Diabetes Care in Humanitarian Settings

Despite the increasing prevalence of diabetes in populations experiencing humanitarian crisis, along with evidence that people living with diabetes are at higher risk for poor outcomes in a crisis, diabetes care is not routinely included in humanitarian health interventions. We here describe 4 factors that have contributed to the inequities and lack of diabetes inclusion in humanitarian programmes: (1) evolving paradigms in humanitarian health care, (2) complexities of diabetes service provision in humanitarian settings, (3) social and cultural challenges, and (4) lack of financing. We also outline opportunities and possible interventions to address these challenges and improve diabetes care among crisis-affected populations.

Advancing the Role of Higher Education Institutions to Support Palliative Care Education in Primary Care and Humanitarian Settings within Low- and Middle-Income Countries: Online Workshop Report

The need for palliative care is increasing, especially in low- and middle-income countries (LMICs). Higher education institutions (HEIs) have a role to play in developing a skilled palliative care workforce in LMICs. A workshop was held to discuss this issue, and it was attended by experts from around the world. The workshop highlighted the challenges and opportunities for palliative care education in HEIs for LMIC settings. The participants discussed the importance of a collaborative interprofessional approach and advocacy for the inclusion of palliative care into a wide range of curricula. They also expressed the hope to explore possibilities of networks to continue this discussion and incorporate the wider perspectives from primary care and humanitarian practitioners.

Investigating Incidence, Correlates, and Consequences of Child Marriage Among Syrian Refugees Residing in the South of Lebanon: A Cross-Sectional Study

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.

Understanding and Responding to Substance Use and Abuse in the Palestinian Refugee Camps in Lebanon Prior to and During COVID-19 Times

Due to its geographical proximity to the Syrian conflict and the occupied territories, Lebanon has experienced an influx of refugees in recent times. Palestinian refugees are an identified key vulnerable population, with displaced communities increasingly experiencing camp insecurity, vulnerability to drug use and related health harms. A qualitative study consisting of in-depth interviews and focus group discussions (FGDs) was undertaken as part of a regional exercise investigating Palestinian community experiences of substance and drug use in refugee camps. Thematic analysis triangulated the perspectives of 11 professional stakeholders representing United Nations, human rights and non-governmental organizations (NGOs), and eight Palestinian community members. Emerging themes centered on the interplay between socio-economic instability, lack of law enforcement and camp governance contributing to concerning levels of familial, drug and camp violence, trafficking and availability of drugs. Transactional sex and the exploitation of women and children in drug dealing, diversification toward drug manufacture and dealing of drugs with the outside community were described. There is a lack of harm reduction and rehabilitation supports for those in need. This study highlights the complexities in tackling drug dealing and related criminal activity within refugee camps and humanitarian settings, and the vulnerabilities of those living within to harmful drug use.

Epidemiology of surgery in a protracted humanitarian setting: a 20-year retrospective study of Nyarugusu Refugee Camp, Kigoma, Western Tanzania

Background

There are 80 million forcibly displaced persons worldwide, 26.3 million of whom are refugees. Many refugees live in camps and have complex health needs, including a high burden of non-communicable disease. It is estimated that 3 million procedures are needed for refugees worldwide, yet very few studies exist on surgery in refugee camps, particularly protracted refugee settings. This study utilizes a 20-year dataset, the longest dataset of surgery in a refugee setting to be published to date, to assess surgical output in a setting of protracted displacement.

Methods

A retrospective review of surgeries performed in Nyarugusu Camp was conducted using paper logbooks containing entries between November 2000 and September 2020 inclusive. Abstracted data were digitized into standard electronic form and included date, patient nationality, sex, age, indication, procedure performed, and anesthesia used. A second reviewer checked 10% of entries for accuracy. Entries illegible to both reviewers were excluded. Demographics, indication for surgery, procedures performed, and type of anesthesia were standardized for descriptive analysis, which was performed in STATA.

Results

There were 10,799 operations performed over the 20-year period. Tanzanians underwent a quarter of the operations while refugees underwent the remaining 75%. Ninety percent of patients were female and 88% were 18 years of age or older. Caesarean sections were the most common performed procedure followed by herniorrhaphies, tubal ligations, exploratory laparotomies, hysterectomies, appendectomies, and repairs. The most common indications for laparotomy procedures were ectopic pregnancy, uterine rupture, and acute abdomen. Spinal anesthesia was the most common anesthesia type used. Although there was a consistent increase in procedural volume over the study period, this is largely explained by an increase in overall camp population and an increase in caesarean sections rather than increases in other, specific surgical procedures.

Conclusion

There is significant surgical volume in Nyarugusu Camp, performed by staff physicians and visiting surgeons. Both refugees and the host population utilize these surgical services. This work provides context to the surgical training these settings require, but further study is needed to assess the burden of surgical disease and the extent to which it is met in this setting and others.

Factors influencing the effective management of diabetes during humanitarian crises in low- and middle-income countries: a systematic review

OBJECTIVES

The management of non-communicable chronic diseases such as diabetes mellitus is often poor in humanitarian crisis settings. Poor disease management can have serious long-term consequences. This review sought to identify studies that explored the effectiveness of interventions and the determinants that may improve the management of diabetes in the humanitarian context.

STUDY DESIGN

A systematic review was conducted of all types of studies that implemented diabetes programmes in humanitarian settings.

METHODS

MEDLINE, Embase, CINAHL and Web of Science were searched for relevant articles using multiple search terms for relevant studies published in English between 2000 and June 2020. Quality assessments using valid tools, were conducted. A narrative synthesis of the findings was then performed.

RESULTS

The search yielded 550 citations. After de-duplicating and screening, 19 studies were eligible for inclusion. Most studies were conducted in the Middle East (74%), Asia (16%) and Africa (10%). The interventions reported to improved diabetes care included the mHealth tool, intensive lifestyle intervention, task-shifting, psychosocial support, distribution of glucometers and comprehensive care. Insufficient drug supply, out-of-pocket cost, the complexity of insulin therapy and low adherence to guidelines were identified as barriers.

CONCLUSION

There is a paucity of evidence on optimal diabetes care in acute crisis and natural disaster settings. The review was constrained by the low quality of the studies included. Nevertheless, it is likely that mHealth can be feasibly utilised, as educational SMS messages are cost-effective and electronic medical records can enhance disease monitoring. In addition, a multidisciplinary approach to care improves glycaemic control and is desirable due to the multifaceted nature of the disease and management required. Several key barriers have been identified that need to be tackled. Overall, the evidence base for diabetes care in humanitarian settings remains sparse, and further research is needed.

The role of integrated programs in the prevention of COVID-19 in a humanitarian setting

The COVID-19 pandemic has caused a severe depletion to health systems worldwide. In the South Kordofan state, a war-torn humanitarian region in Sudan, the United Nations High Commissioner for Refugees and the WHO Emergencies Programme have led the development of integrated programs for health, peace and rehabilitation by training rapid response teams to strengthen both surveillance system and response capacities, engaging the communities at risk with health education and promotion activities, as well as following proper infection, prevention and control measures during case investigation. Also, Early Help Assessment coordinators met with health services managers and recruited 14 teams who were trained to ensure a rapid response to COVID-19. Also, the implementation of water, sanitation and hygiene services was upscaled. Although the local community of South Kordofan is fragile and at high risk of infectious diseases, the limited numbers of detected cases of COVID-19 and COVID-19 deaths could be attributed to the early preparation and integration of programs that helped to prevent the local spread of COVID-19. This lesson needs to be thoroughly investigated to estimate whether it is cost-effective and to determine the feasibility of it being successfully implemented in other humanitarian settings.

Using a community-based system dynamics approach for understanding inclusion and wellbeing: a case study of special needs education in an eastern African refugee camp

BACKGROUND

Children with disabilities face unique challenges in humanitarian aid settings and education may provide protective measures against abuse and exploitation. There are growing calls for inclusive education of children with disabilities in formal education, but little guidance exists on how to enhance inclusion in complex and resource-constrained contexts of humanitarian settings.

CASE PRESENTATION

This study used a community-based system dynamics approach to understand key stakeholders' perspectives of the drivers and effects of inclusion and wellbeing for children with disabilities, and to elicit recommendations to enhance educational inclusion in a refugee camp in Eastern Africa. Community-based system dynamics sessions, designed based on group model building scripts and facilitated by a team of four people, took place with organization staff, community leaders, and parents and caregivers of children with disabilities. The process produced a causal loop diagram depicting the stakeholders' perspectives of how multiple components interact in a system to drive inclusion and wellbeing of children with disabilities over time.

CONCLUSIONS

Findings indicate participants have a broad conceptualization of inclusion, highlighting the value of community interaction and importance of meeting basic needs, and also demonstrate that including children in mainstream educational settings in a complex humanitarian context requires a more nuanced approach given the lack of existing resources to support Western models of educational inclusion fully.

A qualitative study on health care providers' experiences of providing comprehensive abortion care in Cox's Bazar, Bangladesh

Background

Humanitarian settings are characterised by limited access to comprehensive abortion care. At the same time, humanitarian settings can increase the vulnerability of women and girls to unintended pregnancies and unsafe abortions. Humanitarian actors and health care providers can play important roles in ensuring the availability and accessibility of abortion-related care. This study explores health care providers’ perceptions and experiences of providing comprehensive abortion care in a humanitarian setting in Cox’s Bazar, Bangladesh and identifies barriers and facilitators in service provision.

Method

In-depth interviews (n = 24) were conducted with health care providers (n = 19) providing comprehensive abortion care to Rohingya refugee women and with key informants (n = 5), who were employed by an organisation involved in the humanitarian response. Data were analysed using an inductive content analysis approach.

Results

The national menstrual regulation policy provided a favourable legal environment and facilitated the provision of comprehensive abortion care, while the Mexico City policy created organisational barriers since it made organisations unable or unwilling to provide the full comprehensive abortion care package. Supplies were available, but a lack of space created a barrier to service provision. Although training from organisations had made the health care providers confident and competent and had facilitated the provision of services, their knowledge of the national abortion law and menstrual regulation policy was limited and created a barrier to comprehensive abortion services. Even though the health care providers were willing to provide comprehensive abortion care and had acquired skills and applied strategies to communicate with and provide care to Rohingya women, their personal beliefs and their perceptions of Rohingya women influenced their provision of care.

Conclusion

The availability and accessibility of comprehensive abortion care was limited by unfavourable abortion policies, a lack of privacy, a lack of knowledge of abortion laws and policies, health care providers’ personal beliefs and a lack of cultural safety. To ensure the accessibility and availability of quality services, a comprehensive approach to sexual and reproductive health and rights is needed. Organisations must ensure that health care providers have knowledge of abortion policies and the ability to provide quality care that is woman-centred and non-judgmental.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00338-9.

Comprehensive development and testing of the ASIST-GBV, a screening tool for responding to gender-based violence among women in humanitarian settings

Background

Conflict affected refugees and internally displaced persons (IDPs) are at increased vulnerability to gender-based violence (GBV). Health, psychosocial, and protection services have been implemented in humanitarian settings, but GBV remains under-reported and available services under-utilized. To improve access to existing GBV services and facilitate reporting, the ASIST-GBV screening tool was developed and tested for use in humanitarian settings. This process was completed in four phases: 1) systematic literature review, 2) qualitative research that included individual interviews and focus groups with GBV survivors and service providers, respectively, 3) pilot testing of the developed screening tool, and 4) 3-month implementation testing of the screening tool. Research was conducted among female refugees, aged ≥15 years in Ethiopia, and female IDPs, aged ≥18 years in Colombia.

Results

The systematic review and meta-analysis identified a range of GBV experiences and estimated a 21.4 % prevalence of sexual violence (95 % CI:14.9-28.7) among conflict-affected populations. No existing screening tools for GBV in humanitarian settings were identified. Qualitative research with GBV survivors in Ethiopia and Colombia found multiple forms of GBV experienced by refugees and IDPs that occurred during conflict, in transit, and in displaced settings. Identified forms of violence were combined into seven key items on the screening tool: threats of violence, physical violence, forced sex, sexual exploitation, forced pregnancy, forced abortion, and early or forced marriage. Cognitive testing further refined the tool. Pilot testing in both sites demonstrated preliminary feasibility where 64.8 % of participants in Ethiopia and 44.9 % of participants in Colombia were identified with recent (last 12 months) cases of GBV. Implementation testing of the screening tool, conducted as a routine service in camp/district hospitals, allowed for identification of GBV cases and referrals to services. In this phase, 50.6 % of participants in Ethiopia and 63.4 % in Colombia screened positive for recent experiences of GBV. Psychometric testing demonstrated appropriate internal consistency of the tool (Cronbach’s α = 0.77) and item response theory demonstrated appropriate discrimination and difficulty of the tool.

Conclusion

The ASIST-GBV screening tool has demonstrated utility and validity for use in confidential identification and referral of refugees and IDPs who experience GBV.

Psychometric properties and reliability of the Assessment Screen to Identify Survivors Toolkit for Gender Based Violence (ASIST-GBV): results from humanitarian settings in Ethiopia and Colombia

Background

Refugees and internally displaced persons who are affected by armed-conflict are at increased vulnerability to some forms of sexual violence or other types of gender-based violence. A validated, brief and easy-to-administer screening tool will help service providers identify GBV survivors and refer them to appropriate GBV services. To date, no such GBV screening tool exists. We developed the 7-item ASIST-GBV screening tool from qualitative research that included individual interviews and focus groups with GBV refugee and IDP survivors. This study presents the psychometric properties of the ASIST-GBV with female refugees living in Ethiopia and IDPs in Colombia.

Methods

Several strategies were used to validate ASIST-GBV, including a 3 month implementation to validate the brief screening tool with women/girls seeking health services, aged ≥15 years in Ethiopia (N = 487) and female IDPs aged ≥ 18 years in Colombia (N = 511).

Results

High proportions of women screened positive for past-year GBV according to the ASIST-GBV: 50.6 % in Ethiopia and 63.4 % in Colombia. The factor analysis identified a single dimension, meaning that all items loaded on the single factor. Cronbach’s α = 0.77. A 2-parameter logistic IRT model was used for estimating the precision and discriminating power of each item. Item difficulty varied across the continuum of GBV experiences in the following order (lowest to highest): threats of violence (0.690), physical violence (1.28), forced sex (2.49), coercive sex for survival (2.25), forced marriage (3.51), and forced pregnancy (6.33). Discrimination results showed that forced pregnancy was the item with the strongest ability to discriminate between different levels of GBV. Physical violence and forced sex also have higher levels of discrimination with threats of violence discriminating among women at the low end of the GBV continuum and coercive sex for survival among women at the mid-range of the continuum.

Conclusion

The findings demonstrate that the ASIST-GBV has strong psychometric properties and good reliability. The tool can be used to screen and identify female GBV survivors confidentially and efficiently among IDPs in Colombia and refugees in Ethiopia. Early identification of GBV survivors can enable safety planning, early referral for treatment, and psychosocial support to prevent long-term harmful consequence of GBV.

Mental health in humanitarian settings: shifting focus to care systems

Mental health in low- and middle income countries has received increasing attention. This attention has shifted focus, roughly moving from demonstrating the burden of mental health problems, to establishing an evidence base for interventions, to thinking about care delivery frameworks. This paper reviews these trends specifically for humanitarian settings and discusses lessons learned. Notably, that mental health assessments need to go beyond measuring the impact of traumatic events on circumscribed psychiatric disorders; that evidence for effectiveness of interventions is still too weak and its focus too limited; and that development of service delivery in the context of instable community and health systems should be an area of key priority.