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Elnakib S, Akhu-Zaheya L, Khater W, Bou-Karroum L, Honein-AbouHaidar G, Salameh S, Shawar YR, Spiegel P. The emergence and regression of political priority for refugee integration into the Jordanian health system: an analysis using the Kingdon's multiple streams model. Confl Health 2024; 18:30. [PMID: 38622646 PMCID: PMC11017472 DOI: 10.1186/s13031-024-00588-3] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 03/25/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND The prolonged presence of Syrian refugees in Jordan has highlighted the need for sustainable health service delivery models for refugees. In 2012, the Jordanian government adopted a policy that granted Syrian refugees access, free of charge, to the national health system. However since 2012, successive policy revisions have limited refugee access. This paper seeks to understand factors that initially put refugee integration into the health system on the policy agenda, as well as how these same factors later affected commitment to sustain the policy. METHODS This paper draws on data from a document review of 197 peer-reviewed and grey literature publications, a media analysis of newspaper articles retrieved from four officially recognized newspapers in Jordan, and 33 semi-structured key informant interviews. We used Kingdon's Multiple Streams Model - a well-established tool for analyzing policy adoption - to understand how political priority developed for integration of refugees into the health system. RESULTS We find that several factors helped bring attention to the issue, namely concerns over infectious disease transmission to host communities, high rates of chronic conditions among the refugee population and the increasingly urban and dispersed nature of refugees. At the outset of the conflict, the national mood was receptive to refugees. Politicians and government officials quickly recognized the crisis as an opportunity to secure material and technical support from the international humanitarian community. At the same time, global pressures for integrating refugees into national health systems helped move the integration agenda forward in Jordan and the region more broadly. Since 2012, there were several modifications to the policy that signal profound changes in national views around the continued presence of Syrian refugees in the country, as well as reduced external financial support which has undermined the sustainability of the policy. CONCLUSION This case study underscores the dynamic nature of policymaking and the challenge of sustaining government commitment to the right to health among refugees. Our analysis has important implications for advocates seeking to advance and maintain momentum for the integration of refugees into national health systems.
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Affiliation(s)
- Shatha Elnakib
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Laila Akhu-Zaheya
- Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Wejdan Khater
- Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | | | | | | | - Yusra Ribhi Shawar
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Paul H. Nitze School of Advanced International Studies, Washington, DC, USA
| | - Paul Spiegel
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Elnakib S, Jackson C, Lalani U, Shawar YR, Bennett S. How integration of refugees into national health systems became a global priority: a qualitative policy analysis. Confl Health 2024; 18:31. [PMID: 38622721 PMCID: PMC11017473 DOI: 10.1186/s13031-024-00587-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 03/25/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Despite a long history of political discourse around refugee integration, it wasn't until 2016 that this issue emerged as a global political priority. Limited research has examined the evolution of policies of global actors around health service provision to refugees and how refugee integration into health systems came onto the global agenda. This study seeks to fill this gap. METHODS Drawing on a document review of 20 peer-reviewed articles, 46 global policies and reports, and 18 semi-structured interviews with actors representing various bilateral, multilateral and non-governmental organizations involved with refugee health policy and funding, we analyze factors that have shaped the global policy priority of integration. We use the Shiffman and Smith Policy Framework on determinants of political priority to organize our findings. RESULTS Several important factors generated global priority for refugee integration into national health systems. Employing the above-mentioned framework, actor power increased due to network expansion through collaborations between humanitarian and development actors. Ideas took hold through the framing of integration as a human rights and responsibility sharing. While political context was influenced through several global movements, it was ultimately the influx of Syrian refugees into Europe and the increasing securitization of the refugee crisis that led to key policies, and critically, global funding to support integration within refugee hosting nations. Finally, issue characteristics, namely the magnitude of the global refugee crisis, its protractedness and the increasing urbanicity of refugee inflows, led integration to emerge as a manageable solution. CONCLUSION The past decade has seen a substantial reframing of refugee integration, along with increased financing sources and increased collaboration, explains this shift towards their integration into health systems. However, despite the emergence of integration as a global political priority, the extent to which efforts around integration have translated into action at the national level remains uncertain.
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Affiliation(s)
- Shatha Elnakib
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Caitlin Jackson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Yusra Ribhi Shawar
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Paul H. Nitze School of Advanced International Studies, Washington, DC, USA
| | - Sara Bennett
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Elnakib S, Fair M, Mayrhofer E, Afifi M, Jamaluddine Z. Pregnant women in Gaza require urgent protection. Lancet 2024; 403:244. [PMID: 38219768 DOI: 10.1016/s0140-6736(23)02835-0] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/16/2024]
Affiliation(s)
- Shatha Elnakib
- International Health, Johns Hopkins University School of Public Health, Baltimore, MD 21218, USA.
| | - Mollie Fair
- UNFPA Arab States Regional Office, Cario, Egypt
| | | | - Mohamed Afifi
- WHO Eastern Mediterranean Regional Office, Cairo, Egypt
| | - Zeina Jamaluddine
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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VanTreeck K, Elnakib S, Chandra-Mouli V. A reanalysis of the Institute for Research and Evaluation report that challenges non-US, school-based comprehensive sexuality education evidence base. Sex Reprod Health Matters 2023; 31:2237791. [PMID: 37548507 PMCID: PMC10408562 DOI: 10.1080/26410397.2023.2237791] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
Comprehensive sexuality education (CSE) prepares young people to make informed decisions about their sexuality. A review by the Institute of Research and Evaluation that analysed 43 CSE studies in non-US settings found the majority to be ineffective and concluded that there was little evidence of the effectiveness of CSE. We reanalysed the review to investigate its validity. We found several weaknesses with the review's methodology and analysis: (1) there was an absence of a clearly articulated search strategy and specific eligibility criteria; (2) the authors put forth criteria for programme effectiveness but included studies that did not collect the data needed to show programme effectiveness and thus several studies were determined to be ineffective by default; (3) the analytical framework minimised positive intervention effects and privileged negative intervention effects; and (4) there were errors in the data extracted, with 74% of studies containing one or more discrepancies. Overall, our reanalysis reveals that the IRE review suffers from significant methodological flaws and contains many errors which compromise its conclusions about CSE. Our reanalysis is a tool for the international community to refute CSE opposition campaigns based on poor science.
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Affiliation(s)
- Kelly VanTreeck
- Consultant, Department of Sexual and Reproductive Health and Research, World Health Organization, Av. Appia 20, 1202Geneva, Switzerland
| | - Shatha Elnakib
- Consultant, Department of Sexual and Reproductive Health and Research, World Health Organization, Av. Appia 20, 1202Geneva, Switzerland
- Full-time faculty, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Venkatraman Chandra-Mouli
- Scientist, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Elnakib S, Paina L, Attal B, Akter R, Khoury G, Karim L, Barkat HH, Tamang A, Yenokyan G, Metzler J, Robinson C. Incidence of child marriage among refugees and internally displaced persons in the Middle East and South Asia: evidence from six cross-sectional surveys. BMJ Open 2023; 13:e070056. [PMID: 37321808 PMCID: PMC10277033 DOI: 10.1136/bmjopen-2022-070056] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 04/28/2023] [Indexed: 06/17/2023] Open
Abstract
OBJECTIVE To examine incidence of child marriage among displaced and host populations in humanitarian settings. DESIGN Cross-sectional surveys. SETTING Data were collected in Djibouti, Yemen, Lebanon and Iraq in the Middle East and in Bangladesh and Nepal in South Asia. PARTICIPANTS Adolescent girls aged 10-19 in the six settings and age cohort comparators. OUTCOME MEASURES Cumulative incidence of marriage by age 18. RESULTS In Bangladesh and Iraq, the hazard of child marriage did not differ between internally displaced populations (IDPs) and hosts (p value=0.25 and 0.081, respectively). In Yemen, IDPs had a higher hazard of child marriage compared with hosts (p value<0.001). In Djibouti, refugees had a lower hazard of child marriage compared with hosts (p value<0.001). In pooled data, the average hazard of child marriage was significantly higher among displaced compared with host populations (adjusted HR (aHR) 1.3; 95% CI 1.04 to 1.61).In age cohort comparisons, there was no significant difference between child marriage hazard across age cohorts in Bangladesh (p value=0.446), while in Lebanon and Nepal, younger cohorts were less likely to transition to child marriage compared with older comparators (p value<0.001). Only in Yemen were younger cohorts more likely to transition to child marriage, indicating an increase in child marriage rates after conflict (p value=0.034). Pooled data showed a downward trend, where younger age cohorts had, on average, a lower hazard of child marriage compared with older cohorts (aHR 0.36; 95% CI 0.29 to 0.4). CONCLUSIONS We did not find conclusive evidence that humanitarian crises are associated with universal increases in child marriage rates. Our findings indicate that decision-making about investments in child marriage prevention and response must be attuned to the local context and grounded in data on past and current trends in child marriage among communities impacted by crisis.
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Affiliation(s)
- Shatha Elnakib
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ligia Paina
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Bothaina Attal
- Centre for Business Research, Cambridge Judge Business School, Cambridge, UK
- Faculty of Medicine and Health Sciences, Sana'a University, Sana'a, Yemen
| | - Rumana Akter
- Community Partners International, Cox's Bazar, Bangladesh
| | - Ghada Khoury
- School of Pharmacy, Lebanese American University, Byblos, Lebanon
| | | | | | - Anand Tamang
- Center for Research on Environment Health and Population Activities, Kathmandu, Nepal
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Courtland Robinson
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Elnakib S, Metzler J. A scoping review of FGM in humanitarian settings: an overlooked phenomenon with lifelong consequences. Confl Health 2022; 16:49. [PMID: 36109790 PMCID: PMC9476296 DOI: 10.1186/s13031-022-00479-5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
Background Female genital mutilation (FGM) is widely recognized as a human rights violation. Little is known about FGM rates and practices in humanitarian settings, and about the impact of crisis on the drivers and consequences of FGM. This scoping review set out to investigate the current research landscape on FGM in humanitarian settings. Methods We conducted a search of electronic databases and gray literature published between 1990 and 2021. This was coupled with backward citation tracking on eligible studies and reviews. We analyzed studies that met our eligibility criteria using thematic analysis. Results We found 13 peer-reviewed and four grey literature articles. Most studies were published in the last decade between 2010 and 2021, signaling growing attention to the issue. Five of the 17 articles provided estimates of incidence based on primary data collection amongst crisis-affected populations, ten focused on drivers, ten on consequences and five on interventions. The limited studies that have examined FGM in humanitarian settings indicate that the impact of crisis on FGM is multifaceted and context-specific, depending in part on interactions with host and other displaced communities and their social norms and practices. There is evidence that the acquisition and transfer of harmful social norms may take place during migration flows, but also that social norms underlying FGM may weaken in contexts of displacement, causing the practice to decrease. The incidence of FGM may also remain unchanged, but the type of FGM practiced may shift from more harmfully perceived forms to less radical forms. We found that drivers of FGM may be exacerbated, attenuated, or unchanged by crisis and displacement. Overall, there was predominant focus on medical consequences of FGM, and limited research on the social, economic, and psychological consequences of the practice. There was also a dearth of research into intervention effectiveness. Conclusions Despite an increase in research on FGM in humanitarian settings, there is still a notable dearth of studies investigating the impact of emergencies on FGM and the factors that propel it. More research and documentation of evidence are needed to inform interventions and policies. Supplementary Information The online version contains supplementary material available at 10.1186/s13031-022-00479-5.
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Kraft JM, Paina L, Boydell V, Elnakib S, Sihotang A, Bailey A, Tolmie C. Social Accountability Reporting for Research (SAR4Research): checklist to strengthen reporting on studies on social accountability in the literature. Int J Equity Health 2022; 21:121. [PMID: 36042426 PMCID: PMC9425941 DOI: 10.1186/s12939-022-01716-2] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND An increasing number of evaluations of social accountability (SA) interventions have been published in the past decade, however, reporting gaps make it difficult to summarize findings. We developed the Social Accountability Reporting for Research (SAR4Research) checklist to support researchers to improve the documentation of SA processes, context, study designs, and outcomes in the peer reviewed literature and to enhance application of findings. METHODS We used a multi-step process, starting with an umbrella review of reviews on SA to identify reporting gaps. Next, we reviewed existing guidelines for reporting on behavioral interventions to determine whether one could be used in its current or adapted form. We received feedback from practitioners and researchers and tested the checklist through three worked examples using outcome papers from three SA projects. RESULTS Our umbrella review of SA studies identified reporting gaps in all areas, including gaps in reporting on the context, intervention components, and study methods. Because no existing guidelines called for details on context and the complex processes in SA interventions, we used CONSORT-SPI as the basis for the SAR4Research checklist, and adapted it using other existing checklists to fill gaps. Feedback from practitioners, researchers and the worked examples suggested the need to eliminate redundancies, add explanations for items, and clarify reporting for quantitative and qualitative study components. CONCLUSIONS Results of SA evaluations in the peer-reviewed literature will be more useful, facilitating learning and application of findings, when study designs, interventions and their context are described fully in one or a set of papers. This checklist will help authors report better in peer-reviewed journal articles. With sufficient information, readers will better understand whether the results can inform accountability strategies in their own contexts. As a field, we will be better able to identify emerging findings and gaps in our understanding of SA.
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Affiliation(s)
- Joan Marie Kraft
- Office of Population and Reproductive Health, United States Agency for International Development, 500 D St SW, UA-5th Floor, Washington DC, 20547 USA
| | - Ligia Paina
- Department of International Health, Health Systems Program, Johns Hopkins University School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205 USA
| | - Victoria Boydell
- School of Health and Social Care, University of Essex, Wivenhoe Park, Colchester, CO4 3SQ UK
| | - Shatha Elnakib
- Department of International Health, Health Systems Program, Johns Hopkins University School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205 USA
| | - Andreas Sihotang
- Harry S Truman School of Public Affairs, University of Missouri, 101 Middlebush Hall, Columbia, Missouri 65211 USA
| | - Angela Bailey
- Accountability Research Center, American University, 4400 Massachusetts Ave NW, Washington DC, 20016 USA
| | - Courtney Tolmie
- Wonderlight Consulting, 8342 Charlise Rd, Richmond, VA 23235 USA
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Elnakib S, Vecino-Ortiz AI, Gibson DG, Agarwal S, Trujillo AJ, Zhu Y, Labrique A. A novel score for mobile health applications to predict and prevent mortality: Further validation and adaptation to US population using the US NHANES dataset. J Med Internet Res 2022; 24:e36787. [PMID: 35483022 PMCID: PMC9240932 DOI: 10.2196/36787] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/14/2022] [Accepted: 04/28/2022] [Indexed: 11/28/2022] Open
Abstract
Background The C-Score, which is an individual health score, is based on a predictive model validated in the UK and US populations. It was designed to serve as an individualized point-in-time health assessment tool that could be integrated into clinical counseling or consumer-facing digital health tools to encourage lifestyle modifications that reduce the risk of premature death. Objective Our study aimed to conduct an external validation of the C-Score in the US population and expand the original score to improve its predictive capabilities in the US population. The C-Score is intended for mobile health apps on wearable devices. Methods We conducted a literature review to identify relevant variables that were missing in the original C-Score. Subsequently, we used data from the 2005 to 2014 US National Health and Nutrition Examination Survey (NHANES; N=21,015) to test the capacity of the model to predict all-cause mortality. We used NHANES III data from 1988 to 1994 (N=1440) to conduct an external validation of the test. Only participants with complete data were included in this study. Discrimination and calibration tests were conducted to assess the operational characteristics of the adapted C-Score from receiver operating curves and a design-based goodness-of-fit test. Results Higher C-Scores were associated with reduced odds of all-cause mortality (odds ratio 0.96, P<.001). We found a good fit of the C-Score for all-cause mortality with an area under the curve (AUC) of 0.72. Among participants aged between 40 and 69 years, C-Score models had a good fit for all-cause mortality and an AUC >0.72. A sensitivity analysis using NHANES III data (1988-1994) was performed, yielding similar results. The inclusion of sociodemographic and clinical variables in the basic C-Score increased the AUCs from 0.72 (95% CI 0.71-0.73) to 0.87 (95% CI 0.85-0.88). Conclusions Our study shows that this digital biomarker, the C-Score, has good capabilities to predict all-cause mortality in the general US population. An expanded health score can predict 87% of the mortality in the US population. This model can be used as an instrument to assess individual mortality risk and as a counseling tool to motivate behavior changes and lifestyle modifications.
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Affiliation(s)
- Shatha Elnakib
- Department of International Health., Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street.E8620, Baltimore, US
| | - Andres I Vecino-Ortiz
- Department of International Health., Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street.E8620, Baltimore, US
| | - Dustin G Gibson
- Department of International Health., Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street.E8620, Baltimore, US
| | - Smisha Agarwal
- Department of International Health., Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street.E8620, Baltimore, US
| | - Antonio J Trujillo
- Department of International Health., Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street.E8620, Baltimore, US
| | - Yifan Zhu
- Department of International Health., Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street.E8620, Baltimore, US
| | - Alain Labrique
- Department of International Health., Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street.E8620, Baltimore, US
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Elnakib S, El Khoury G, Salameh P, Sacre H, Abirafeh L, Robinson WC, Metzler J. Investigating Incidence, Correlates, and Consequences of Child Marriage Among Syrian Refugees Residing in the South of Lebanon: A Cross-Sectional Study. J Adolesc Health 2022; 70:S64-S71. [PMID: 35184834 DOI: 10.1016/j.jadohealth.2021.08.022] [Citation(s) in RCA: 5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/01/2021] [Accepted: 08/24/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Research on child marriage has increased in volume but remains scarce in humanitarian settings. This study aimed to investigate rates, correlates, and consequences of child marriage among Syrian refugees in South Lebanon. METHODS A sample of 1,593 female adolescents and 893 adults was selected using a multistage stratified cluster survey design. We quantified the cumulative incidence of child marriage among age cohorts of female refugees and identified risk factors associated with child marriage using survival methods. We also presented sexual and reproductive health measures among child brides. RESULTS We found evidence that child marriage was widely practiced among adolescent girls, with Kaplan-Meier curves showing that 32.56% of girls aged 10-19 transitioned to marriage by age 17. Although high, this was lower than rates among women aged 25-29 (p < .005), indicating that child marriage was already widely practiced in prewar Syria. Our Cox models indicated that several factors, which mirror drivers of child marriage in stable settings, are associated with hazard of child marriage in this context. We additionally found important sexual and reproductive health gaps among child brides, such as low levels of knowledge of the dangers of early childbearing and closely spaced births as well as high rates of early and multiple births. CONCLUSIONS Child marriage is a pervasive practice among Syrian refugees residing in this setting. Our results suggest that a confluence of factors at different levels of the social ecology increase refugee girls' vulnerability to child marriage. They also demonstrate the pressing need for interventions that target refugee child brides.
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Affiliation(s)
- Shatha Elnakib
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Maryland.
| | - Ghada El Khoury
- School of Pharmacy, Lebanese American University, Byblos, Lebanon
| | - Pascale Salameh
- Department of Public Health, INSPECT-LB (Institut National de Santé Publique d'Épidémiologie Clinique et de Toxicologie-Liban), Beirut, Lebanon; Department of Research, Faculty of Pharmacy, Lebanese University, Beirut, Lebanon; Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus
| | - Hala Sacre
- Department of Public Health, INSPECT-LB (Institut National de Santé Publique d'Épidémiologie Clinique et de Toxicologie-Liban), Beirut, Lebanon
| | - Lina Abirafeh
- Department of Research, The Arab Institute for Women, Lebanese American University, Beirut, Lebanon
| | - W Courtland Robinson
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Maryland
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Elnakib S, Elsallab M, Wanis MA, Elshiwy S, Krishnapalan NP, Naja NA. Understanding the impacts of child marriage on the health and well-being of adolescent girls and young women residing in urban areas in Egypt. Reprod Health 2022; 19:8. [PMID: 35033114 PMCID: PMC8761304 DOI: 10.1186/s12978-021-01315-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Egypt has made progress in delaying age at marriage, but child marriage continues to be practiced in many places across the country. This study investigates the impacts of child marriage on the health and wellbeing of girls residing in urban Egypt using a multi-method approach. METHODS The quantitative component leveraged data from the 2014 Egypt Demographic and Health Survey and focused on (1) reproductive health, (2) maternal health and (3) social outcomes among a subsample of ever-married urban women ages 20-24 (N = 1041). Simple and multivariable logistic regressions were used to estimate prevalence odds ratios and 95% confidence intervals for associations between child marriage and the three sets of outcomes. The qualitative component drew from 11 focus groups, 23 in-depth interviews, and 13 key informant interviews conducted in three urban sites in Egypt. The data was thematically analyzed using a combination of inductive and deductive coding. RESULTS The prevalence of marriage under age 18 was 13.22%. Child marriage was significantly associated with ever use of contraception (Adjusted Odds Ratio (AOR) 2.95 95% CI 1.67-5.19), multiple births (AOR 12.93 95% CI 5.45-30.72), rapid repeat childbirth (AOR 2.20 95% CI 1.34-3.63), and pregnancy termination (AOR 1.89 95% CI 1.11-3.23). Many of these associations disappeared after adjusting for marriage duration. Girls married under age 18 had larger spousal age gaps (AOR 2.06; 95% CI 1.24-3.41) and higher odds of FGM (AOR 2.14; 95% CI 1.11-4.13). They were significantly more likely to report receiving no ANC care (AOR 0.39; 95% CI 0.19-0.80), and less likely to deliver through C-section (AOR: 0.53; 95% CI 0.34-0.83). Consequences emerging from the qualitative data centered around five themes: (1) Access to and use of sexual and reproductive health services; (2) exposure to FGM; (3) marriage and birth registration; (4) marital relations; and (5) relationship with in-laws. CONCLUSION Findings provide important insights into the practice of child marriage in urban areas in Egypt and illustrate a range of adverse consequences associated with the practice.
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Affiliation(s)
- Shatha Elnakib
- Johns Hopkins Bloomberg School of Public Health, Maryland, USA.
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Diaz T, Strong KL, Cao B, Guthold R, Moran AC, Moller AB, Requejo J, Sadana R, Thiyagarajan JA, Adebayo E, Akwara E, Amouzou A, Aponte Varon JJ, Azzopardi PS, Boschi-Pinto C, Carvajal L, Chandra-Mouli V, Crofts S, Dastgiri S, Dery JS, Elnakib S, Fagan L, Jane Ferguson B, Fitzner J, Friedman HS, Hagell A, Jongstra E, Kann L, Chatterji S, English M, Glaziou P, Hanson C, Hosseinpoor AR, Marsh A, Morgan AP, Munos MK, Noor A, Pavlin BI, Pereira R, Porth TA, Schellenberg J, Siddique R, You D, Vaz LME, Banerjee A. A call for standardised age-disaggregated health data. Lancet Healthy Longev 2021; 2:e436-e443. [PMID: 34240065 PMCID: PMC8245325 DOI: 10.1016/s2666-7568(21)00115-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The 2030 Sustainable Development Goals agenda calls for health data to be disaggregated by age. However, age groupings used to record and report health data vary greatly, hindering the harmonisation, comparability, and usefulness of these data, within and across countries. This variability has become especially evident during the COVID-19 pandemic, when there was an urgent need for rapid cross-country analyses of epidemiological patterns by age to direct public health action, but such analyses were limited by the lack of standard age categories. In this Personal View, we propose a recommended set of age groupings to address this issue. These groupings are informed by age-specific patterns of morbidity, mortality, and health risks, and by opportunities for prevention and disease intervention. We recommend age groupings of 5 years for all health data, except for those younger than 5 years, during which time there are rapid biological and physiological changes that justify a finer disaggregation. Although the focus of this Personal View is on the standardisation of the analysis and display of age groups, we also outline the challenges faced in collecting data on exact age, especially for health facilities and surveillance data. The proposed age disaggregation should facilitate targeted, age-specific policies and actions for health care and disease management.
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Affiliation(s)
- Theresa Diaz
- Maternal, Newborn, Child and Adolescent Health, and Ageing Department, WHO, Geneva, Switzerland
| | - Kathleen L Strong
- Maternal, Newborn, Child and Adolescent Health, and Ageing Department, WHO, Geneva, Switzerland
| | - Bochen Cao
- Data and Analytics Department, WHO, Geneva, Switzerland
| | - Regina Guthold
- Maternal, Newborn, Child and Adolescent Health, and Ageing Department, WHO, Geneva, Switzerland
| | - Allisyn C Moran
- Maternal, Newborn, Child and Adolescent Health, and Ageing Department, WHO, Geneva, Switzerland
| | - Ann-Beth Moller
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Jennifer Requejo
- Division of Data, Analysis, Planning and Monitoring, UNICEF, New York, NY, USA
| | - Ritu Sadana
- Maternal, Newborn, Child and Adolescent Health, and Ageing Department, WHO, Geneva, Switzerland
| | | | - Emmanuel Adebayo
- Adolescent Health Unit, Institute of Child Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Elsie Akwara
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Agbessi Amouzou
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Peter S Azzopardi
- Global Adolescent Health Group, Maternal Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
- Adolescent Health and Wellbeing Program, Wardliparingga Aboriginal Health Equity Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- Department of Pediatrics, VIC, Australia
- University of Melbourne, VIC, Australia
| | - Cynthia Boschi-Pinto
- Department of Epidemiology and Biostatistics, Fluminense Federal University, Rio de Janeiro, Brazil
| | - Liliana Carvajal
- Division of Data, Analysis, Planning and Monitoring, UNICEF, New York, NY, USA
| | - Venkatraman Chandra-Mouli
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | | | - Saeed Dastgiri
- Tabriz Health Services Management Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Shatha Elnakib
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Laura Fagan
- UN Major Group for Children and Youth, New York, NY, USA
| | | | - Julia Fitzner
- Global Infectious Hazard Preparedness Department, WHO, Geneva, Switzerland
| | | | - Ann Hagell
- Association for Young People's Health, London, UK
| | | | | | | | | | | | - Claudia Hanson
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | | | - Andrew Marsh
- Maternal, Newborn, Child and Adolescent Health, and Ageing Department, WHO, Geneva, Switzerland
| | - Alison P Morgan
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, VIC, Australia
- Global Financing Facility, World Bank, Washington, DC, USA
| | - Melinda K Munos
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Boris I Pavlin
- Health Emergency Information and Risk Assessment Department, WHO, Geneva, Switzerland
| | | | - Tyler A Porth
- Division of Data, Analysis, Planning and Monitoring, UNICEF, New York, NY, USA
| | | | | | - Danzhen You
- Division of Data, Analysis, Planning and Monitoring, UNICEF, New York, NY, USA
| | - Lara M E Vaz
- Population Reference Bureau, Washington, DC, USA
| | - Anshu Banerjee
- Maternal, Newborn, Child and Adolescent Health, and Ageing Department, WHO, Geneva, Switzerland
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12
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Elnakib S, Hunersen K, Metzler J, Bekele H, Robinson WC. Child marriage among Somali refugees in Ethiopia: a cross sectional survey of adolescent girls and adult women. BMC Public Health 2021; 21:1051. [PMID: 34078326 PMCID: PMC8173891 DOI: 10.1186/s12889-021-11080-5] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 05/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite child marriage receiving increased attention over the past two decades, research on child marriage in humanitarian settings remains scarce. This study sought to quantify child marriage among Somali adolescent girls residing in Kobe refugee camp in Ethiopia and to identify its correlates and consequences. METHODS A cross-sectional survey was conducted using multi-stage cluster-based sampling with probability proportional to size. We randomly sampled households that have at least one female aged 15-49 and at least one adolescent female aged 10-19. In addition to calculating the proportion of girls married under age 18, we used survival methods - namely Kaplan Meier graphs and Cox proportional hazard models - to identify risk factors associated with child marriage in this context. We also used descriptive statistics to describe marital age preferences among female adults and presented measures of important sexual and reproductive health indicators among married adolescent girls. RESULTS A total of 603 adult women were surveyed and a household roster was created with information on 3319 household members, of whom 522 were adolescent girls aged 15-19. Of those, 14% were currently married (95% Confidence Interval [CI] 0.11-0.18), and 11% were ever married under age 18 (95% CI 8-15%). Several variables were found to be significantly associated with hazard of child marriage including schooling, sex and employment status of head of household, as well as number of girls under age 18 in the childhood home.. Adult women tended to incorrectly identify minimum legal age at marriage and preferred low marital age for boys and girls - particularly in households of child brides. Among married adolescent girls, contraceptive use was very low (11%; 95% CI 4.94-22.40), and early childbearing was common (60%; 95% CI 45.56-72.89). CONCLUSIONS This research contributes to the evidence base on child marriage in humanitarian settings. Insights generated from this study have the potential to inform programs and interventions aiming to prevent and mitigate the impacts of this harmful practice.
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Affiliation(s)
- Shatha Elnakib
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Kara Hunersen
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | | | - Hailu Bekele
- International Medical Corps, Addis Ababa, Ethiopia
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13
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Malhotra A, Elnakib S. 20 Years of the Evidence Base on What Works to Prevent Child Marriage: A Systematic Review. J Adolesc Health 2021; 68:847-862. [PMID: 33446401 DOI: 10.1016/j.jadohealth.2020.11.017] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/17/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE This review assesses evaluations published from 2000 to 2019 to shed light on what approaches work, especially at scale and sustainably, to prevent child marriage in low- and middle-income countries. METHODS We conducted a search of electronic databases and gray literature and evaluated the methodological quality and risk of bias of included studies. RESULTS A total of 30 studies met the inclusion criteria. Interventions that support girls' schooling through cash or in-kind transfers show the clearest pattern of success in preventing child marriage, with 8 of 10 medium-high quality studies showing positive results. Although limited in number, five studies on favorable job markets and targeted life skills and livelihoods training show consistent positive results. Comparatively, asset or cash transfers conditional on delaying marriage show success only among two of four evaluations, and the three studies on unconditional cash transfers for poverty mitigation show no effect. Findings also show a low success rate for multicomponent interventions with positive results in only one of eight medium-high quality studies. Further, single component interventions were much more likely to be at scale and sustainable than multicomponent interventions. CONCLUSIONS These results indicate that enhancement of girls' own human capital and opportunities is the most compelling pathway to delaying marriage. In contrast, low rates of success, scale-up, and sustainability of multicomponent programs requires reconsideration of this approach.
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Affiliation(s)
- Anju Malhotra
- United Nations University--International Institute of Global Health (UNU-IIGH), Kuala Lumpur, Malaysia.
| | - Shatha Elnakib
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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14
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Elnakib S, Hussein SA, Hafez S, Elsallab M, Hunersen K, Metzler J, Robinson WC. Drivers and consequences of child marriage in a context of protracted displacement: a qualitative study among Syrian refugees in Egypt. BMC Public Health 2021; 21:674. [PMID: 33827503 PMCID: PMC8028254 DOI: 10.1186/s12889-021-10718-8] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 03/28/2021] [Indexed: 11/10/2022] Open
Abstract
Background Child marriage is a human rights violation disproportionately impacting girls in low- and middle-income countries. In the Middle East region, conflict and displacement have prompted concerns that families are increasingly resorting to child marriage to cope with economic insecurity and fears from sexual violence. This study set out to examine child marriage among Syrian refugees residing in Egypt with the aim of understanding drivers of child marriage in this context of displacement as well as how child marriage affects refugee girls’ wellbeing. Methods This analysis draws from 15 focus group discussions (FGD) conducted with married and unmarried girls, as well as parents of adolescent girls in three governorates in Egypt. FGDs included a participatory ranking exercise and photo-elicitation. Additionally, we conducted 29 in-depth interviews with girls and mothers, as well as 28 key informant interviews with health providers, community leaders, and humanitarian actors. The data was thematically analyzed using a combination of inductive and deductive coding. Results A prevalent phenomenon in pre-war Syria, child marriage has been sustained after the influx of Syrian refugees into Egypt by pre-existing cultural traditions and gender norms that prioritize the role of girls as wives and mothers. However, displacement into Egypt engendered different responses. For some families, displacement-specific challenges such as disruptions to girls’ education, protection concerns, and livelihood insecurity were found to exacerbate girls’ vulnerability to child marriage. For others, however, displacement into urban areas in Egypt may have contributed to the erosion of social norms that favored child marriage, leading to marriage postponement. Among girls who were married early, we identified a range of negative health and social consequences, including lack of family planning use, disruption to schooling and curtailment of girls’ mobility as well as challenges with marriage and birth registration which accentuated their vulnerability. Conclusion Efforts to address child marriage among Syrian refugees must acknowledge the different ways in which displacement can influence child marriage attitudes and practices and should capitalize on positive changes that have the potential to catalyze social norm change. Moreover, targeted, focused and contextualized interventions should not only focus on preventing child marriage but also on mitigating its impacts. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-10718-8.
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Affiliation(s)
- Shatha Elnakib
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | | | | | | | - Kara Hunersen
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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15
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Elnakib S, Elaraby S, Othman F, BaSaleem H, Abdulghani AlShawafi NA, Saleh Al-Gawfi IA, Shafique F, Al-Kubati E, Rafique N, Tappis H. Providing care under extreme adversity: The impact of the Yemen conflict on the personal and professional lives of health workers. Soc Sci Med 2021; 272:113751. [PMID: 33588206 PMCID: PMC7938221 DOI: 10.1016/j.socscimed.2021.113751] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/24/2020] [Accepted: 02/03/2021] [Indexed: 11/28/2022]
Abstract
The war in Yemen, described as the world's 'worst humanitarian crisis,' has seen numerous attacks against health care. While global attention to attacks on health workers has increased significantly over the past decade, gaps in research on the lived experiences of frontline staff persist. This study draws on perspectives of frontline health workers in Yemen to understand the impact of the ongoing conflict on their personal and professional lives. Forty-three facility-based health worker interviews, and 6 focus group discussions with community-based health workers and midwives were conducted in Sana'a, Aden and Taiz governorates at the peak of the Yemen conflict. Data were analysed using content analysis methods. Findings highlight the extent and range of violence confronting health workers in Yemen as well as the coping strategies they use to attenuate the impact of acute and chronic stressors resulting from conflict. We find that the complex security situation - characterized by multiple parties to the conflict, politicization of humanitarian aid and constraints in humanitarian access - was coupled with everyday stressors that prevented health workers from carrying out their work. Participants reported sporadic attacks by armed civilians, tensions with patients, and harassment at checkpoints. Working conditions were dire, and participants reported chronic suspension of salaries as well as serious shortages of essential supplies and medicines. Themes specific to coping centered around fatalism and religious motivation, resourcefulness and innovation, and sense of duty and patriotism. Our findings demonstrate that health workers experience substantial stress and face various pressures while delivering lifesaving services in Yemen. While they exhibit considerable resilience and coping, they have needs that remain largely unaddressed. Accordingly, the humanitarian community should direct more attention to responding to the mental health and psychosocial needs of health workers, while actively working to ameliorate the conditions in which they work.
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Affiliation(s)
- Shatha Elnakib
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sarah Elaraby
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Alexandria University, Alexandria, Egypt
| | | | | | | | | | | | | | | | - Hannah Tappis
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Akwara E, Elnakib S. Taking stock of progress made in reducing adolescent motherhood in low-income and middle-income countries. Lancet Child Adolesc Health 2020; 5:2-3. [PMID: 33245864 DOI: 10.1016/s2352-4642(20)30351-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 11/02/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Elsie Akwara
- Department of Sexual and Reproductive Health and Research and Human Reproduction Programme, World Health Organization, Geneva, Switzerland.
| | - Shatha Elnakib
- John Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Tappis H, Elaraby S, Elnakib S, AlShawafi NAA, BaSaleem H, Al-Gawfi IAS, Othman F, Shafique F, Al-Kubati E, Rafique N, Spiegel P. Reproductive, maternal, newborn and child health service delivery during conflict in Yemen: a case study. Confl Health 2020; 14:30. [PMID: 32514295 PMCID: PMC7254736 DOI: 10.1186/s13031-020-00269-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 03/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Armed conflict, food insecurity, epidemic cholera, economic decline and deterioration of essential public services present overwhelming challenges to population health and well-being in Yemen. Although the majority of the population is in need of humanitarian assistance and civil servants in many areas have not received salaries since 2016, many healthcare providers continue to work, and families continue to need and seek care. METHODS This case study examines how reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH+N) services have been delivered since 2015, and identifies factors influencing implementation of these services in three governorates of Yemen. Content analysis methods were used to analyze publicly available documents and datasets published since 2000 as well as 94 semi-structured individual and group interviews conducted with government officials, humanitarian agency staff and facility-based healthcare providers and six focus group discussions conducted with community health midwives and volunteers in September-October 2018. RESULTS Humanitarian response efforts focus on maintaining basic services at functioning facilities, and deploying mobile clinics, outreach teams and community health volunteer networks to address urgent needs where access is possible. Attention to specific aspects of RMNCAH+N varies slightly by location, with differences driven by priorities of government authorities, levels of violence, humanitarian access and availability of qualified human resources. Health services for women and children are generally considered to be a priority; however, cholera control and treatment of acute malnutrition are given precedence over other services along the continuum of care. Although health workers display notable resilience working in difficult conditions, challenges resulting from insecurity, limited functionality of health facilities, and challenges in importation and distribution of supplies limit the availability and quality of services. CONCLUSIONS Challenges to providing quality RMNCAH+N services in Yemen are formidable, given the nature and scale of humanitarian needs, lack of access due to insecurity, politicization of aid, weak health system capacity, costs of care seeking, and an ongoing cholera epidemic. Greater attention to availability, quality and coordination of RMNCAH services, coupled with investments in health workforce development and supply management are needed to maintain access to life-saving services and mitigate longer term impacts on maternal and child health and development. Lessons learned from Yemen on how to address ongoing primary health care needs during massive epidemics in conflict settings, particularly for women and children, will be important to support other countries faced with similar crises in the future.
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Affiliation(s)
- Hannah Tappis
- Center for Humanitarian Health, Johns Hopkins Center for Humanitarian Health, Baltimore, MD USA
| | - Sarah Elaraby
- Center for Humanitarian Health, Johns Hopkins Center for Humanitarian Health, Baltimore, MD USA
| | - Shatha Elnakib
- Center for Humanitarian Health, Johns Hopkins Center for Humanitarian Health, Baltimore, MD USA
| | | | | | | | | | | | | | | | - Paul Spiegel
- Center for Humanitarian Health, Johns Hopkins Center for Humanitarian Health, Baltimore, MD USA
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Elnakib S, Abdel-Tawab N, Orbay D, Hassanein N. Medical and non-medical reasons for cesarean section delivery in Egypt: a hospital-based retrospective study. BMC Pregnancy Childbirth 2019; 19:411. [PMID: 31703638 PMCID: PMC6842224 DOI: 10.1186/s12884-019-2558-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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: 12/12/2018] [Accepted: 10/14/2019] [Indexed: 12/17/2022] Open
Abstract
Background Caesarean section (CS) is an important lifesaving intervention that can reduce maternal and newborn morbidity and mortality. The dramatic increase in CS rates globally has prompted concerns that the procedure may be overused or used for inappropriate indications. In Egypt, CS rates are alarmingly high, accounting for 52% of all deliveries. This study sought to (1) explore indications and risk factors for CS in public hospitals in four governorates in Egypt and (2) examine health care provider factors impacting the decision to perform a CS. Methods We reviewed medical records for all deliveries that took place during April 2016 in 13 public hospitals situated in four governorates in Egypt (Cairo, Alexandria, Assiut and Behera), and extracted information pertaining to medical indications and women’s obstetric characteristics. We also interviewed obstetricians in the study hospitals to explore factors associated with the decision to perform CS. Results A total of 4357 deliveries took place in the study hospitals during that period. The most common medical indications were previous CS (50%), an “other” category (13%), and fetal distress (9%). Multilevel analysis revealed that several obstetric risk factors were associated with increased odds of CS mode of delivery – including previous CS, older maternal age, and nulliparity – while factors such as partograph completion and oxytocin use were associated with reduced odds of CS. Interviews with obstetricians highlighted non-medical factors implicated in the high CS rates, including a convenience incentive, lack of supervision and training in public hospitals, as well as absence of or lack of familiarity with clinical guidelines. Conclusion A combination of both medical and non-medical factors drives the increase in CS rates. Our analysis however suggests that a substantial number of CS deliveries took place in the absence of strong medical justification. Health care provider factors seem to be powerful factors influencing CS rates in the study hospitals.
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Affiliation(s)
- Shatha Elnakib
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | | | | | - Nevine Hassanein
- Independent Consultant, Reproductive Health Consultant, Cairo, Egypt
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Hughes L, Elnakib S. Garden-Enhanced Nutrition Education: What NJ Teachers Say They Need to Integrate Farm To School Concepts Into the Everyday Curriculum. J Acad Nutr Diet 2016. [DOI: 10.1016/j.jand.2016.06.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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