource scarcity). Both men who have sex with men (MSM) and transgender women among the displaced Syrians are particularly vulnerable to mental health challenges given that they also often face stigma-related stressors (eg, discrimination). METHODS Between January and December 2019 in greater Beirut, 258 Lebanese-born MSM and transgender women and 230 displaced Syrian MSM and transgender women were recruited via respondent-driven sampling to complete an in-person survey assessing displacement-related stressors, stigma-related stressors, depression, anxiety and post-traumatic stress disorder. In the total sample, we first documented the prevalence of psychiatric morbidity among the displaced Syrians; we then assessed associations among displacement-related and stigma-related stressors and each psychiatric outcome. RESULTS Sixty-three per cent of Syrian participants met criteria for depression compared with 43.8% of Lebanese participants (p<0.001); 21.3% of Syrians met criteria for severe anxiety compared with 13.1% of Lebanese participants (p<0.05) and 33.0% of Syrians met criteria for post-traumatic stress disorder compared with 18.4% of Lebanese participants (p<0.001). Among Syrian MSM and transgender women, sociodemographic characteristics, displacement-related stressors and stigma-related stressors were uniquely associated with psychiatric morbidity. CONCLUSION Displaced Syrian MSM and transgender women experience higher levels of psychiatric comorbidities than Lebanese MSM and transgender women in part due to compounding exposure to displacement-related stressors and stigma-related stressors. Informed by tenets of minority stress theory and intersectionality theory, we discuss mental health intervention implications and future directions.
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Affiliation(s)
- Kirsty Clark
- Social and Behavioral Sciences, Yale University School of Public Health, New Haven, Connecticut, USA
| | - John Pachankis
- Social and Behavioral Sciences, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Kaveh Khoshnood
- Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, Connecticut, USA
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, Connecticut, USA
| | | | - David Seal
- Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | | | | | - Russell Barbour
- Biostatistics, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Robert Heimer
- Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, Connecticut, USA
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, Connecticut, USA
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Zard M, Lau LS, Bowser DM, Fouad FM, Lucumí DI, Samari G, Harker A, Shepard DS, Zeng W, Moresky RT, Audi MN, Greene CM, Kachur SP. Leave no one behind: ensuring access to COVID-19 vaccines for refugee and displaced populations. Nat Med 2021; 27:747-749. [PMID: 33875889 PMCID: PMC10413720 DOI: 10.1038/s41591-021-01328-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The Spanish translation of this Comment, provided as Supplementary Information , has not been edited by the publisher.
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Affiliation(s)
- Monette Zard
- Program on Forced Migration and Health, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA.
| | - Ling San Lau
- Program on Forced Migration and Health, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Diana M Bowser
- Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Fouad M Fouad
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Diego I Lucumí
- School of Government, Universidad de los Andes, Bogotá, Colombia
| | - Goleen Samari
- Program on Forced Migration and Health, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Arturo Harker
- School of Government, Universidad de los Andes, Bogotá, Colombia
| | - Donald S Shepard
- Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Wu Zeng
- Department of International Health, School of Nursing and Health Studies, Georgetown University, Washington, DC, USA
| | - Rachel T Moresky
- Program on Forced Migration and Health, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Mhd Nour Audi
- Program on Forced Migration and Health, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Claire M Greene
- Program on Forced Migration and Health, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - S Patrick Kachur
- Program on Forced Migration and Health, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
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Jabbour S, Leaning J, Nuwayhid I, Ager A, Cammett M, Dewachi O, Fouad FM, Giacaman R, Sapir DG, Hage G, Majed Z, Nasser R, Sparrow A, Spiegel P, Tarakji A, Whitson SL, Yassin N. 10 years of the Syrian conflict: a time to act and not merely to remember. Lancet 2021; 397:1245-1248. [PMID: 33721564 DOI: 10.1016/s0140-6736(21)00623-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Samer Jabbour
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
| | - Jennifer Leaning
- FXB Center for Health & Human Rights, Harvard University, Cambridge, MA, USA
| | - Iman Nuwayhid
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Alastair Ager
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Melani Cammett
- Department of Government, Harvard University, Boston, MA, USA
| | - Omar Dewachi
- Department of Anthropology, Rutgers University, New Brunswick, NJ, USA
| | - Fouad M Fouad
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Rita Giacaman
- Institute for Community and Public Health, Birzeit University, Birzeit, occupied Palestinian territory
| | - Debarati Guha Sapir
- Centre for Research on the Epidemiology of Disasters, Université Catholique de Louvain, Brussels, Belgium
| | - Ghassan Hage
- School of Social and Political Sciences, University of Melbourne, Parkville, VIC, Australia
| | - Ziad Majed
- Department of History and Politics, American University of Paris, Paris, France
| | | | - Annie Sparrow
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul Spiegel
- Center for Humanitarian Health, Johns Hopkins University, Baltimore, MD, USA
| | - Ahmad Tarakji
- Syrian American Medical Society, Washington, DC, USA
| | | | - Nasser Yassin
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
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23
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Fahme SA, Walsh KF, Rouzier V, Chebrolu P, Jaka H, Kingery JR, Fouad FM, Mathad JS, Downs JA, McNairy M. Practical recommendations for the prevention and management of COVID-19 in low-income and middle-income settings: adapting clinical experience from the field. Fam Med Community Health 2021; 9:e000930. [PMID: 33811089 PMCID: PMC8023753 DOI: 10.1136/fmch-2021-000930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/18/2021] [Accepted: 03/18/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
- Sasha Abdallah Fahme
- Center for Global Health Research, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Kathleen F Walsh
- Center for Global Health Research, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
- GHESKIO, Port-au-Prince, Ouest, Haiti
| | - Vanessa Rouzier
- Center for Global Health Research, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
- GHESKIO, Port-au-Prince, Ouest, Haiti
| | - Puja Chebrolu
- Center for Global Health Research, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
| | - Hyasinta Jaka
- Catholic University of Health and Allied Sciences, Mwanza, Mwanza, Tanzania
| | - Justin Roy Kingery
- Center for Global Health Research, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
- Catholic University of Health and Allied Sciences, Mwanza, Mwanza, Tanzania
| | - Fouad M Fouad
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Jyoti S Mathad
- Center for Global Health Research, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
| | - Jennifer A Downs
- Center for Global Health Research, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
- Catholic University of Health and Allied Sciences, Mwanza, Mwanza, Tanzania
| | - Margaret McNairy
- Center for Global Health Research, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
- GHESKIO, Port-au-Prince, Ouest, Haiti
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24
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Nabulsi D, Abou Saad M, Ismail H, Doumit MAA, El-Jamil F, Kobeissi L, Fouad FM. Minimum initial service package (MISP) for sexual and reproductive health for women in a displacement setting: a narrative review on the Syrian refugee crisis in Lebanon. Reprod Health 2021; 18:58. [PMID: 33685476 PMCID: PMC7938550 DOI: 10.1186/s12978-021-01108-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 02/15/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Women and girls are disproportionately affected in times of conflict and forced displacement, with disturbance in access to healthcare services leading to poor sexual and reproductive health outcomes. The minimal initial service package (MISP) was created to mitigate the consequences of conflict and prevent poor sexual and reproductive health (SRH) outcomes, especially among women and girls. The aim of this narrative review was to explore the SRH response for Syrian refugee women and girls in Lebanon, with a focus on MISP implementation. METHODOLOGY A comprehensive literature search was conducted for peer-reviewed articles in 8 electronic databases and multiple grey literature sites for articles published from March 2011 to May 2019. The target population was Syrian refugee women in Lebanon displaced from Syria as a result of the conflict that erupted in March 2011. The selected articles addressed MISP, SRH needs and services, and barriers to service access. A narrative synthesis was conducted, guided by the six main objectives of the MISP. RESULTS A total of 254 documents were retrieved, from which 12 peer-reviewed articles and 12 reports were included in the review. All identified articles were descriptive in nature and no studies evaluating MISP or other interventions or programs were found. The articles described the wide range of SRH services delivered in Lebanon to Syrian refugee women. However, access to and quality of these services remain a challenge. Multiple sources reported a lack of coordination, leading to fragmented service provision and duplication of effort. Studies reported a high level of sexual and gender-based violence, pregnancy complications and poor antenatal care compliance, and limited use of contraceptive methods. Very few studies reported on the prevalence of HIV and other STIs, reporting low levels of infection. Multiple barriers to healthcare access were identified, which included system-level, financial, informational and cultural factors, healthcare workers. CONCLUSION This study highlights the main SRH services provided, their use and access by Syrian refugee women in Lebanon. Despite the multitude of services provided, the humanitarian response remains decentralized with limited coordination and multiple barriers that limit the utilization of these services. A clear gap remains, with limited evaluation of SRH services that are pertinent to achieve the MISP objectives and the ability to transition into comprehensive services. Improving the coordination of services through a lead agency can address many of the identified barriers and allow the transition into comprehensive services.
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Affiliation(s)
- Dana Nabulsi
- Refugee Health Program, Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Maya Abou Saad
- Refugee Health Program, Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Hussein Ismail
- Refugee Health Program, Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Myrna A A Doumit
- Alice Ramez Chagoury School of Nursing, Lebanese American University, Byblos, Lebanon
| | - Fatima El-Jamil
- Department of Psychology, American University of Beirut, Beirut, Lebanon
| | - Loulou Kobeissi
- Department of Reproductive Health and Research (RHR), World Health Organization (WHO), Geneva, Switzerland
| | - Fouad M Fouad
- Refugee Health Program, Global Health Institute, American University of Beirut, Beirut, Lebanon.
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
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25
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Fouad FM, McCall SJ, Ayoub H, Abu-Raddad LJ, Mumtaz GR. Vulnerability of Syrian refugees in Lebanon to COVID-19: quantitative insights. Confl Health 2021; 15:13. [PMID: 33673855 PMCID: PMC7934989 DOI: 10.1186/s13031-021-00349-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 02/26/2021] [Indexed: 12/13/2022] Open
Abstract
Lebanon, a middle-income country with ongoing political turmoil, unstable economic situation, and a fragmented and under-resourced health system, hosts about one million Syrian refugees since 2011. While the country is currently experiencing substantial COVID-19 epidemic spread, no outbreaks have been reported yet among Syrian refugees. However, testing of this population remains limited and exposure levels are high given dire living conditions and close interaction with the host community. Here, we use quantitative insights of transmission dynamics to outline risk and contextual factors that may modulate vulnerability of Syrian refugees in Lebanon to potentially large COVID-19 epidemics. Syrian refugees live in close contact with the host community, and their living conditions are favorable for epidemic spread. We found that the high levels of crowding within Syrian refugee households and among those in informal tented settlements, the inadequate water supply and sanitation, limited use of masks, inadequate access to health care, and inadequate community awareness levels are vulnerability factors that directly impact important parameters of transmission dynamics, leading to larger epidemic scale. Poverty, stigma, and fear of legal consequences are contextual factors that further exacerbate this vulnerability. The relatively high prevalence of non-communicable diseases in this population could also affect the severity of the disease among those infected. Mathematical modeling simulations we conducted illustrated that even modest increases in transmission among Syrian refugees could result in a large increase in the incidence and cumulative total number of infections in the absence of interventions. In conclusion, while the young age structure of the Syrian refugee population might play a protective role against the scale and disease-burden severity of a potential COVID-19 epidemic, the epidemic potential due to several vulnerability factors warrants an immediate response in this population group. Local and international actors are required to mobilize and coordinate efforts to prevent the transmission of COVID-19, and to mitigate its impact amongst the vulnerable refugee populations globally.
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Affiliation(s)
- Fouad M Fouad
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, P.O.Box 11-0236, Riad El Solh, Beirut, 1107 2020, Lebanon
| | - Stephen J McCall
- Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Houssein Ayoub
- Department of Mathematics, Statistics, and Physics, Qatar University, Doha, Qatar
| | - Laith J Abu-Raddad
- Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar.,Department of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Ghina R Mumtaz
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, P.O.Box 11-0236, Riad El Solh, Beirut, 1107 2020, Lebanon.
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26
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Fouad FM, Barkil-Oteo A, Diab JL. Mental Health in Lebanon's Triple-Fold Crisis: The Case of Refugees and Vulnerable Groups in Times of COVID-19. Front Public Health 2021; 8:589264. [PMID: 33553090 PMCID: PMC7855303 DOI: 10.3389/fpubh.2020.589264] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 12/21/2020] [Indexed: 01/18/2023] Open
Abstract
Lebanon's management of the COVID-19 pandemic is largely being maneuvered amid the country's escalating triple fold crisis. As the country continues to grapple with political stagnation, a dwindling economy and currency, all while working through an ongoing refugee crisis, mental health in times of Coronavirus in Lebanon remains unaddressed. This piece explores the effects of this triple fold crisis upon the mental health of the country's refugees and most vulnerable groups, and provides room for discussions on the potential benefits of telemental health as an intervention in low-income and conflict settings. Although the implementation of TMH services in Lebanon among vulnerable communities in times of COVID-19 is not a priority, this piece insists it would ultimately fill a substantial mental health gap during the country's ongoing difficult transitory period.
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Affiliation(s)
- Fouad M Fouad
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | | | - Jasmin Lilian Diab
- Refugee Health Program, Global Health Institute, American University of Beirut, Beirut, Lebanon
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27
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Khachfe HH, Rahal Z, Sammouri J, Kheil M, Baydoun H, Chatila D, Dirawi H, Fouad FM. Cancer in Lebanon: A Review of Incidence Rates from 2008 to 2015 and Projections Till 2025. South Asian J Cancer 2020; 9:147-152. [PMID: 33937137 PMCID: PMC8075630 DOI: 10.1055/s-0040-1721291] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Background and Objectives Cancer carries one of the heaviest burdens globally in terms of mortality. Lebanon is a middle-income Middle East country also plagued with cancer, as such a study and analysis of cancer trends and projections would serve a great benefit in the fight against the disease. Materials and Methods All data pertaining to cancers in Lebanon were extracted from the National Cancer Registry of Lebanon Web site. Data were analyzed to produce trends over the years of our study (2008-2015). Ten-year projections were further calculated for the top cancers by the primary site using logarithmic models. Results The top cancers in Lebanon are the breast, lung, colorectal, bladder, and prostate. The top cancers affecting females are the breast, lung, and colorectal. The top cancers affecting males are the prostate, lung, and bladder. Cancer cases are projected to increase in Lebanon over the next 10 years. Conclusion Lebanon had a steady incidence rate of cancer cases during the time of our study. A more complete understanding of cancer trends and their ultimate reduction will require further research into the origins of specific cancers and the means of prevention and control.
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Affiliation(s)
- Hussein H Khachfe
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon.,Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Zahraa Rahal
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Julie Sammouri
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Mira Kheil
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Hussein Baydoun
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Dana Chatila
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Hiba Dirawi
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Fouad M Fouad
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
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28
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Jamal Z, Alameddine M, Diaconu K, Lough G, Witter S, Ager A, Fouad FM. Health system resilience in the face of crisis: analysing the challenges, strategies and capacities for UNRWA in Syria. Health Policy Plan 2020; 35:26-35. [PMID: 31625558 DOI: 10.1093/heapol/czz129] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2019] [Indexed: 11/13/2022] Open
Abstract
Health system resilience reflects the ability to continue service delivery in the face of extraordinary shocks. We examined the case of the United Nations Relief and Works Agency (UNRWA) and its delivery of services to Palestine refugees in Syria during the ongoing crisis to identify factors enabling system resilience. The study is a retrospective qualitative case study utilizing diverse methods. We conducted 35 semi-structured interviews with UNRWA clinical and administrative professionals engaged in health service delivery over the period of the Syria conflict. Through a group model building session with a sub-group of eight of these participants, we then elicited a causal loop diagram of health system functioning over the course of the war, identifying pathways of threat and mitigating resilience strategies. We triangulated analysis with data from UNRWA annual reports and routine health management information. The UNRWA health system generally sustained service provision despite individual, community and system challenges that arose during the conflict. We distinguish absorptive, adaptive and transformative capacities of the system facilitating this resilience. Absorptive capacities enabled immediate crisis response, drawing on available human and organizational resources. Adaptive capacities sustained service delivery through revised logistical arrangements, enhanced collaborative mechanisms and organizational flexibility. Transformative capacity was evidenced by the creation of new services in response to changing community needs. Analysis suggests factors such as staff commitment, organizational flexibility and availability of collaboration mechanisms were important assets in maintaining service continuity and quality. This evidence regarding alternative strategies adopted to sustain service delivery in Syria is of clear relevance to other actors seeking organizational resilience in crisis contexts.
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Affiliation(s)
- Zeina Jamal
- Institute for Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Mohamad Alameddine
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, P.O. Box 11-0236, Riad El-Solh/Beirut 1107 2020, Lebanon
| | - Karin Diaconu
- Institute for Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Graham Lough
- Institute for Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Alastair Ager
- Institute for Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Fouad M Fouad
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, P.O. Box 11-0236, Riad El-Solh/Beirut 1107 2020, Lebanon
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29
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Alawa J, Alawa N, Coutts A, Sullivan R, Khoshnood K, Fouad FM. Addressing COVID-19 in humanitarian settings: a call to action. Confl Health 2020; 14:64. [PMID: 32934662 PMCID: PMC7483047 DOI: 10.1186/s13031-020-00307-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 08/19/2020] [Indexed: 12/22/2022] Open
Abstract
Refugees and internally displaced persons in humanitarian settings are particularly susceptible to the spread of infectious illnesses such as COVID-19 due to overcrowding and inadequate access to clean water, sanitation, and hygiene facilities. Countries facing conflict or humanitarian emergencies often have damaged or fragmented health systems and little to no capacity to test, isolate, and treat COVID-19 cases. Without a plan to address COVID-19 in humanitarian settings, host governments, aid agencies, and international organizations risk prolonging the spread of the virus across borders, threatening global health security, and devastating vulnerable populations. Stakeholders must coordinate a multifaceted response to address COVID-19 in humanitarian settings that incorporates appropriate communication of risks, sets forth resource-stratified guidelines for the use of limited testing, provides resources to treat affected patients, and engages displaced populations.
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Affiliation(s)
- Jude Alawa
- Stanford University School of Medicine, Stanford, California USA
| | - Nawara Alawa
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas USA
| | - Adam Coutts
- Department of Sociology, University of Cambridge, Cambridge, UK
| | - Richard Sullivan
- Institute for Cancer Policy and Conflict & Health Research Group, King’s College London, London, UK
| | | | - Fouad M. Fouad
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
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30
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Aggarwal A, Patel P, Lewison G, Ekzayez A, Coutts A, Fouad FM, Shamieh O, Giacaman R, Kutluk T, Khalek RA, Lawler M, Boyle P, Sarfati D, Sullivan R. The Profile of Non-Communicable Disease (NCD) research in the Middle East and North Africa (MENA) region: Analyzing the NCD burden, research outputs and international research collaboration. PLoS One 2020; 15:e0232077. [PMID: 32339197 PMCID: PMC7185716 DOI: 10.1371/journal.pone.0232077] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/07/2020] [Indexed: 11/18/2022] Open
Abstract
Objectives Despite the rising risk factor exposure and non-communicable disease (NCD) mortality across the Middle East and the North African (MENA) region, public health policy responses have been slow and appear discordant with the social, economic and political circumstances in each country. Good health policy and outcomes are intimately linked to a research-active culture, particularly in NCD. In this study we present the results of a comprehensive analysis of NCD research with particular a focus on cancer, diabetes and cardiovascular disease in 10 key countries that represent a spectrum across MENA between 1991 and 2018. Methods The study uses a well validated bibliometric approach to undertake a quantitative analysis of research output in the ten leading countries in biomedical research in the MENA region on the basis of articles and reviews in the Web of Science database. We used filters for each of the three NCDs and biomedical research to identify relevant papers in the WoS. The countries selected for the analyses were based on the volume of research outputs during the period of analysis and stability, included Egypt, Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Turkey and the United Arab Emirates. Results A total of 495,108 biomedical papers were found in 12,341 journals for the ten MENA countries (here we consider Turkey in the context of MENA). For all three NCDs, Turkey's output is consistently the highest. Iran has had considerable growth in research output to occupy second place across all three NCDs. It appears that, relative to their wealth (measured by GDP), some MENA countries, particularly Oman, Qatar, Kuwait and the United Arab Emirates, are substantially under-investing in biomedical research. In terms of investment on particular NCDs, we note the relatively greater commitment on cancer research compared with diabetes or cardiovascular disease in most MENA countries, despite cardiovascular disease causing the greatest health-related burden. When considering the citation impact of research outputs, there have been marked rises in citation scores in Qatar, Lebanon, United Arab Emirates and Oman. However, Turkey, which has the largest biomedical research output in the Middle East has the lowest citation scores overall. The level of intra-regional collaboration in NCD research is highly variable. Saudi Arabia and Egypt are the dominant research collaborators across the MENA region. However, Turkey and Iran, which are amongst the leading research-active countries in the area, show little evidence of collaboration. With respect to international collaboration, the United States and United Kingdom are the dominant research partners across the region followed by Germany and France. Conclusion The increase in research activity in NCDs across the MENA region countries during the time period of analysis may signal both an increasing focus on NCDs which reflects general global trends, and greater investment in research in some countries. However, there are several risks to the sustainability of these improvements that have been identified in particular countries within the region. For example, a lack of suitably trained researchers, low political commitment and poor financial support, and minimal international collaboration which is essential for wider global impact.
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Affiliation(s)
- Ajay Aggarwal
- Institute of Cancer Policy, Cancer Epidemiology, Population & Global Health, School of Cancer Sciences, King’s College London, London, United Kingdom
- Department of Clinical Oncology, Guy’s & St.Thomas’ NHS Trust, London, United Kingdom
- * E-mail:
| | - Preeti Patel
- Department of War Studies, King’s College London, London, United Kingdom
- Conflict and Health Research Group, King’s College London, London, United Kingdom
| | - Grant Lewison
- Institute of Cancer Policy, Cancer Epidemiology, Population & Global Health, School of Cancer Sciences, King’s College London, London, United Kingdom
| | - Abdulkarim Ekzayez
- Department of War Studies, King’s College London, London, United Kingdom
- Conflict and Health Research Group, King’s College London, London, United Kingdom
| | - Adam Coutts
- Department of Sociology, University of Cambridge, Cambridge, United Kingdom
| | - Fouad M. Fouad
- Global Health Institute/Department of Epidemiology and Population Health, American University of Beirut, Beirut, Lebanon
| | | | - Rita Giacaman
- Institute of Community and Public Health, Birzeit University, Birzeit, West Bank, occupied Palestinian territory
| | - Tezer Kutluk
- Department of Pediatric Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Rima Abdul Khalek
- Global Health Institute/Department of Epidemiology and Population Health, American University of Beirut, Beirut, Lebanon
| | - Mark Lawler
- Queen’s University Belfast, Centre for Cancer Research and Cell Biology, Belfast, United Kingdom
| | - Peter Boyle
- International Prevention Research Institute, Lyon, France
| | - Diana Sarfati
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Richard Sullivan
- Institute of Cancer Policy, Cancer Epidemiology, Population & Global Health, School of Cancer Sciences, King’s College London, London, United Kingdom
- Conflict and Health Research Group, King’s College London, London, United Kingdom
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31
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Sibai AM, Rizk A, Coutts AP, Monzer G, Daoud A, Sullivan R, Roberts B, Meho LI, Fouad FM, DeJong J. North-South inequities in research collaboration in humanitarian and conflict contexts. Lancet 2019; 394:1597-1600. [PMID: 31690433 DOI: 10.1016/s0140-6736(19)32482-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/14/2019] [Accepted: 08/05/2019] [Indexed: 11/20/2022]
Affiliation(s)
- Abla M Sibai
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Riad El-Solh, Beirut 1107 2020, Lebanon
| | - Anthony Rizk
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Riad El-Solh, Beirut 1107 2020, Lebanon
| | - Adam P Coutts
- Magdalene College and Department of Sociology, University of Cambridge, Cambridge, UK
| | - Ghinwa Monzer
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Riad El-Solh, Beirut 1107 2020, Lebanon
| | - Adel Daoud
- Center for Population and Development Studies, Harvard T H Chan School of Public Health, Harvard University, Cambridge, MA, USA
| | - Richard Sullivan
- KCL Institute of Cancer Policy, King's College London, London, UK
| | - Bayard Roberts
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Lokman I Meho
- University Libraries, American University of Beirut, Beirut, Lebanon
| | - Fouad M Fouad
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Riad El-Solh, Beirut 1107 2020, Lebanon
| | - Jocelyn DeJong
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Riad El-Solh, Beirut 1107 2020, Lebanon.
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32
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Honein-AbouHaidar G, Noubani A, El Arnaout N, Ismail S, Nimer H, Menassa M, Coutts AP, Rayes D, Jomaa L, Saleh S, Fouad FM. Correction to: Informal healthcare provision in Lebanon: an adaptive mechanism among displaced Syrian health professionals in a protracted crisis. Confl Health 2019; 13:44. [PMID: 31624495 PMCID: PMC6781308 DOI: 10.1186/s13031-019-0229-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Gladys Honein-AbouHaidar
- 1Global Health Institute, American University of Beirut, Beirut, Lebanon.,2Hariri School of Nursing, American University of Beirut, Beirut, Lebanon
| | - Aya Noubani
- 1Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Nour El Arnaout
- 1Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Sharif Ismail
- 3Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Hana Nimer
- 1Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Marilyne Menassa
- 1Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Adam P Coutts
- 4Department of Sociology and Magdalene College, University of Cambridge, Cambridge, UK
| | | | - Lamis Jomaa
- 1Global Health Institute, American University of Beirut, Beirut, Lebanon.,6Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences, American University of Beirut, Beirut, Lebanon
| | - Shadi Saleh
- 1Global Health Institute, American University of Beirut, Beirut, Lebanon.,7Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Fouad M Fouad
- 1Global Health Institute, American University of Beirut, Beirut, Lebanon.,8Department of Epidemiology & Population Health, Faculty of Health Sciences, American University of Beirut, P.O. Box 11-0236, Riad El Solh, Beirut, 1107 2020 Lebanon
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Phillimore P, Sibai AM, Rizk A, Maziak W, Unal B, Abu Rmeileh N, Ben Romdhane H, Fouad FM, Khader Y, Bennett K, Zaman S, Mataria A, Ghandour R, Kılıç B, Ben Mansour N, Fadhil I, O'Flaherty M, Capewell S, Critchley JA. Context-led capacity building in time of crisis: fostering non-communicable diseases (NCD) research skills in the Mediterranean Middle East and North Africa. Glob Health Action 2019; 12:1569838. [PMID: 30721116 PMCID: PMC6366406 DOI: 10.1080/16549716.2019.1569838] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: This paper examines one EC-funded multinational project (RESCAP-MED), with a focus on research capacity building (RCB) concerning non-communicable diseases (NCDs) in the Mediterranean Middle East and North Africa. By the project’s end (2015), the entire region was engulfed in crisis. Objective: Designed before this crisis developed in 2011, the primary purpose of RESCAP-MED was to foster methodological skills needed to conduct multi-disciplinary research on NCDs and their social determinants. RESCAP-MED also sought to consolidate regional networks for future collaboration, and to boost existing regional policy engagement in the region on the NCD challenge. This analysis examines the scope and sustainability of RCB conducted in a context of intensifying political turmoil. Methods: RESCAP-MED linked two sets of activities. The first was a framework for training early- and mid-career researchers through discipline-based and writing workshops, plus short fellowships for sustained mentoring. The second integrated public-facing activities designed to raise the profile of the NCD burden in the region, and its implications for policymakers at national level. Key to this were two conferences to showcase regional research on NCDs, and the development of an e-learning resource (NETPH). Results: Seven discipline-based workshops (with 113 participants) and 6 workshops to develop writing skills (84 participants) were held, with 18 fellowship visits. The 2 symposia in Istanbul and Beirut attracted 280 participants. Yet the developing political crisis tagged each activity with a series of logistical challenges, none of which was initially envisaged. The immediacy of the crisis inevitably deflected from policy attention to the challenges of NCDs. Conclusions: This programme to strengthen research capacity for one priority area of global public health took place as a narrow window of political opportunity was closing. The key lessons concern issues of sustainability and the paramount importance of responsively shaping a context-driven RCB.
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Affiliation(s)
- Peter Phillimore
- a School of Geography, Politics & Sociology , Newcastle University , Newcastle , UK
| | - Abla M Sibai
- b Department of Epidemiology & Population Health , American University of Beirut , Beirut , Lebanon
| | - Anthony Rizk
- b Department of Epidemiology & Population Health , American University of Beirut , Beirut , Lebanon
| | - Wasim Maziak
- c Department of Epidemiology , Florida International University, USA; and Syrian Center for Tobacco Studies , Aleppo , Syria
| | - Belgin Unal
- d Department of Public Health , Dokuz Eylul University , Izmir , Turkey
| | - Niveen Abu Rmeileh
- e Institute of Community and Public Health , Birzeit University , Palestine
| | | | - Fouad M Fouad
- g Department of Epidemiology & Population Health American University of Beirut , Lebanon; and Syrian Center for Tobacco Studies , Aleppo , Syria
| | - Yousef Khader
- h Public Health Department , Jordan University of Science and Technology , Irbid , Jordan
| | | | | | - Awad Mataria
- k WHO Regional Office for the Eastern Mediterranean (EMRO) , Cairo , Egypt
| | - Rula Ghandour
- e Institute of Community and Public Health , Birzeit University , Palestine
| | - Bülent Kılıç
- d Department of Public Health , Dokuz Eylul University , Izmir , Turkey
| | | | - Ibtihal Fadhil
- k WHO Regional Office for the Eastern Mediterranean (EMRO) , Cairo , Egypt
| | - Martin O'Flaherty
- m Institute of Psychology, Health & Society , University of Liverpool , Liverpool , UK
| | - Simon Capewell
- m Institute of Psychology, Health & Society , University of Liverpool , Liverpool , UK
| | - Julia A Critchley
- n Population Health Research Institute , St George's, University of London , London , UK
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Akik C, Ghattas H, Mesmar S, Rabkin M, El-Sadr WM, Fouad FM. Host country responses to non-communicable diseases amongst Syrian refugees: a review. Confl Health 2019; 13:8. [PMID: 30949232 PMCID: PMC6431037 DOI: 10.1186/s13031-019-0192-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 03/06/2019] [Indexed: 11/10/2022] Open
Abstract
Background Since the beginning of the Syrian conflict in 2011, Jordan, Lebanon and Turkey have hosted large refugee populations, with a high pre-conflict burden of non-communicable diseases (NCDs). Objectives We aimed to describe the ways in which these three host country health systems have provided NCD services to Syrian refugees over time, and to highlight the successes and challenges they encountered. Methods We conducted a descriptive review of the academic and grey literature, published between March 2011 and March 2017, using PubMed and Google searches complemented with documents provided by relevant stakeholders. Results Forty-one articles and reports met our search criteria. Despite the scarcity of systematic population-level data, these documents highlight the high burden of reported NCDs among Syrian refugees, especially amongst older adults. The three host countries utilized different approaches to the design, delivery and financing of NCD services for these refugees. In Jordan and Lebanon, Ministries of Health and the United Nations High Commissioner for Refugees (UNHCR) coordinate a diverse group of health care providers to deliver health services to Syrian refugees at a subsidized cost. In Turkey, however, services are provided solely by the Disaster and Emergency Management Presidency (AFAD), a Turkish governmental agency, with no cost to patients for primary or secondary care. Access to NCD services varied both within and between countries, with no data available from Turkey. The cost of NCD treatment is the primary barrier to accessing healthcare, with high out-of-pocket payments required for medications and secondary and tertiary care services, despite the availability of free or subsidized primary health services. Financial impediments led refugees to adopt coping strategies, including returning to Syria to seek treatment, with associated frequent treatment interruptions. These gaps were compounded by health system related barriers such as complex referral systems, lack of effective guidance on navigating the health system, limited health facility capacity and suboptimal NCD health education. Conclusion As funding shortages for refugee services continue, innovative service delivery models are needed to create responsive and sustainable solutions to the NCD burden among refugees in host countries.
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Affiliation(s)
- Chaza Akik
- 1Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Hala Ghattas
- 1Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Sandra Mesmar
- 1Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Miriam Rabkin
- 2ICAP, Columbia University Mailman School of Public Health, New York, USA
| | - Wafaa M El-Sadr
- 2ICAP, Columbia University Mailman School of Public Health, New York, USA
| | - Fouad M Fouad
- 3Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
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Abubakar I, Aldridge RW, Devakumar D, Orcutt M, Burns R, Barreto ML, Dhavan P, Fouad FM, Groce N, Guo Y, Hargreaves S, Knipper M, Miranda JJ, Madise N, Kumar B, Mosca D, McGovern T, Rubenstein L, Sammonds P, Sawyer SM, Sheikh K, Tollman S, Spiegel P, Zimmerman C. The UCL-Lancet Commission on Migration and Health: the health of a world on the move. Lancet 2018; 392:2606-2654. [PMID: 30528486 PMCID: PMC7612863 DOI: 10.1016/s0140-6736(18)32114-7] [Citation(s) in RCA: 369] [Impact Index Per Article: 61.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/27/2018] [Accepted: 08/29/2018] [Indexed: 12/22/2022]
Abstract
With one billion people on the move or having moved in 2018, migration is a global reality, which has also become a political lightning rod. Although estimates indicate that the majority of global migration occurs within low-income and middle-income countries (LMICs), the most prominent dialogue focuses almost exclusively on migration from LMICs to high-income countries (HICs). Nowadays, populist discourse demonises the very same individuals who uphold economies, bolster social services, and contribute to health services in both origin and destination locations. Those in positions of political and economic power continue to restrict or publicly condemn migration to promote their own interests. Meanwhile nationalist movements assert so-called cultural sovereignty by delineating an us versus them rhetoric, creating a moral emergency. In response to these issues, the UCL-Lancet Commission on Migration and Health was convened to articulate evidence-based approaches to inform public discourse and policy. The Commission undertook analyses and consulted widely, with diverse international evidence and expertise spanning sociology, politics, public health science, law, humanitarianism, and anthropology. The result of this work is a report that aims to be a call to action for civil society, health leaders, academics, and policy makers to maximise the benefits and reduce the costs of migration on health locally and globally. The outputs of our work relate to five overarching goals that we thread throughout the report. First, we provide the latest evidence on migration and health outcomes. This evidence challenges common myths and highlights the diversity, dynamics, and benefits of modern migration and how it relates to population and individual health. Migrants generally contribute more to the wealth of host societies than they cost. Our Article shows that international migrants in HICs have, on average, lower mortality than the host country population. However, increased morbidity was found for some conditions and among certain subgroups of migrants, (eg, increased rates of mental illness in victims of trafficking and people fleeing conflict) and in populations left behind in the location of origin. Currently, in 2018, the full range of migrants’ health needs are difficult to assess because of poor quality data. We know very little, for example, about the health of undocumented migrants, people with disabilities, or lesbian, gay, bisexual, transsexual, or intersex (LGBTI) individuals who migrate or who are unable to move. Second, we examine multisector determinants of health and consider the implication of the current sector-siloed approaches. The health of people who migrate depends greatly on structural and political factors that determine the impetus for migration, the conditions of their journey, and their destination. Discrimination, gender inequalities, and exclusion from health and social services repeatedly emerge as negative health influences for migrants that require cross-sector responses. Third, we critically review key challenges to healthy migration. Population mobility provides economic, social, and cultural dividends for those who migrate and their host communities. Furthermore, the right to the highest attainable standard of health, regardless of location or migration status, is enshrined in numerous human rights instruments. However, national sovereignty concerns overshadow these benefits and legal norms. Attention to migration focuses largely on security concerns. When there is conjoining of the words health and migration, it is either focused on small subsets of society and policy, or negatively construed. International agreements, such as the UN Global Compact for Migration and the UN Global Compact on Refugees, represent an opportunity to ensure that international solidarity, unity of intent, and our shared humanity triumphs over nationalist and exclusionary policies, leading to concrete actions to protect the health of migrants. Fourth, we examine equity in access to health and health services and offer evidence-based solutions to improve the health of migrants. Migrants should be explicitly included in universal health coverage commitments. Ultimately, the cost of failing to be health-inclusive could be more expensive to national economies, health security, and global health than the modest investments required. Finally, we look ahead to outline how our evidence can contribute to synergistic and equitable health, social, and economic policies, and feasible strategies to inform and inspire action by migrants, policy makers, and civil society. We conclude that migration should be treated as a central feature of 21st century health and development. Commitments to the health of migrating populations should be considered across all Sustainable Development Goals (SDGs) and in the implementation of the Global Compact for Migration and Global Compact on Refugees. This Commission offers recommendations that view population mobility as an asset to global health by showing the meaning and reality of good health for all. We present four key messages that provide a focus for future action.
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Affiliation(s)
- Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK.
| | - Robert W Aldridge
- Institute for Health Informatics, University College London, London, UK
| | - Delan Devakumar
- Institute for Global Health, University College London, London, UK
| | - Miriam Orcutt
- Institute for Global Health, University College London, London, UK
| | - Rachel Burns
- Institute for Global Health, University College London, London, UK
| | - Mauricio L Barreto
- Centre for Data and Knowledge Integration for Health, Fundação Oswaldo Cruz, Salvador-Bahia, Brazil
| | - Poonam Dhavan
- International Organization for Migration, Geneva, Switzerland
| | - Fouad M Fouad
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Nora Groce
- Leonard Cheshire Centre, Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Yan Guo
- School of Public Health, Peking University, Beijing, China
| | - Sally Hargreaves
- Institute of Infection and Immunity, St George's, University of London, London, UK; International Health Unit, Section of Infectious Diseases and Immunity, Imperial College London, London, UK
| | - Michael Knipper
- Institute for the History of Medicine, Justus Liebig University Giessen, Giessen, Germany
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Nyovani Madise
- African Institute for Development Policy, Lilongwe, Malawi; Centre for Global Health, Population, Poverty and Policy, University of Southampton, Southampton, UK
| | - Bernadette Kumar
- Norwegian Centre for Minority Health Research, Oslo, Norway; Department of Community Medicine and Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Davide Mosca
- International Organization for Migration, Geneva, Switzerland
| | - Terry McGovern
- Program on Global Health Justice and Governance, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Leonard Rubenstein
- Center for Public Health and Human Rights, Johns Hopkins University, Baltimore, MD, USA; Johns Hopkins Bloomberg School of Public Health, and Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Peter Sammonds
- Institute for Risk and Disaster Reduction, University College London, London, UK
| | - Susan M Sawyer
- Department of Paediatrics, University of Melbourne, University of Melbourne, Parkville, VIC, Australia; Centre for Adolescent Health, and Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | - Kabir Sheikh
- Public Health Foundation of India, Institutional Area Gurgaon, India; Nossal Institute of Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Stephen Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Paul Spiegel
- Department of International Health, Johns Hopkins University, Baltimore, MD, USA; Johns Hopkins Center for Humanitarian Health, Johns Hopkins University, Baltimore, MD, USA
| | - Cathy Zimmerman
- Gender, Violence and Health Centre, London School of Hygiene and Tropical Medicine, London, UK
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Madi F, Ismail H, Fouad FM, Kerbage H, Zaman S, Jayawickrama J, Sibai AM. Death, Dying, and End-of-Life Experiences Among Refugees: A Scoping Review. J Palliat Care 2018; 34:139-144. [PMID: 30458699 DOI: 10.1177/0825859718812770] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND: The objective of this scoping review is to identify and map the global literature on death, dying, and end-of-life experiences among refugees. The study aims at identifying gaps in the literature produced on the topic and informs areas for future research in the field. METHODS: We included articles that met the following inclusion criteria: (1) Population: Refugees and/or internally or externally displaced individuals due to wars, conflicts, nonnatural disasters, or emergencies; (2) Setting: End-of-life phase, dying, and death that took place following the refuge or displacement and reported after the year 1980; and (3) Study Design: All types of studies including but not limited to primary studies, narrative reviews, systematic reviews, news, editorials, commentaries, opinion pieces, technical reports, and policy briefs. A systematic search of the following electronic databases: Medline, Scopus, CINAHL, and JSTOR yielded 11 153 records. The search of the United Nations High Commissioner for Refugees database Refworld retrieved an additional 7510 records. RESULTS: Seven articles met our inclusion criteria. All articles were coauthored by scholars in universities/research institutes in high-income countries, and except for one, all were conducted in the country of the final settlement of refugees. One article adopted a qualitative approach, another article adopted a mixed-methods approach, one was a narrative review, and 4 articles were reviews of the literature. Three articles discussed access to medical/palliative care among older refugees, and 3 others addressed bereavement and death arrangements. Moreover, one article examined how transmigration and previous experiences from 2 cultural settings in home countries affect the contemplation of death and dying. IMPLICATIONS: Research on end-of-life experiences among refugees is sorely lacking. This study raises awareness of the need for empirical data on end-of-life challenges and palliative care among refugees, thus equipping humanitarian agencies with a more explicit and culturally sensitive lens targeting those with life-limiting conditions.
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Affiliation(s)
- Farah Madi
- 1 Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Hussein Ismail
- 1 Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Fouad M Fouad
- 1 Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Hala Kerbage
- 2 Faculty of Medicine, Universite Saint-Joseph, Beirut, Lebanon
| | - Shahaduz Zaman
- 3 Department of Global Health and Infection, University of Sussex, Brighton, United Kingdom
| | | | - Abla M Sibai
- 1 Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
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Bou-Karroum L, Daou KN, Nomier M, El Arnaout N, Fouad FM, El-Jardali F, Akl EA. Health Care Workers in the setting of the "Arab Spring": a scoping review for the Lancet-AUB Commission on Syria. J Glob Health 2018; 9:010402. [PMID: 30410745 PMCID: PMC6207103 DOI: 10.7189/jogh.09.010402] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background "Health Care Workers in Conflict Areas" emerged as one of the priority themes for a Lancet Commission addressing health in conflict. The objective of our study was to conduct a scoping review on health workers in the setting of the Syrian conflict, addressing four topics of interest: violence against health care workers, education, practicing in conflict setting, and migration. Methods Considering the likelihood of scarcity of data, we broadened the scope of the scoping review to include indirect evidence on health care workers from other countries affected by the "Arab Spring". We electronically searched six electronic databases. We conducted descriptive analysis of the general characteristics of the included papers. We also used the results of this scoping review to build an evidence gap map. Results Out of the 11 165 identified citations, 136 met our eligibility criteria. The majority of the articles tackled the issue of violence against health care workers (63%) followed by practicing in conflict setting (19%), migration (17%) and education (10%). Countries in focus of most articles were: Syria (35%), Iraq (33%), and Bahrain (29%). News, editorials, commentaries and opinion pieces made up 81% of all included papers, while primary studies made up only 9%. All the primary studies identified in this review were conducted on Iraq. Most of the articles about violence against health care workers were on Bahrain, followed by Syria and Iraq. The first and corresponding authors were most frequently affiliated with institutions from non-Arab countries (79% and 79% respectively). Conclusions Research evidence on health care workers in the setting of the "Arab Spring" is scarce. This review and the gap map can inform the research agendas of funders and researchers working in the field of health care workers in conflict setting. More well-designed primary studies are needed to inform the decisions of policymakers and other interested parties.
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Affiliation(s)
- Lama Bou-Karroum
- Center for Systematic Reviews for Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon.,Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Karim N Daou
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Mohamed Nomier
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Nour El Arnaout
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Fouad M Fouad
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.,Refugee Health Program, Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Fadi El-Jardali
- Center for Systematic Reviews for Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon.,Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Elie A Akl
- Center for Systematic Reviews for Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.,Department of Internal Medicine, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
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Ager A, Alameddine M, Witter S, Fouad FM, Diaconu K, Jamal Z, Lough G. In support of UNRWA appeal for health and dignity of Palestinian refugees. Lancet 2018; 391:1260-1261. [PMID: 29619957 DOI: 10.1016/s0140-6736(18)30568-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 02/26/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Alastair Ager
- Institute for Global Health & Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Mohamad Alameddine
- Faculty of Health Science, American University of Beirut, Beirut, Lebanon
| | - Sophie Witter
- Institute for Global Health & Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Fouad M Fouad
- Faculty of Health Science, American University of Beirut, Beirut, Lebanon
| | - Karin Diaconu
- Institute for Global Health & Development, Queen Margaret University, Edinburgh EH21 6UU, UK.
| | - Zeina Jamal
- Faculty of Health Science, American University of Beirut, Beirut, Lebanon
| | - Graham Lough
- Institute for Global Health & Development, Queen Margaret University, Edinburgh EH21 6UU, UK
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Jabbour S, Fouad FM, Leaning J, McKay D, Nasser R, Rubenstein LS, Sparrow A, Spiegel P, Tarakji A, Waldman R, Hallam R, Mukwege D, Tayara G. Death and suffering in Eastern Ghouta, Syria: a call for action to protect civilians and health care. Lancet 2018; 391:815-817. [PMID: 29496277 DOI: 10.1016/s0140-6736(18)30527-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Samer Jabbour
- Faculty of Health Sciences, American University of Beirut, Beirut 1107 2020, Lebanon.
| | - Fouad M Fouad
- Faculty of Health Sciences, American University of Beirut, Beirut 1107 2020, Lebanon
| | - Jennifer Leaning
- FXB Center for Health and Human Rights, Harvard University, Cambridge, MA, USA
| | - Donna McKay
- Physicians for Human Rights, New York, NY, USA
| | - Rabie Nasser
- Syrian Center for Policy Studies, Beirut, Lebanon
| | - Leonard S Rubenstein
- Safeguarding Health in Conflict Coalition and Program on Human Rights, Health and Conflict, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Annie Sparrow
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul Spiegel
- Johns Hopkins Center for Humanitarian Health and Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ahmad Tarakji
- Syrian American Medical Society, Washington, DC, USA
| | - Ronald Waldman
- Milken Institute School of Public Health, George Washington University and Doctors of the World, Washington, DC, USA
| | - Rola Hallam
- CanDo, London, UK; Royal Free Hospital, London, UK
| | - Denis Mukwege
- Panzi Hospital, Bukavu, Democratic Republic of Congo
| | - Ghanem Tayara
- Union of Medical Care and Relief Organizations International, Birmingham, UK
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Goldhagen JL, Kadir A, Fouad FM, Spencer NJ, Raman S. The Budapest declaration for children and youth on the move. Lancet Child Adolesc Health 2018; 2:164-165. [PMID: 30169251 DOI: 10.1016/s2352-4642(18)30030-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 10/18/2022]
Affiliation(s)
- Jeffrey L Goldhagen
- Division of Community and Societal Pediatrics, University of Florida, Jacksonville, FL 32207, USA.
| | - Ayesha Kadir
- Center for Social Paediatrics, Herlev Hospital, Copenhagen, Denmark
| | - Fouad M Fouad
- Faculty of Health Sciences, Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Nicholas J Spencer
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Shanti Raman
- Community Paediatrics, South Western Sydney Local Health District, Liverpool NSW, Australia
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Fouad FM, Sparrow A, Tarakji A, Alameddine M, El-Jardali F, Coutts AP, El Arnaout N, Karroum LB, Jawad M, Roborgh S, Abbara A, Alhalabi F, AlMasri I, Jabbour S. Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet-American University of Beirut Commission on Syria. Lancet 2017; 390:2516-2526. [PMID: 28314568 DOI: 10.1016/s0140-6736(17)30741-9] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 02/26/2017] [Accepted: 02/27/2017] [Indexed: 11/21/2022]
Abstract
The conflict in Syria presents new and unprecedented challenges that undermine the principles and practice of medical neutrality in armed conflict. With direct and repeated targeting of health workers, health facilities, and ambulances, Syria has become the most dangerous place on earth for health-care providers. The weaponisation of health care-a strategy of using people's need for health care as a weapon against them by violently depriving them of it-has translated into hundreds of health workers killed, hundreds more incarcerated or tortured, and hundreds of health facilities deliberately and systematically attacked. Evidence shows use of this strategy on an unprecedented scale by the Syrian Government and allied forces, in what human rights organisations described as a war-crime strategy, although all parties seem to have committed violations. Attacks on health care have sparked a large-scale exodus of experienced health workers. Formidable challenges face health workers who have stayed behind, and with no health care a major factor in the flight of refugees, the effect extends well beyond Syria. The international community has left these violations of international humanitarian and human rights law largely unanswered, despite their enormous consequences. There have been repudiated denunciations, but little action on bringing the perpetrators to justice. This inadequate response challenges the foundation of medical neutrality needed to sustain the operations of global health and humanitarian agencies in situations of armed conflict. In this Health Policy, we analyse the situation of health workers facing such systematic and serious violations of international humanitarian law. We describe the tremendous pressures that health workers have been under and continue to endure, and the remarkable resilience and resourcefulness they have displayed in response to this crisis. We propose policy imperatives to protect and support health workers working in armed conflict zones.
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Affiliation(s)
- Fouad M Fouad
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon; Global Health Initiative, American University of Beirut, Beirut, Lebanon
| | - Annie Sparrow
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ahmad Tarakji
- Syrian American Medical Society (SAMS), Washington, DC, USA
| | - Mohamad Alameddine
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Fadi El-Jardali
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon; Knowledge to Policy (K2P) Center, American University of Beirut, Beirut, Lebanon; Center for Systematic Reviews on Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
| | - Adam P Coutts
- Department of Sociology, University of Cambridge, Cambridge, UK
| | - Nour El Arnaout
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Lama Bou Karroum
- Center for Systematic Reviews on Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
| | - Mohammed Jawad
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon; Imperial College London, London, UK
| | - Sophie Roborgh
- Department of Politics and International Studies, University of Cambridge, Cambridge, UK
| | - Aula Abbara
- Syrian American Medical Society (SAMS), Washington, DC, USA; Imperial College London, London, UK
| | | | | | - Samer Jabbour
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
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DeJong J, Sbeity F, Schlecht J, Harfouche M, Yamout R, Fouad FM, Manohar S, Robinson C. Young lives disrupted: gender and well-being among adolescent Syrian refugees in Lebanon. Confl Health 2017; 11:23. [PMID: 29167697 PMCID: PMC5688457 DOI: 10.1186/s13031-017-0128-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background The conflict in Syria that began in 2011 has resulted in the exodus of over 5 million Syrian refugees to neighbouring countries, with more than one million refugees currently registered by UNHCR in Lebanon. While some are living in tented settlements, the majority are living in strained conditions in rented accommodation or collective shelters in the Bekaa Valley next to Syria. Adolescents are particularly vulnerable in any crisis. In 2013–4, the American University in Beirut in collaboration with the Women’s Refugee Commission, Johns Hopkins and Save the Children, sought to understand the specific experiences of very young adolescents, those 10–14 years of age, in this protracted crisis context. Methods The study was conducted in 2014 in Barelias and Qabelias – two urban areas located close to each other in the Beka’a valley that has a large concentration of Syrian refugees. Focus group discussions (FGDs), including community mapping and photo elicitation, were conducted with 10–12 and 13–14 year old Syrian refugee adolescents, in order to obtain information about their experiences and perspectives. FGDs were also implemented with 15–16 year old Syrian refugees and separately also with adult refugees, to consider their perspectives on the needs and risks of these adolescents. Results A total of 16 FGD (8 for each sex, with 6–9 participants in each) were conducted in Arabic across the two sites, with 59 female participants and 59 male participants. The experiences and risks faced by these adolescents were significantly impacted by economic strain and loss of educational opportunities during displacement, and only a minority of adolescents in the study reported attending school. Additionally, on-going protection risks for girls were felt to be higher due to the crisis and displacement. In Lebanon this has resulted in increased risks of child marriage and limitations in mobility for adolescent girls. Adolescents, themselves expressed tensions with their Lebanese counterparts and feared verbal attacks and beatings from school-aged Lebanese male youth. Conclusions Families and adolescents have been dramatically affected by the conflict in Syria, and the resulting forced displacement. The loss of educational opportunities is perhaps the most significant effect, with long-term devastating outcomes. Additionally, the futures of Syrian girls are deeply affected by new protection concerns, particularly as they are exposed to an unfamiliar and more liberal society in Lebanon. Child marriage and limitations in their mobility – particularly for girls - are presented by families as coping strategies to these risks. Programming is needed to ensure sustained education access for all adolescents, and to educate very young adolescents and their parents on managing their own health and well-being, given the multiple strains. More effort is needed to encourage positive interaction between adolescent Lebanese and adolescent Syrian refugees.
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Affiliation(s)
- Jocelyn DeJong
- Faculty of Health Sciences, American University in Beirut, Beirut, Lebanon
| | - Farah Sbeity
- Faculty of Health Sciences, American University in Beirut, Beirut, Lebanon
| | | | - Manale Harfouche
- Faculty of Health Sciences, American University in Beirut, Beirut, Lebanon
| | - Rouham Yamout
- Faculty of Health Sciences, American University in Beirut, Beirut, Lebanon
| | - Fouad M Fouad
- Faculty of Health Sciences, American University in Beirut, Beirut, Lebanon
| | | | - Courtland Robinson
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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Bahelah R, DiFranza JR, Ward KD, Eissenberg T, Fouad FM, Taleb ZB, Jaber R, Maziak W. Waterpipe smoking patterns and symptoms of nicotine dependence: The Waterpipe Dependence in Lebanese Youth Study. Addict Behav 2017. [PMID: 28624697 DOI: 10.1016/j.addbeh.2017.06.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Waterpipe typically is smoked intermittently over long smoking sessions. Waterpipe is addictive and its users show symptoms of nicotine dependence (ND). This study examined the risk of developing ND symptoms across waterpipe use patterns among Lebanese youth. METHODS Waterpipe use patterns (length of smoking session, smoking a whole waterpipe without sharing, past-30day use frequency, number of waterpipes smoked) were assessed. Symptoms of ND were assessed using the 10-item Hooked on Nicotine Checklist (HONC; endorsement of ≥1 symptom) and the 6 criteria of the International Classification of Diseases-10th revision (ICD-10 ND; presence of ≥3 criteria during 12months). RESULTS Both the proportion of participants endorsing ND symptoms and the average number of endorsed ND symptoms increased with increasing waterpipe use frequency, number of waterpipes smoked, and length of smoking session. The risk of endorsing≥1 HONC symptom increased with increasing number of waterpipes smoked in the past 30-days (≥10 vs. <4 waterpipes; Hazard ratio (HR)=2.05, 95% CI: 1.52-2.58, p=0.007), and session length (>60min vs. <30min; HR=2.87, 95% CI: 2.83-2.91, p=0.001). The risk of attaining ICD-10 ND increased with increasing number of waterpipes used in the past 30-days (≥10 vs. <4 waterpipes; HR=2.56, 95% CI: 1.89-3.22, p=0.006), and smoking every day/almost every day vs. less than once weekly (HR=2.86, 95% CI: 2.12-3.60, p=0.007). CONCLUSIONS Increasing use frequency, number of waterpipes smoked, and longer smoking sessions were associated with higher risk of ND. The length of smoking session emerged as a novel indicator of ND among waterpipe smokers.
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Affiliation(s)
- Raed Bahelah
- Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL, USA; Faculty of Medicine and Health Sciences, Aden University, Yemen
| | - Joseph R DiFranza
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, USA
| | - Kenneth D Ward
- Syrian Center for Tobacco Studies, Aleppo, Syria; University of Memphis School of Public Health, Memphis, TN, USA
| | - Thomas Eissenberg
- Department of Psychology, Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, VA, USA
| | - Fouad M Fouad
- Syrian Center for Tobacco Studies, Aleppo, Syria; American University of Beirut, Lebanon
| | - Ziyad Ben Taleb
- Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL, USA
| | - Rana Jaber
- Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL, USA
| | - Wasim Maziak
- Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL, USA; Syrian Center for Tobacco Studies, Aleppo, Syria.
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Abstract
The crisis in Syria has forced more than 4 million people to find refuge outside Syria. In Lebanon, in 2015, the refugee population represented 30 % of the total population. International health assistance has been provided to refugee populations in Lebanon. However, the current humanitarian system has also contributed to increase fragmentation of the Lebanese health system. Ensuring universal health coverage to vulnerable Lebanese, Syrian and Palestinian refugees will require in Lebanon to redistribute the key functions and responsibilities of the Ministry of Health and its partners to generate more coherence and efficiency.
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Affiliation(s)
- Karl Blanchet
- Public Health in Humanitarian Crises Group, London School of Hygiene & Tropical Medicine, London, UK
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45
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Abstract
The crisis in Syria has forced more than 4 million people to find refuge outside Syria. In Lebanon, in 2015, the refugee population represented 30 % of the total population. International health assistance has been provided to refugee populations in Lebanon. However, the current humanitarian system has also contributed to increase fragmentation of the Lebanese health system. Ensuring universal health coverage to vulnerable Lebanese, Syrian and Palestinian refugees will require in Lebanon to redistribute the key functions and responsibilities of the Ministry of Health and its partners to generate more coherence and efficiency.
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Affiliation(s)
- Karl Blanchet
- Public Health in Humanitarian Crises Group, London School of Hygiene & Tropical Medicine, London, UK
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46
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Rabkin M, Fouad FM, El-Sadr WM. Addressing chronic diseases in protracted emergencies: Lessons from HIV for a new health imperative. Glob Public Health 2016; 13:227-233. [PMID: 27141922 DOI: 10.1080/17441692.2016.1176226] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Forcible displacement has reached unprecedented levels, with more refugees and internally displaced people reported since comprehensive statistics have been collected. The rising numbers of refugees requiring health services, the protracted nature of modern displacement, and the changing demographics of refugee populations have created compelling new health needs and challenges. In addition to the risk of malnutrition, infectious diseases and exposure to the elements attendant upon conflict and the breakdown of public health systems, many displaced people now require continuity care for the prevention and treatment of cardiovascular disease, diabetes, asthma, cancer, and mental health, as well as maternal and child health services. In some regions, most refugee health services need to be provided in dispersed settings within host communities, rather than in traditional refugee camps, and the number of refugees suffering protracted displacement is growing rapidly. These realities highlight a significant disconnect between the health needs of twenty-first century refugees, and the global systems that have been established to address them. The global response to the HIV epidemic offers lessons about ways to support continuity care for chronic conditions during complex emergencies and may provide important blueprints as the global community struggles to redesign refugee health services.
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Affiliation(s)
- Miriam Rabkin
- a ICAP at Columbia University, Columbia University Mailman School of Public Health , New York , NY , USA.,b Department of Epidemiology , Columbia University Mailman School of Public Health , New York , NY , USA.,c Department of Medicine , Columbia University College of Physicians and Surgeons , New York , NY, USA
| | - Fouad M Fouad
- d Department of Epidemiology and Population Health , American University of Beirut , Beirut , Lebanon
| | - Wafaa M El-Sadr
- a ICAP at Columbia University, Columbia University Mailman School of Public Health , New York , NY , USA.,b Department of Epidemiology , Columbia University Mailman School of Public Health , New York , NY , USA.,c Department of Medicine , Columbia University College of Physicians and Surgeons , New York , NY, USA
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47
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Bahelah R, DiFranza JR, Fouad FM, Ward KD, Eissenberg T, Maziak W. Early symptoms of nicotine dependence among adolescent waterpipe smokers. Tob Control 2016; 25:e127-e134. [PMID: 27113610 DOI: 10.1136/tobaccocontrol-2015-052809] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 03/24/2016] [Accepted: 04/04/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Although waterpipe smoking is increasingly popular among youth and can lead to nicotine dependence (ND), no studies have documented how ND develops in waterpipe smokers. We examined the emerging symptoms of ND among adolescent waterpipe smokers in Lebanon. METHODS Individual confidential interviews were used to evaluate ND in 160 waterpipe smokers and 24 cigarette smokers from a sample of 498 students enrolled in 8th and 9th grades in Lebanon. RESULTS Among waterpipe smokers, 71.3% endorsed at least one Hooked on Nicotine Checklist (HONC) symptom and 38.1% developed the full syndrome of ND (≥3 criteria using the International Classification of Diseases, 10th revision). The early symptoms of ND among waterpipe smokers were craving (25%), feeling addicted (22.5%), and failed quit attempts (14.3%). Among those who reached the respective milestones, median tobacco use when the first HONC symptom emerged was 7.5 waterpipes/month with smoking frequency of 6 days/month; the median tobacco use for the full syndrome of ND was 15 waterpipes/month with smoking frequency of 15 days/month. Among those who had already reached these milestones, the first HONC symptom appeared 10.9 months after the initiation of waterpipe smoking, and the full syndrome of ND was reached at 13.9 months. In addition, cues such as seeing or smelling waterpipe, and the café environment triggered craving in most waterpipe smokers with symptoms of ND. CONCLUSIONS Symptoms of ND develop among adolescent waterpipe smokers at low levels of consumption and frequency of use. Craving for nicotine triggered by waterpipe-specific cues is reported even at this young age. Waterpipe-specific ND prevention and intervention programmes for youth are needed.
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Affiliation(s)
- Raed Bahelah
- Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, Florida, USA.,Faculty of Medicine and Health Sciences, Aden University, Yemen
| | - Joseph R DiFranza
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Fouad M Fouad
- Syrian Center for Tobacco Studies, Aleppo, Syria.,American University of Beirut, Beirut, Lebanon
| | - Kenneth D Ward
- Syrian Center for Tobacco Studies, Aleppo, Syria.,University of Memphis School of Public Health, Memphis, Tennessee, USA
| | - Thomas Eissenberg
- Department of Psychology and Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Wasim Maziak
- Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, Florida, USA.,Syrian Center for Tobacco Studies, Aleppo, Syria
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48
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Affiliation(s)
- Fouad M Fouad
- American University of Beirut, Beirut 1107 2020, Lebanon.
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49
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Abbara A, Coutts A, Fouad FM, Ismail SA, Orcutt M. Mental Health among displaced Syrians: findings from the Syria Public Health Network. J R Soc Med 2016; 109:88-90. [PMID: 26819236 DOI: 10.1177/0141076816629765] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Aula Abbara
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Adam Coutts
- Department of Politics and International Studies, University of Cambridge, Cambridge, UK
| | - Fouad M Fouad
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Sharif A Ismail
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Miriam Orcutt
- Conflict and Health Research Group, King's College London, London, UK
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50
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Affiliation(s)
- Hussam Jefee-Bahloul
- Department of Psychiatry, University of Massachusetts School of Medicine, Worcester, MA, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
| | | | | | - Fouad M Fouad
- American University of Beirut, Faculty of Health Sciences, Beirut, Lebanon
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