Delivering infectious disease interventions to women and children in conflict settings: a systematic reviefw

Changes in healthcare seeking behaviors among caretakers of children in the previously occupied ISIS territory: Hadeetha, Anbar, Iraq: a cross-sectional survey of 415 households

BACKGROUND

The western province of Anbar, and the district of Hadeetha, have suffered direct impacts from the second United States led invasion (2003) through the ISIS invasion (2014-2017). With the primary health care centers being closed or inaccessible, the remaining population experienced changes in health seeking. The area of Anbar, Iraq remains largely remote from the discourse of health system recovery post-conflict. The objective of this study was to describe changes in health seeking behaviors of caregivers of children ages 12-72 months of age in Hadeetha, Anbar, Iraq from the conflict period of ISIS (Islamic State of Syria and Iraq), 2014-2017, to the post-conflict period, 2021.

METHODS

This was a mixed-methods study composed of a cross-sectional 415 household survey and focus groups in Hadeetha, Anbar, Iraq. Caretakers of children were interviewed from February to April 2021. Children were sampled from a list of children who missed at least one vaccination appointment without a return for follow-up from the birth cohorts of 2014 to 2020. Healthcare workers focus groups and key informant interviews occurred from 2019 to 2021 centered around experiences from the 2014 to 2021 period.

RESULTS

In the post-conflict period, there were no differences in health seeking based upon provider type between respondents. Physicians were primary healthcare providers in the post-conflict period for 79% of respondents versus only 47% in the conflict period. Healthcare workers described major barriers to delivering services in Hadeetha during the ISIS occupation due to infrastructure damage, threats of violence, decreased medical personnel, lack of compensation and disruptions in medical supplies from 2014 to 2017.

CONCLUSION

This study provides insight into health seeking challenges among the many individuals who remained in Hadeetha during the ISIS occupation. Health use patterns by provider type mirror the concerns the healthcare providers shared: limited availability, efflux of professional workers, limited resources and security challenges to providing care. Positive trends toward increased access to physicians during periods of peace are an encouraging marker for continued population resilience during the post-conflict period. Recovery efforts continue to be hampered by internal sectarian discord within Iraq as well as insufficient resources to maintain health services as well as provide catch-up health services, such as immunizations.

Impact of Ebola and COVID-19 on maternal, neonatal, and child health care among populations affected by conflicts: a scoping review exploring demand and supply-side barriers and solutions

INTRODUCTION

Armed conflicts have a severe impact on the health of women and children. Global health emergencies such as pandemics and disease outbreaks further exacerbate the challenges faced by vulnerable populations in accessing maternal, neonatal, and child healthcare (MNCH). There is a lack of evidence that summarizes the challenges faced by conflict-affected pregnant women, mothers, and children in accessing MNCH services during global health emergencies, mainly the Ebola and COVID-19 pandemics. This scoping review aimed to analyze studies evaluating and addressing barriers to accessing comprehensive MNCH services during Ebola and COVID-19 emergencies in populations affected by conflict.

METHODS

The search was conducted on PubMed, Scopus, and Web of Science databases using terms related to Ebola and COVID-19, conflicts, and MNCH. Original studies published between 1990 and 2022 were retrieved. Articles addressing the challenges in accessing MNCH-related services during pandemics in conflict-affected settings were included. Thematic analysis was performed to categorize the findings and identify barriers and solutions.

RESULTS

Twenty-nine studies met the inclusion criteria. Challenges were identified in various MNCH domains, including antenatal care, intrapartum care, postnatal care, vaccination, family planning, and the management of childhood illnesses. Ebola-related supply-side challenges mainly concerned accessibility issues, health workforce constraints, and the adoption of stringent protocols. COVID-19 has resulted in barriers related to access to care, challenges pertaining to the health workforce, and new service adoption. On the demand-side, Ebola- and COVID-19-related risks and apprehensions were the leading barriers in accessing MNCH care. Community constraints on utilizing services during Ebola were caused by a lack of trust and awareness. Demand-side challenges of COVID-19 included fear of disease, language barriers, and communication difficulties. Strategies such as partnerships, strengthening of health systems, service innovation, and community-based initiatives have been employed to overcome these barriers.

CONCLUSION

Global health emergencies amplify the barriers to accessing MNCH services faced by conflict-affected populations. Cultural, linguistic, and supply-side factors are key challenges affecting various MNCH domains. Community-sensitive initiatives enhancing primary health care (PHC), mobile clinics, or outreach programs, and the integration of MNCH into PHC delivery should be implemented. Efforts should prioritize the well-being and empowerment of vulnerable populations. Addressing these barriers is crucial for achieving universal health coverage and the Sustainable Development Goals.

The Governance of Childhood Vaccination Services in Crisis Settings: A Scoping Review

The persistence of inadequate vaccination in crisis-affected settings raises concerns about decision making regarding vaccine selection, timing, location, and recipients. This review aims to describe the key features of childhood vaccination intervention design and planning in crisis-affected settings and investigate how the governance of childhood vaccination is defined, understood, and practised. We performed a scoping review of 193 peer-reviewed articles and grey literature on vaccination governance and service design and planning. We focused on 41 crises between 2010 and 2021. Following screening and data extraction, our analysis involved descriptive statistics and applying the governance analysis framework to code text excerpts, employing deductive and inductive approaches. Most documents related to active outbreaks in conflict-affected settings and to the mass delivery of polio, cholera, and measles vaccines. Information on vaccination modalities, target populations, vaccine sources, and funding was limited. We found various interpretations of governance, often implying hierarchical authority and regulation. Analysis of governance arrangements suggests a multi-actor yet fragmented governance structure, with inequitable actor participation, ineffective actor collaboration, and a lack of a shared strategic vision due to competing priorities and accountabilities. Better documentation of vaccination efforts during emergencies, including vaccination decision making, governance, and planning, is needed. We recommend empirical research within decision-making spaces.

A Systematic Review of Vaccination Guidance for Humanitarian Responses

Delivering vaccines in humanitarian response requires rigourous and continuous analysis of evidence. This systematic review mapped the normative landscape of vaccination guidance on vaccine-preventable diseases in crisis-affected settings. Guidance published between 2000 and 2022 was searched for, in English and French, on websites of humanitarian actors, Google, and Bing. Peer-reviewed database searches were performed in Global Health and Embase. Reference lists of all included documents were screened. We disseminated an online survey to professionals working in vaccination delivery in humanitarian contexts. There was a total of 48 eligible guidance documents, including technical guidance (n = 17), descriptive guidance (n = 16), operational guidance (n = 11), evidence reviews (n = 3), and ethical guidance (n = 1). Most were World Health Organization documents (n = 21) targeting children under 5 years of age. Critical appraisal revealed insufficient inclusion of affected populations and limited rigour in guideline development. We found limited information on vaccines including, yellow fever, cholera, meningococcal, hepatitis A, and varicella, as well as human papilloma virus (HPV). There is a plethora of vaccination guidance for vaccine-preventable diseases in humanitarian contexts. However, gaps remain in the critical and systematic inclusion of evidence, inclusion of the concept of "zero-dose" children and affected populations, ethical guidance, and specific recommendations for HPV and non-universally recommended vaccines, which must be addressed.

Resilience in childhood vaccination: analysing delivery system responses to shocks in Lebanon

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.

The impacts of the Syrian conflict on child and adolescent health: a scoping review

BACKGROUND

The Syrian conflict has had a profound impact on Syrian children and adolescents. We sought to determine the extent and range of literature on the conflict's health effects on this vulnerable population.

METHODS

A scoping review describing the impact of the Syrian conflict on children was undertaken while utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews methodology. Qualitative thematic analyses were undertaken to both identify patterns of morbidity and mortality and gaps in evidence.

RESULTS

A total of 982 articles meeting search criteria were identified between 1 January 2011 and 30 April 2021. After iterative screening, 12 were identified from academic databases and 4 were identified from grey literature and hand searching, yielding a total of 16 studies for final, full-text analysis. Four distinct themes recurred in the literature; these include children suffering from violent injury, a resurgence of communicable diseases, malnutrition and micronutrient deficiency and impacts on their mental health.

CONCLUSIONS

The health of children and adolescents in Syria has been significantly impacted by the indiscriminate attacks against civilians, flagrant human rights violations and the disintegration of the national health care system. Neonates were largely absent from the literature. The themes from this scoping review can inform health programming priorities by aid organizations.

Population-Level Risk Factors Related to Measles Case Fatality: A Conceptual Framework Based on Expert Consultation and Literature Review

A better understanding of population-level factors related to measles case fatality is needed to estimate measles mortality burden and impact of interventions such as vaccination. This study aimed to develop a conceptual framework of mechanisms associated with measles case fatality ratios (CFRs) and assess the scope of evidence available for related indicators. Using expert consultation, we developed a conceptual framework of mechanisms associated with measles CFR and identified population-level indicators potentially associated with each mechanism. We conducted a literature review by searching PubMed on 31 October 2021 to determine the scope of evidence for the expert-identified indicators. Studies were included if they contained evidence of an association between an indicator and CFR and were excluded if they were from non-human studies or reported non-original data. Included studies were assessed for study quality. Expert consultation identified five mechanisms in a conceptual framework of factors related to measles CFR. We identified 3772 studies for review and found 49 studies showing at least one significant association with CFR for 15 indicators (average household size, educational attainment, first- and second-dose coverage of measles-containing vaccine, human immunodeficiency virus prevalence, level of health care available, stunting prevalence, surrounding conflict, travel time to major city or settlement, travel time to nearest health care facility, under-five mortality rate, underweight prevalence, vitamin A deficiency prevalence, vitamin A treatment, and general malnutrition) and only non-significant associations for five indicators (antibiotic use for measles-related pneumonia, malaria prevalence, percent living in urban settings, pneumococcal conjugate vaccination coverage, vitamin A supplementation). Our study used expert consultation and a literature review to provide additional insights and a summary of the available evidence of these underlying mechanisms and indicators that could inform future measles CFR estimations.

Estimating treatment costs for uncomplicated diabetes at a hospital serving refugees in Kenya

Diabetes mellitus (DM) is increasing markedly in low- and middle-income countries where over three-quarters of global deaths occur due to non-communicable diseases. Unfortunately, these conditions are considered costly and often deprioritized in humanitarian settings with competing goals. Using a mixed methods approach, this study aimed to quantify the cost of outpatient treatment for uncomplicated type-1 (T1DM) and type-2 (T2DM) diabetes at a secondary care facility serving refugees in Kenya. A retrospective cost analysis combining micro- and gross-costings from a provider perspective was employed. The main outcomes included unit costs per health service activity to cover the total cost of labor, capital, medications and consumables, and overheads. A care pathway was mapped out for uncomplicated diabetes patients to identify direct and indirect medical costs. Interviews were conducted to determine inputs required for diabetes care and estimate staff time allocation. A total of 360 patients, predominantly Somali refugees, were treated for T2DM (92%, n = 331) and T1DM (8%, n = 29) in 2017. Of the 3,140 outpatient consultations identified in 2017; 48% (n = 1,522) were for males and 52% (n = 1,618) for females. A total of 56,144 tests were run in the setting, of which 9,512 (16.94%) were Random Blood Sugar (RBS) tests, and 90 (0.16%) HbA1c tests. Mean costs were estimated as: $2.58 per outpatient consultation, $1.37 per RBS test and $14.84 per HbA1c test. The annual pharmacotherapy regimens cost $91.93 for T1DM and $20.34 for T2DM. Investment in holistic and sustainable non-communicable disease management should be at the forefront of humanitarian response. It is expected to be beneficial with immediate implications on the COVID-19 response while also reducing the burden of care over time. Despite study limitations, essential services for the management of uncomplicated diabetes in a humanitarian setting can be modest and affordable. Therefore, integrating diabetes care into primary health care should be a fundamental pillar of long-term policy response by stakeholders.

Delivering nutrition interventions to women and children in conflict settings: a systematic review

Background

Low/middle-income countries (LMICs) face triple burden of malnutrition associated with infectious diseases, and non-communicable diseases. This review aims to synthesise the available data on the delivery, coverage, and effectiveness of the nutrition programmes for conflict affected women and children living in LMICs.

Methods

We searched MEDLINE, Embase, CINAHL, and PsycINFO databases and grey literature using terms related to conflict, population, and nutrition. We searched studies on women and children receiving nutrition-specific interventions during or within five years of a conflict in LMICs. We extracted information on population, intervention, and delivery characteristics, as well as delivery barriers and facilitators. Data on intervention coverage and effectiveness were tabulated, but no meta-analysis was conducted.

Results

Ninety-one pubblications met our inclusion criteria. Nearly half of the publications (n=43) included population of sub-Saharan Africa (n=31) followed by Middle East and North African region. Most publications (n=58) reported on interventions targeting children under 5 years of age, and pregnant and lactating women (n=27). General food distribution (n=34), micronutrient supplementation (n=27) and nutrition assessment (n=26) were the most frequently reported interventions, with most reporting on intervention delivery to refugee populations in camp settings (n=63) and using community-based approaches. Only eight studies reported on coverage and effectiveness of intervention. Key delivery facilitators included community advocacy and social mobilisation, effective monitoring and the integration of nutrition, and other sectoral interventions and services, and barriers included insufficient resources, nutritional commodity shortages, security concerns, poor reporting, limited cooperation, and difficulty accessing and following-up of beneficiaries.

Discussion

Despite the focus on nutrition in conflict settings, our review highlights important information gaps. Moreover, there is very little information on coverage or effectiveness of nutrition interventions; more rigorous evaluation of effectiveness and delivery approaches is needed, including outside of camps and for preventive as well as curative nutrition interventions.

PROSPERO registration number

CRD42019125221.

Delivering health and nutrition interventions for women and children in different conflict contexts: a framework for decision making on what, when, and how

Existing global guidance for addressing women's and children's health and nutrition in humanitarian crises is not sufficiently contextualised for conflict settings specifically, reflecting the still-limited evidence that is available from such settings. As a preliminary step towards filling this guidance gap, we propose a conflict-specific framework that aims to guide decision makers focused on the health and nutrition of women and children affected by conflict to prioritise interventions that would address the major causes of mortality and morbidity among women and children in their particular settings and that could also be feasibly delivered in those settings. Assessing local needs, identifying relevant interventions from among those already recommended for humanitarian settings or universally, and assessing the contextual feasibility of delivery for each candidate intervention are key steps in the framework. We illustratively apply the proposed decision making framework to show what a framework-guided selection of priority interventions might look like in three hypothetical conflict contexts that differ in terms of levels of insecurity and patterns of population displacement. In doing so, we aim to catalyse further iteration and eventual field-testing of such a decision making framework by local, national, and international organisations and agencies involved in the humanitarian health response for women and children affected by conflict.

Vaccination strategies for measles control and elimination: time to strengthen local initiatives

BACKGROUND

Through a combination of strong routine immunization (RI), strategic supplemental immunization activities (SIA) and robust surveillance, numerous countries have been able to approach or achieve measles elimination. The fragility of these achievements has been shown, however, by the resurgence of measles since 2016. We describe trends in routine measles vaccine coverage at national and district level, SIA performance and demographic changes in the three regions with the highest measles burden.

FINDINGS

WHO-UNICEF estimates of immunization coverage show that global coverage of the first dose of measles vaccine has stabilized at 85% from 2015 to 19. In 2000, 17 countries in the WHO African and Eastern Mediterranean regions had measles vaccine coverage below 50%, and although all increased coverage by 2019, at a median of 60%, it remained far below levels needed for elimination. Geospatial estimates show many low coverage districts across Africa and much of the Eastern Mediterranean and southeast Asian regions. A large proportion of children unvaccinated for MCV live in conflict-affected areas with remote rural areas and some urban areas also at risk. Countries with low RI coverage use SIAs frequently, yet the ideal timing and target age range for SIAs vary within countries, and the impact of SIAs has often been mitigated by delays or disruptions. SIAs have not been sufficient to achieve or sustain measles elimination in the countries with weakest routine systems. Demographic changes also affect measles transmission, and their variation between and within countries should be incorporated into strategic planning.

CONCLUSIONS

Rebuilding services after the COVID-19 pandemic provides a need and an opportunity to increase community engagement in planning and monitoring services. A broader suite of interventions is needed beyond SIAs. Improved methods for tracking coverage at the individual and community level are needed together with enhanced surveillance. Decision-making needs to be decentralized to develop locally-driven, sustainable strategies for measles control and elimination.