Conflict-affected Populations Research Articles

Delivery of sexual and reproductive health interventions in conflict settings: a systematic review

BackgroundIt is essential to provide comprehensive sexual and reproductive health (SRH) interventions to women affected by armed conflict, but there is a lack of evidence on effective approaches to delivering...

Cango Lyec (Healing the Elephant): HIV incidence in post-conflict Northern Uganda.

BackgroundCivil war in Northern Uganda resulted in widespread atrocities, human rights violations, and death, and caused millions to flee to internally displaced persons camps. War-related traumas combined with difficulties accessing HIV prevention and health services has led to extreme HIV-related vulnerability among conflict-affected people who survived the war. Objectives were to (1) determine HIV incidence among conflict-affected people in Northern Uganda and (2) identify vulnerabilities associated with HIV infection.MethodsThe Cango Lyec (Healing the Elephant) Project is a prospective cohort involving conflict-affected populations in three districts in Northern Uganda. In 2011, eight randomly selected communities were mapped, and a census was conducted. Consenting participants aged 13–49 years were followed over three rounds of follow-up. Longitudinal data collected included war-related experiences, sexual vulnerabilities, and sociodemographics. Blood samples were tested for HIV-1 at baseline and each 12-month follow-up. Multivariable Cox proportional hazard models determined factors associated with HIV incidence.FindingsOverall, 1920 baseline HIV-negative participants with at least one follow-up contributed 3877 person-years (py) for analysis. Thirty-nine (23 female, 16 male) participants contracted HIV during follow-up. Age- and gender-standardised HIV incidence rate was 10•2 per 1000py (95%CI: 7•2-14•0). Stratified by sex, the age-adjusted HIV incidence was 11•0 per 1000py (95%CI: 6•9-16•6) among women and 9•4 per 1000py (95%CI: 5•3-15•3) among men. Adjusting for confounders, factors associated with risk of HIV included: having been abducted (HR: 3•70; 95%CI: 1•87-7•34), experiencing ≥12 war-related traumatic events (HR: 2•91 95%CI: 1•28-6•60), suicide ideation (HR: 2•83; 95%CI: 1•00-8•03), having ≥2 sexual partners (HR: 4•68; 95%CI: 1•36-16•05), inconsistent condom use (HR: 6•75; 95%CI: 2•49-18•29), and self-reported genital ulcers (HR: 4•39; 95%CI: 2•04-9•45).InterpretationConflict-affected participants who had experienced abduction and multiple traumas during the war were at greater risk of HIV infection. Trauma-informed HIV prevention and treatment services, and culturally-safe mental health initiatives, are urgent for Northern Uganda.

STUDY ON MENTAL HEALTH AND EMOTIONAL WELL-BEING OF CONFLICT-AFFECTED ADOLESCENTS AT EASTERN UKRAINE

Children and adolescents are one of the most vulnerable population groups suffered from the war. During adolescence, an individual’s psyche is being transformed and proved to be especially sensitive. This process of transformation becomes complicated and burdened with psychological trauma experienced in the situation of an armed conflict. Impact of everyday stress factors grows as combined with traumatic war events: watching military vehicles, shooting, killing, wounding, loss of family members and home, as well as general social, economic, and psychological problems. Not every psychological trauma results in mental disorder, however, those stresses often cause painful emotions and lead to maladjustment. The effective programs of psychosocial support to conflict-affected adolescents should take into account their individual characteristics and the specific situational context. For this purpose, we conducted psychodiagnostics study on mental health and emotional well-being of adolescents living near the front line in Eastern Ukraine. Totally, 222 high school students from Donetsk region aged 15 to 17 participated in the survey. The following questionnaires were used: Strength and Difficulties Questionnaire (SDQ), Child Psychosocial Distress Screener (CPDS) assessing distress, emotional and behavioural problems of children and adolescents aged 8-18, and Mental Health Assessment Instrument (MHAI) screening mental health symptoms and disorders at conflict-affected populations. The study findings showed that the majority (94,7%) of the respondents experienced war traumatic events, having at least one symptom of psychological problems; 25,5% were experiencing depression, 34,9% did PTS, 7,8% had anxiety and 7,7% had problems with alcohol use. Women were more likely than males to experience stress and had mental health problems, while men had problems with prosocial behavior. Both genders had difficulties in peer relationships and behavior. The existing psychological problems were aggravated by hyperactivity, difficulties in behavior and relationships with peer and indicated worsened mental health and emotional well-being of conflict-affected adolescents in the Eastern Ukraine, risk of mental disorders and asocial behavior. These data should be taken into account for effective psychological support for this category of adolescents. &nbsp

C\u2019est vraiment compliqu\xe9: a case study on the delivery of maternal and child health and nutrition interventions in the conflict-affected regions of Mali

BackgroundMali is currently in the midst of ongoing conflicts which involve jihadist groups, rebels, and the state. This conflict has primarily centered in the North of the country. Humanitarian actors delivering services in these geographies must navigate the complex environment created by conflict. This study aimed to understand how humanitarian actors make decisions around health service delivery within this context.MethodsThe current case-study utilized a mixed methods approach and focused on Mopti, Mali’s fifth administrative region and fourth largest in population. Latent content analysis was used to analyze interview transcripts guided by our research objectives and new concepts as they emerged. Indicators of coverage of health interventions in the area of maternal and child health and nutrition were compiled using Mali’s National Evaluation Platform and are presented for the conflict and non-conflict regions. Development assistance estimates for Mali by year were obtained from the Developmental Assistance for Health Database compiled by the Institute for Health Metrics and Evaluation. Administrative data was compiled from the annual reports of Mali’s Système Local d’Information Sanitaire (SLIS), Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS).ResultsOur data suggests that the reaction of the funding mechanisms to the conflict in Mali was a major barrier to timely delivery of health services to populations in need and the nature of the conflict is likely a key modifier of such reaction patterns. Concerns have been raised about the disconnect between the very high administrative capacity of large NGOs that control the work, and the consequent burden it puts on local NGOs. Population displacement and inaccurate estimates of needs made it difficult for organizations to plan program services. Moreover, actors delivering services to populations in need had to navigate an unpredictable context and numerous security threats.ConclusionsOur study highlights the need for a more flexible funding and management mechanism that can better respond to concerns and issues arising at a local level. As the conflict in Mali continues to worsen, there is an urgent need to improve service delivery to conflict-affected populations.

A systematic literature review of the ethics of conducting research in the humanitarian setting

BackgroundResearch around humanitarian crises, aid delivery, and the impact of these crises on health and well-being has expanded dramatically. Ethical issues around these topics have recently received more attention. We conducted a systematic literature review to synthesize the lessons learned regarding the ethics of research in humanitarian crises.MethodsWe conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines to identify articles regarding the ethics of research in humanitarian contexts between January 1, 1997 and September 1, 2019. We analyzed the articles to extract key themes and develop an agenda for future research.ResultsWe identified 52 articles that matched our inclusion criteria. We categorized the article data into five categories of analysis: 32 were expert statements, 18 were case studies, 11 contained original research, eight were literature reviews and three were book chapters. All included articles were published in English. Using a step-wise qualitative analysis, we identified 10 major themes that encompassed these concepts and points. These major themes were: ethics review process (21 articles, [40.38%]); community engagement (15 articles [28.85%]); the dual imperative, or necessity that research be both academically sound and policy driven, clinical trials in the humanitarian setting (13 articles for each, [25.0%)]; informed consent (10 articles [19.23%]); cultural considerations (6 articles, [11.54%]); risks to researchers (5 articles, [9.62%]); child participation (4 articles [7.69%]); and finally mental health, and data ownership (2 articles for each [3.85%]).ConclusionsInterest in the ethics of studying humanitarian crises has been dramatically increasing in recent years. While key concepts within all research settings such as beneficence, justice and respect for persons are crucially relevant, there are considerations unique to the humanitarian context. The particular vulnerabilities of conflict-affected populations, the contextual challenges of working in humanitarian settings, and the need for ensuring strong community engagement at all levels make this area of research particularly challenging. Humanitarian crises are prevalent throughout the globe, and studying them with the utmost ethical forethought is critical to maintaining sound research principles and ethical standards.

Noncommunicable disease burden among conflict-affected adults in Ukraine: A cross-sectional study of prevalence, risk factors, and effect of conflict on severity of disease and access to care.

BackgroundThere is limited research on noncommunicable diseases (NCDs) in humanitarian settings despite the overall global burden and disproportionate growth in many conflicts and disaster-prone settings. This study aimed to determine the prevalence of NCDs and assess the perceived effect of conflict on NCD severity and access to treatment among conflict-affected adults (≥ 30 years) in Ukraine.Methods and findingsWe conducted two population-representative, stratified, cross-sectional household surveys: one among adult internally displaced people (IDPs) throughout Ukraine and one among adults living in Donbas in eastern Ukraine. One randomly selected adult per household answered questions about their demographics, height and weight, diagnosed NCDs, access to medications and healthcare since the conflict began, as well as questions assessing psychological distress, trauma exposure, and posttraumatic stress disorder. More than half of participants reported having at least one NCD (55.7% Donbas; 59.8% IDPs) A higher proportion of IDPs compared to adults in Donbas experienced serious psychological distress (29.9% vs. 18.7%), interruptions in care (9.7–14.3% vs. 23.1–51.3%), and interruptions in medication than adults in Donbas (14.9–45.6% vs. 30.2–77.5%). Factors associated with perceived worsening of disease included psychological distress (p: 0.002–0.043), displacement status (IDP vs. Donbas) (p: <0.001–0.011), interruptions in medication (p: 0.002–0.004), and inability to see a doctor at some point since the start of the conflict (p: <0.001–0.008).ConclusionsOur study found a high burden of NCDs among two conflict-affected populations in Ukraine and identified obstacles to accessing care and medication. Psychological distress, interruptions to care, and interruptions in medication were all reported by a higher proportion of IDPs than adults in Donbas. There is a need for targeted policies and programs to support the unique needs of displaced conflict-affected individuals in Ukraine that address the economic and perceived barriers to NCD treatment and care.

Journeys to Knua: displacement, return and translocality in Timor-Leste

ABSTRACT Return journeys to ancestral lands are a central dimension that underscores contemporary ideas of origin, identity, kinship, custom, health and prosperity for the East Timorese. The material and social reproduction of knua – both in the sense of the ancestral territory and associated kin-based ritual community – is heavily reliant on ongoing place-based and translocal customary reciprocal exchanges. Based on multi-sited fieldwork, this article examines the return journeys to Lesuai, an ancestral settlement in the remote central southern highlands of Timor-Leste, which was abandoned during the Indonesian invasion and restored in the later years of occupation. Lesuai community believes the spirit realm exerts an overwhelming influence over their general well-being, compelling ‘house’ members to renew their connection with knua to maintain family ties and benefit from ancestral protection. Closer ethnographic attention reveals how the motivations, experiences and understandings of ‘return’ to origin places are highly personal, gendered and generational. Broadly, these return mobilities demonstrate the agency, adaptability and resilience of conflict-affected populations. Through prolonged displacement and resettlement, dispersed knua members have created new livelihoods, subjectivities and attachments across multiple places, which are reconfiguring family ties, connections to ancestral places, and how ritual obligations are fulfilled.

Improving quality of care in conflict settings: access and infrastructure are fundamental.

Armed conflicts pose significant challenges to ensuring timely access to quality health care services for millions around the world. Ensuring access and basic infrastructure for conflict-affected populations are overlooked in the global movement to provide quality of care. This paper identifies strategies and interventions to improve access to good quality care in settings and communities afflicted by conflict. t is crucial to focus more attention on, and develop an evidence base for, ensuring access and basic infrastructure to improve quality of care in conflict-affected regions.

Armed conflict and public health: into the 21st century.

Many people worldwide are affected by conflict, and countries affected are less likely to meet the UN Sustainable Development Goals. This review outlines the effects of conflict on health and focuses on areas requiring more attention. We completed a search of the literature using Medline, Embase and Global Health. Health effects of conflict include trauma; mental health; non-communicable diseases (NCDs); child health; sexual, reproductive and maternal health; and infectious diseases. Conflict damages health directly through fighting, and indirectly through wider socioeconomic effects. Health outcomes are influenced by pre-existing population health and demographics, and access to appropriate healthcare. Vulnerable populations (the elderly, children, neonates and women) are especially at risk. Several areas pose key challenges including: tactics of war as a public health problem; a lack of focus on neonatal care and NCDs; the long-term consequences of conflict across a life-course and into future generations; and the need to focus on wellbeing beyond standard health parameters. Clear decisions about prioritisation need to be made. The effects on civilians must be documented and recorded. Further research is required to understand chronic health needs and effects on future generations, to support fair and equitable resource prioritisation to best meet the needs of conflict-affected populations.

Researching violence against women and girls in South Sudan: ethical and safety considerations and strategies

BackgroundGlobally, it is estimated that at least one out of every three women experiences violence by an intimate partner and/or non-partner throughout their lifetime. Women and girls are at even higher risk of violence in conflict and humanitarian crises. Although effort has expanded to build rigorous evidence and research on violence against women and girls (VAWG) among conflict-affected populations, methodological and ethical challenges remain. Basic ethical research practices are more challenging in conflict-affected populations and therefore require supplementary protections. While it is important to follow international ethical guidelines, in practice it is sometimes difficult depending on the setting. The aim of this paper is to present the main ethical challenges that occur when conducting research on VAWG in conflict and humanitarian settings, as well as potential strategies to address these challenges, based on a recent study carried out in South Sudan in 2016.Case presentationThis paper provides an analysis utilizing the World Health Organization guidelines on doing research on VAWG and in conflict and humanitarian settings. The paper analyses four main components: the first component is a risk-benefit assessment, which includes identifying the research gap and evaluating feasibility with local stakeholders. The second component is a methodological and conceptual approach, which involves both local stakeholders and external experts in order to develop flexible methods that can be used in a volatile conflict setting. The third component is safety considerations, which emphasizes the importance of collaborating with a partner with strong local networks. The last component is analysis and research uptake. This component describes the importance of developing different research products, and disseminating them in a way to ensure they would be relevant and minimize any risks to the participants.ConclusionsThe study in South Sudan provided an excellent opportunity to put into practice the international ethical guidelines to carry out research on VAWG in conflict and humanitarian settings. The study enabled the research team to reflect on the guidelines and develop strategies to cope with new methodological and ethical challenges that arose in this complex setting, adapting the guidelines, as necessary. It demonstrated the necessity of developing a strong yet adaptable methodology with multiple alternative plans to solve any safety or ethical issues that occur throughout the entirety of the study. It also revealed the importance of collaborating with an implementing partner and gathering input from both local and international stakeholders on research design, analysis and uptake. Most importantly, the study in South Sudan emphasized that this type of complex research requires significant planning, in addition to substantial financial and human resources. Donor buy-in and flexibility is therefore essential.

The burden of mental disorders and access to mental health and psychosocial support services in Syria and among Syrian refugees in neighboring countries: a systematic review.

Exposure to conflict, violence and forced displacement can increase poor mental health among affected populations. Our aim was to examine evidence on the burden of mental disorders and access to and effectiveness of mental health and psychosocial support (MHPSS) services in Syria and among Syrian refugees in neighboring countries. A systematic review was done following systematic review criteria. Twelve bibliographic databases and additional gray literature sources were searched for quantitative and qualitative studies. Descriptive analysis and quality assessment were conducted. Twenty-eight eligible studies were identified, of which two were with conflict-affected populations within Syria. Levels of post-traumatic stress disorder ranged from 16 to 84%, depression from 11 to 49%, and anxiety disorder from 49 to 55%. Common risk factors were exposures to trauma and having a personal or family history of mental disorder. Financial and socio-cultural barriers were identified as the main obstacles to accessing MHPSS care. Evaluations of MHPSS services, albeit from predominantly nonrandomised designs, reported positive treatment outcomes. The MHPSS burden was high, but with considerable variation between studies. There are key evidence gaps on: MHPSS burden and interventions-particularly for those living within Syria; access and barriers to care; and implementation and evaluation of MHPSS interventions.

Scaling up mental health interventions in conflict zones

Scaling up mental health interventions in conflict zones

Resource Loss and Stress Outcomes in a Setting of Chronic Conflict: The Conservation of Resources Theory in the Eastern Congo.

The purpose of this cross-sectional study was to examine conservation of resources (COR) theory in the context of armed conflict in Africa. Specifically, within the setting of ongoing chronic conflict in the eastern Democratic Republic of the Congo (DRC), we tested the COR theory prediction that resource loss contributes to various stress outcomes. A randomly selected sample of 312 adults (125 men, 187 women) from villages in North Kivu, DRC completed orally administered measures of resource loss, daily stressors, and four stress outcomes: depression symptoms, anxiety symptoms, posttraumatic distress, and general distress. Consistent with COR theory, resource loss predicted all four stress outcomes above and beyond the contribution of demographics, relocation experiences, and daily stressors; however, this effect was small, ΔR2 = .02-.06. The most consistent and strongest predictors of stress outcomes were daily stressors, βs = .42-.62; number of relocation experiences, βs = .33-.43; and psychosocial resource loss (e.g., loss of hope, meaning or purpose in life, intimacy with friends and family, physical health of family), βs = .17-.26. Additionally, male sex predicted depression, anxiety, and trauma symptoms, and lower educational status predicted anxiety symptoms and general distress. Our exploratory mediation analysis showed that daily stressors partially mediated all four pairs of associations between psychosocial resource loss and mental health outcomes. We discuss the findings with consideration of research on disasters generally and armed conflicts specifically. We also discuss implications for humanitarian interventions with conflict-affected populations in Africa and beyond.

Research round-up

In a systematic review and meta-analysis, Fiona Charlson and colleagues have updated WHO prevalence estimates for mental disorders in populations affected by conflict. 129 studies comprising data from 39 countries for populations affected by conflict less than 10 years previously were included in the study, with five mental disorders included in the analysis (depression, anxiety, post-traumatic stress disorder, bipolar disorder, and schizophrenia). Overall, the estimated point prevalence of mental disorders was 22·1% (95% UI 18·8–25·7) in conflict-affected settings. The estimated point prevalence of severe mental disorders was 5·1% (95% UI 4·0–6·5) and moderate disorders was 4·0% (2·9–5·5). The authors highlighted that their estimates were higher than previously published values. New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysisThe burden of mental disorders is high in conflict-affected populations. Given the large numbers of people in need and the humanitarian imperative to reduce suffering, there is an urgent need to implement scalable mental health interventions to address this burden. Full-Text PDF Open AccessRisk of childhood psychiatric disorders in children of refugee parents with post-traumatic stress disorder: a nationwide, register-based, cohort studyChildren of refugees exposed to parental PTSD are at increased risk of psychiatric morbidity. Targeted screening and interventions are necessary to prevent psychiatric morbidity and ensure access to adequate care. Full-Text PDF Open Access

Research round-up

In a double-blind, randomised withdrawal study in patients with treatment-resistant depression, Daly and colleagues compared an oral antidepressant plus esketamine nasal spray with oral antidepressant plus placebo nasal spray for the prevention of relapse. Treatment (esketamine nasal spray 56 mg or 84 mg flexible dosing) was initiated in 455 patients. 176 achieved stable remission after 16 weeks and entered the randomised maintenance phase of the study (oral antidepressant plus continued treatment with nasal esketamine or withdrawal of nasal esketamine). 121 participants with stable response also entered the randomised study and were analysed for secondary endpoints. In the primary analysis of participants with stable remission, relapse occurred in 24 (27%) of 90 in the esketamine group and 39 (45%) of 86 in the placebo group experienced relapse (hazard ratio 0·49 [95% CI 0·29–0·84]; p=0·003; NNT=6). Prevalence of maternal mental illness among children and adolescents in the UK between 2005 and 2017: a national retrospective cohort analysisOne in four children aged 0–16 years are exposed to maternal mental illness and the prevalence of diagnosed and treated maternal mental illness is increasing. Policy makers and commissioners should consider this information and channel resources to target individuals in greatest need. Full-Text PDF Open AccessNew WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysisThe burden of mental disorders is high in conflict-affected populations. Given the large numbers of people in need and the humanitarian imperative to reduce suffering, there is an urgent need to implement scalable mental health interventions to address this burden. Full-Text PDF Open Access

New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis

SummaryBackgroundExisting WHO estimates of the prevalence of mental disorders in emergency settings are more than a decade old and do not reflect modern methods to gather existing data and derive estimates. We sought to update WHO estimates for the prevalence of mental disorders in conflict-affected settings and calculate the burden per 1000 population.MethodsIn this systematic review and meta-analysis, we updated a previous systematic review by searching MEDLINE (PubMed), PsycINFO, and Embase for studies published between Jan 1, 2000, and Aug 9, 2017, on the prevalence of depression, anxiety disorder, post-traumatic stress disorder, bipolar disorder, and schizophrenia. We also searched the grey literature, such as government reports, conference proceedings, and dissertations, to source additional data, and we searched datasets from existing literature reviews of the global prevalence of depression and anxiety and reference lists from the studies that were identified. We applied the Guidelines for Accurate and Transparent Health Estimates Reporting and used Bayesian meta-regression techniques that adjust for predictors of mental disorders to calculate new point prevalence estimates with 95% uncertainty intervals (UIs) in settings that had experienced conflict less than 10 years previously.FindingsWe estimated that the prevalence of mental disorders (depression, anxiety, post-traumatic stress disorder, bipolar disorder, and schizophrenia) was 22·1% (95% UI 18·8–25·7) at any point in time in the conflict-affected populations assessed. The mean comorbidity-adjusted, age-standardised point prevalence was 13·0% (95% UI 10·3–16·2) for mild forms of depression, anxiety, and post-traumatic stress disorder and 4·0% (95% UI 2·9–5·5) for moderate forms. The mean comorbidity-adjusted, age-standardised point prevalence for severe disorders (schizophrenia, bipolar disorder, severe depression, severe anxiety, and severe post-traumatic stress disorder) was 5·1% (95% UI 4·0–6·5). As only two studies provided epidemiological data for psychosis in conflict-affected populations, existing Global Burden of Disease Study estimates for schizophrenia and bipolar disorder were applied in these estimates for conflict-affected populations.InterpretationThe burden of mental disorders is high in conflict-affected populations. Given the large numbers of people in need and the humanitarian imperative to reduce suffering, there is an urgent need to implement scalable mental health interventions to address this burden.FundingWHO; Queensland Department of Health, Australia; and Bill & Melinda Gates Foundation.

Prevalence of mental disorders and epidemiological associations in post-conflict primary care attendees: a cross-sectional study in the Northern Province of Sri Lanka

BackgroundExperiencing conflict and displacement can have a negative impact on an individual’s mental health. Currently, prevalence of mental health disorders (MHDs) at the primary care level in post-conflict areas within the Northern Province of Sri Lanka is unknown. We aimed to explore this prevalence in conflict-affected populations attending primary care, using a structured package of validated screening tools for MHDs.MethodsThis cross-sectional study aimed to determine factors related to mental health disorders at the primary care level in Northern Province, Sri Lanka. A structured interview was conducted with internally displaced adults attending 25 randomly selected primary care facilities across all districts of Northern Sri Lanka (Jaffna, Mannar, Mullaitivu, Vavuniya). Participants were screened for depression, anxiety, psychosis, PTSD, and somatoform symptoms.ResultsAmong 533 female and 482 male participants (mean age 53.2 years), the prevalence rate for any MHD was 58.8% (95% CI, 53.8–61.4), with 42.4% screening positive for two or more disorders (95% CI, 38.6–46.1). Anxiety prevalence was reported at 46.7% (95% CI, 41.9–51.5), depression at 41.1% (95% CI, 38.7–44.5), PTSD at 13.7% (95% CI, 10.6–16.8), somatoform symptoms at 27.6% (95% CI, 23.6–31.5), and psychosis with hypomania at 17.6% (95% CI, 13.3–21.9).ConclusionThis is the first study at the primary care level to investigate prevalence of MHDs among conflict-affected populations in the Northern Province, Sri Lanka. Results highlight unmet mental health needs in the region. Training intervention to integrate mental health services into primary care is planned.

Health status of returning refugees, internally displaced persons, and the host community in a post-conflict district in northern Sri Lanka: a cross-sectional survey

BackgroundAlthough the adverse impacts of conflict-driven displacement on health are well-documented, less is known about how health status and associated risk factors differ according to displacement experience. This study quantifies health status and quality of life among returning refugees, internally displaced persons, and the host community in a post-conflict district in Northern Sri Lanka, and explores associated risk factors.MethodsWe analysed data collected through a household survey (n = 570) in Vavuniya district, Sri Lanka. The effect of displacement status and other risk factors on perceived quality of life as estimated from the 36-item Short Form Questionnaire, mental health status from 9-item Patient Health Questionnaire, and self-reported chronic disease status were examined using univariable analyses and multivariable regressions.ResultsWe found strong evidence that perceived quality of life was significantly lower for internally displaced persons than for the host community and returning refugees, after adjusting for covariates. Both mental health status and chronic disease status did not vary remarkably among the groups, suggesting that other risk factors might be more important determinants of these outcomes.ConclusionsOur study provides important insights into the overall health and well-being of the different displaced sub-populations in a post-conflict setting. Findings reinforce existing evidence on the relationship between displacement and health but also highlight gaps in research on the long-term health effects of prolonged displacement. Understanding the heterogeneity of conflict-affected populations has important implications for effective and equitable humanitarian service delivery in a post-conflict setting.

A factor analytic investigation of DSM-5 PTSD symptoms in a culturally diverse sample of refugees resettled in Australia

BackgroundRefugees and asylum-seekers are often exposed to multiple types of potentially traumatic events (PTEs) and report elevated rates of psychological disorders, including posttraumatic stress disorder (PTSD). Considering this, refugee populations merit continued research in the field of traumatic stress to better understand the psychological impact of these experiences. The symptom structure of PTSD underwent a major revision in the recent formulation in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and this reformulation has yet to be comprehensively investigated in the context of PTSD arising from traumatic events experienced by refugees. The current study assessed the construct validity of the DSM-5 PTSD structure in a refugee sample from a variety of cultural backgrounds alongside four alternate models commonly identified in western populations, namely the four-factor Dysphoria model, the five-factor Dysphoric Arousal model, and the six-factor Anhedonia and Externalising Behaviours models.MethodsA total of 246 refugees settled in Australia were assessed using the Harvard Trauma Questionnaire, to measure exposure to potentially traumatic events (PTEs), and the Posttraumatic Diagnostic Scale, to assess symptoms of PTSD based on DSM-5 criteria. All measures were translated into Arabic, Farsi or Tamil using rigorous translation procedures, or provided in English.ResultsFindings from five confirmatory factor analyses (CFAs) revealed that all models demonstrated acceptable model fit. However, an examination of relative fit revealed that the DSM-5 model provided the poorest fit overall for our sample. Instead, we found preliminary evidence in support of the six-factor Anhedonia model, comprising the symptom clusters of re-experiencing, avoidance, negative affect, anhedonia, dysphoric arousal and anxious arousal, as the superior model for our data.ConclusionsOur findings offer preliminary support for the applicability of the Anhedonia model to a culturally diverse refugee sample, and contribute to a growing body of studies which indicate that the DSM-5 model may not best represent the symptom structure of PTSD found across non-western conflict-affected populations.

Barriers to mental health care utilization among internally displaced persons in the republic of Georgia: a rapid appraisal study

BackgroundThere is a paucity of evidence on access to services for mental health and psychosocial support for conflict-affected populations in low- and middle-income countries. In the Republic of Georgia, rates of utilization of mental health services among internally displaced people with mental disorders are low. We set out to identify the health system barriers leading to this treatment gap.MethodsWe used rapid appraisal methods (collection and triangulation of multiple data sources) to investigate barriers to accessing mental health care services among adult IDPs in Georgia. Data collection included review of existing policy documents and other published data, as well as semi-structured interviews with 29 key informants including policy makers, NGO staff, health professionals and patients.ResultsThe following factors emerged as important barriers affecting access to mental health care services among IDPs in Georgia: inadequate insurance coverage of mental disorders and poor identification and referral systems, underfunding, shortage of human resources, poor information systems, patient out-of-pocket payments and stigmatization.ConclusionWhile rapid appraisal methods cannot control for potential biases or achieve representativeness, triangulation supports internal validity and reliability of the data collected, allowing data to be used to inform health care interventions. The appropriateness and potential effectiveness of policy interventions such as insurance coverage of a wider range of mental disorders, integration of services for these at the primary health care level, and community-based approaches in this context should be explored.