Lockdowns, lives and livelihoods: the impact of COVID-19 and public health responses to conflict affected populations - a remote qualitative study in Baidoa and Mogadishu, Somalia

BACKGROUND

Authorities in Somalia responded with drastic measures after the first confirmed COVID-19 case in mid-March 2020, closing borders, schools, limiting travel and prohibiting most group functions. However, the impact of the pandemic in Somalia thereafter remained unclear. This study employs a novel remote qualitative research method in a conflict-affected setting to look at how some of the most at-risk internally displaced and host populations were impacted by COVID-19, what determined their responses, and how this affected their health and socio-economic vulnerability.

METHODS

We conducted a remote qualitative study, using Katikati, a 1-to-1 conversation management and analysis platform using short message service (SMS) developed by Lark Systems with Africa's Voices Foundation (AVF), for semi-structured interviews over three months with participants in Mogadishu and Baidoa. We recruited a gender balanced cohort across age groups, and used an analytical framework on the social determinants of health for a narrative analysis on major themes discussed, triangulating data with existing peer-reviewed and grey literature.

RESULTS

The remote research approach demonstrated efficacy in sustaining trusted and meaningful conversations for gathering qualitative data from hard-to-reach conflict-affected communities. The major themes discussed by the 35 participants included health, livelihoods and education. Two participants contracted the disease, while others reported family or community members affected by COVID-19. Almost all participants faced a loss of income and/or education, primarily as a result of the strict public health measures. Some of those who were heavily affected economically but did not directly experienced disease, denied the pandemic. Religion played an important role in participants' beliefs in protection against and salvation from the disease. As lockdowns were lifted in August 2020, many believed the pandemic to be over.

CONCLUSIONS

While the official COVID-19 burden has remained relatively low in Somalia, the impact to people's daily lives, income and livelihoods due to public health responses, has been significant. Participants describe those 'secondary' outcomes as the main impact of the pandemic, serving as a stark reminder of the need to broaden the public health response beyond disease prevention to include social and economic interventions to decrease people's vulnerability to future shocks.

Analgesia for colposcopy: double-masked, randomized comparison of ibuprofen and benzocaine gel

OBJECTIVE

To evaluate pain relief effectiveness of oral ibuprofen and topical benzocaine gel during colposcopy.

METHODS

In a double-masked, randomized controlled trial, women who attended a family medicine colposcopy clinic received one of four treatments, 800 mg of oral ibuprofen, 20% topical benzocaine, both, or placebos. Using visual analog scales, women recorded their pain after speculum placement, endocervical curettage (ECC), and cervical biopsy. Participants were 18-55 years old, spoke English, and were not taking other pain or psychotropic medications. Demographic and historical information was collected from each participant.

RESULTS

Ninety-nine subjects participated. Twenty-five received oral ibuprofen and topical benzocaine (median pain scores on a 10-point scale for speculum placement, ECC, and biopsy were 0.75, 3.00, and 3.38, respectively), 24 received oral placebo and topical benzocaine (1.00, 3.75, and 2.63), 24 received oral ibuprofen and topical placebo (0.63, 3.75, and 2.25), and 26 received oral and topical placebos (0.75, 3.50, and 3.00). There were no statistically significant differences in patient visual analogue pain scale scores across the four groups (statistical power, ECC = 0.74, cervical biopsy = 0.62). Younger women and women who had pain with speculum placement were more likely to have increased pain during ECC. Increased pain during biopsy was associated with history of severe dysmenorrhea but no other demographic or historical factors. Women overall reported ECC and biopsy to be mildly painful, with median scores of 3.5 for ECC and 2.75 for biopsy on a 10-point scale. The range in pain scores was large, with some women reporting severe pain (for ECC minimum = 0.25, maximum = 10.0; biopsy: minimum = 0.0, maximum = 9.0).

CONCLUSION

Colposcopy is perceived as somewhat painful, but oral ibuprofen and topical benzocaine gel, alone or together, provided no advantage over placebo in decreasing colposcopy pain.

Provisions of the Americans with Disabilities Act and the development of essential job functions for family practice residents

BACKGROUND

Family practice residency program directors and faculty are frequently faced with residents who sustain a temporary illness or become disabled during residency. In addition, disabled applicants are seeking positions in medical schools and residencies. Program directors and faculty have an obligation to understand the laws that apply to disability and illness to develop fair and workable policies within their programs. This article explores the provisions of the Americans With Disabilities Act that apply to family practice residency programs and residents with illness and disability. One of the key requirements for dealing with resident illness or disability is the development of essential job functions. We present a strategy to enable individual residency programs to develop a list of essential job requirements for family practice residents. An example of essential job requirements is given.

Silo gas exposure in New York state following the dry growing season of 1995

Exposure to silo gas is a recognized agricultural hazard. Silo gas produced from corn fermentation may consist of oxides of nitrogen and carbon dioxide. The presence of potentially lethal concentrations of nitrogen dioxide (NO2) within vertical silos has been well documented. The risk of silo gas exposure from other silage storage methodologies--including horizontal "ag-bags" and concrete bunkers--has been less well characterized. A dry growing season is known to be a factor for elevating nitrate levels in corn plants and can result in increased NO2 production. Farms in the northeastern United States faced drought conditions during the 1995 growing season. The New York State (NYS) Department of Health (DOH) and the New York Center for Agricultural Medicine and Health (NYCAMH) investigated four exposure incidents involving six farmworkers during September/October 1995. Four of these workers were hospitalized for multiple days, with two workers receiving treatment in intensive care units. The remaining two workers were treated in hospital emergency departments; one refused admission and left against medical advice. We monitored NO2 levels from "ag-bags" at several New York farms. For four days, outdoor concentrations of NO2 at one site remained in excess of the National Institute for Occupational Safety and Health's (NIOSH) immediately dangerous to life and health value (IDLH) of 20 ppm. As a result of the clinical and industrial hygiene data, and the growing season's abnormal weather conditions, DOH and NYCAMH issued statewide health hazard alerts and conducted educational activities to warn farmers and their families. The findings of this study reinforce the potential hazards associated with silo gas exposure and identify the use of ag-bags as a relatively new avenue for significant worker exposure.

Nitrate levels in drinking water in rural New York State

To obtain an indication of the nitrate-nitrogen levels in drinking water in rural areas of upstate New York and the number of infants at risk for methemoglobinemia, 419 wells supplying drinking water to farms were tested. Farmers were identified through two programs run by the New York State Department of Health. The farmers were asked to complete a short questionnaire about the type and size of their farm and their well and to collect the water sample. Overall, nitrates were detectable in 95% of the wells tested (concentration levels greater than 0.05 mg/L) and 15.7% had levels which exceeded 10 mg/L. Fifteen percent of the wells tested from farms where infants resided were also elevated. Wells which were shallow, dug or located on large farms, or springs were more likely to have elevated concentrations of nitrates.

Positioning hospital-based home care agencies for managed care

Over the next several years, Medicare cost-cutting strategies and changing market forces will decrease home health visits and revenue per visit and will probably eliminate the Medicare overhead allocation for hospital-based home care agencies and freestanding home care facilities. Consequently, home care agency managers need to plan now to make their operations more efficient and more competitive in the future. Managers should improve their collection of data needed for cost-reporting to optimize overhead reimbursement while it is still allowed and to begin lowering costs per visit. Chief financial officers have an important role to play in making hospital-based home care agencies financially successful.

The new rules of home health

Home care is an ever more important component of a system's arsenal of care, but most hospital-based programs were set up for reasons that no longer apply in today's marketplace. The author offers a framework for thinking through a hospital home care program for the next decade.