Conflict-affected Populations Research Articles

Depression and its risk factors in a conflict-affected population: findings from a nationwide survey

Abstract Introduction The impact of armed conflict and war on mental health is well documented, with limited data on populations living in unrecognized states. In this study, we examined the prevalence and risk factors of symptoms of depression among the Nagorno-Karabakh population during a ceasefire period, prior to a blockade, full-scale military attack, and their forced displacement. Methods A total of 1023 women, aged 18-49 years, from all regions of Nagorno-Karabakh, participated in a population-based household survey in 2022, which included the Center for Epidemiologic Studies-Depression (CES-D) 16-item scale to assess their depression symptoms. Simple and multivariable linear regression analyses explored the socio-demographic factors associated with CES-D score. Results The mean CES-D score was 8.90 (SD = 8.93), and 13.1% of the respondents had a score >18 (presence of depressive symptoms). The adjusted linear regression showed that CES-D score was higher among divorced (2.66, SE = 1.15, p-value=0.021) or widowed (3.09, SE = 1.57, p-value=0.049) vs. married, and among those having war-related deaths in the household in the previous 2 years (8.60, SE = 1.65, p-value<0.001) vs. not having. Conversely, a vocational/university level (-2.33, SE = 0.70, p-value=0.001) or post-graduate education (-3.81, SE = 1.72, p-value=0.027) vs less than secondary/secondary level, and 3-5 members in the household (-2.71, SE = 1.16, p-value=0.020) vs.1-2 members were significantly associated with lower CES-D score. Conclusions Our findings suggest that depression symptoms are highly prevalent among women in conflict-affected areas, with specific socio-demographic factors increasing the risk of depression symptoms. These results highlight the importance of providing mental health support and interventions for women in conflict-affected areas, particularly for those who experienced loss in the family due to war, are divorced or widowed, live in small households, and have lower education. Key messages • Depression symptoms are highly prevalent among women of reproductive age in areas affected by armed conflict and war. • Mental health intervention is recommended for women in conflict-affected areas who experienced loss due to war, are divorced or widowed, live in small households and/or have lower education.

Social Protection in Conflict and Conflict-Related Displacement Crises

In recent years, efforts to encourage the use of social protection in response to conflict and displacement have increased. Yet many of the lessons from social protection and shock-responsive programmes emerged in response to climate shocks and other disasters and are not necessarily transferable to conflict and displacement settings. Ultimately, the concern must be how to sustain support to the poorest and most vulnerable populations during conflict. This shifts the focus away from simply maintaining the functions and delivery capacities of state‑directed social protection towards how to harmonise multiple channels and providers of social assistance. State‑directed social protection may not be the most appropriate channel to address the needs of conflict-affected and displaced populations. This article considers the challenges to introducing, extending, and sustaining social protection in crises characterised by conflict and displacement.

In-person vs mobile app facilitated life skills education to improve the mental health of internally displaced persons in Nigeria: protocol for the RESETTLE-IDPs cluster randomized hybrid type 2 effectiveness-implementation trial

BackgroundInternally displaced persons (IDPs) in Nigeria face a high burden of mental health disorders, with limited access to evidence-based, culturally relevant interventions. Life skills education (LSE) is a promising approach to promote mental health and psychosocial well-being in humanitarian settings. This study aims to evaluate the effectiveness and implementation of a culturally adapted LSE program delivered through in-person and mobile platforms among IDPs in Northern Nigeria.MethodsThis cluster-randomized hybrid type 2 effectiveness-implementation trial will be conducted in 20 IDP camps or host communities in Maiduguri, Nigeria. Sites will be randomly assigned to receive a 12-week LSE program delivered either through in-person peer support groups or WhatsApp-facilitated mobile groups. The study will recruit 500 participants aged 13 years and older. Intervention effectiveness outcomes include the primary outcome of change in post-traumatic stress disorder (PTSD) symptoms assessed using the PCL-5 scale, and secondary outcomes of depression, anxiety, well-being, and life skills acquisition. Implementation outcomes will be assessed using the Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM). Both sets of outcomes will be compared between the in-person and mobile delivery groups. Quantitative data will be analyzed using mixed-effects linear regression models, while qualitative data will be examined through reflexive thematic analysis. The study will be guided by the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) framework.DiscussionThe RESETTLE-IDPs study addresses key gaps in the evidence base on mental health interventions for conflict-affected populations. It focuses on underserved IDP populations, evaluates the comparative effectiveness of in-person and mobile-delivered LSE, and incorporates implementation science frameworks to assess contextual factors influencing adoption, fidelity, and sustainability. The study employs a community-based participatory approach to enhance cultural relevance, acceptability, and ownership. Findings will inform the development and scale-up of evidence-based, sustainable mental health interventions for IDPs in Nigeria and other humanitarian contexts.Trial sponsorDalhousie University, 6299 South St, Halifax, NS B3H 4R2, Canada.Trial registrationClinicalTrials.gov, NCT06412679 Registered 15 May 2024.

A low-cost digital first aid tool to reduce psychological distress in refugees: a multi-country randomized controlled trial of Self-Help Online in the first months after the invasion of Ukraine

Armed conflicts increase distress levels among affected populations, particularly impacting refugees who often face barriers to accessing psychological support. We evaluate an online version of a previously tested in-person and endorsed for online adaptation by the WHO Self-Help Plus (SH+) program among Ukrainian refugees dispersed across 17 countries, internally displaced and not displaced Ukrainians. This is the first randomized controlled trial to test an online psychological intervention simultaneously on refugees, internally displaced, and non-displaced conflict-affected populations. This study is an online two-arm, individually randomized controlled trial among participants above 18 years old in Ukraine or EU countries who were randomly assigned to receive either the Self-Help Online (SHO) intervention and passive informational resource or the passive informational resource alone. We recruited 652 participants starting the program on July 7th, 2022. The analysis focused on 292 participants who completed the final survey one week after the end of the program. Results indicated significant distress reduction among refugees (β −2.16, 95% CI −4.17 to −0.16; p=0.03; d −0.47) but not among internally displaced in Ukraine (β 0.56, 95% CI −1.1 to 2.99; p=0.17; d 0.2) or non-displaced participants in Ukraine (β 0.2, 95% CI −0.95 to 1.35; p=0.73; d 0.08). The effect size in stress reduction for refugees was comparable to other similar interventions but with lower average costs. The average cost per participant was €11, with €46.16 for each benefiting (refugee) participant, suggesting cost-effectiveness for scale-up. These findings suggest that Self-Help Online is an effective psychological intervention for reducing stress among geographically dispersed refugees at a low cost. We also find that the online delivery format of psychological interventions is feasible for internally displaced and non-displaced conflict-affected populations.

Incidence, outcomes, and predictors of new heart failure in syrian conflict-affected population following hospitalization for atrial fibrillation: A retrospective cohort study.

Atrial fibrillation (AF) is the most common arrhythmia worldwide. Data regarding readmission for new congestive heart failure (CHF) following index admission for AF in the developing world are poorly described. The study aimed to assess the rate, predictors, and outcomes of 120-day CHF readmission after index admission for AF in Syria. This retrospective cohort study collected all adult patients without known CHF who had an index admission with AF to Latakia's tertiary center between June 2021-December 2023. Data were taken from patients' medical notes. The primary outcome included readmission with incident CHF within 120 of index discharge, and secondary outcomes included predictors and outcomes of these CHF readmissions. A total of 660 patients were included in the final analysis, of which 69 (11.7%) were readmitted with new CHF within 120days of index discharge. Readmitted patients had higher median age (58 vs 70years, p < .001). Factors that independently increased 120-day CHF incidence were age ≥60years (HR: 9.8, 95% CI: 4.8-23.6, p < .001), diabetes mellitus (DM) (HR:2.9, 95% CI:1.7-4.9, p < .001), valvular heart disease (VHD) (HR:1.7, 95% CI:1.04-2.78, p = .047), and hypertension (HR:2.5, 95% CI:1.5-4, p < .001). Inpatient mortality occurred in six readmitted patients (9%). LVEF <40% (HR:6.7, 95% CI: 24.31, p = .01) and DM (HR:7.2, 95% CI: 1.9-33, p = .004) were independently associated with inpatient mortality. Hospitalization for new CHF was common in Syrian patients discharged with AF. The clinical predictors of incident CHF emphasize the importance of integrated management of lifestyle risk factors and common comorbidities in AF patients to optimize outcomes in resource-depleted communities.

Possibilities and limitations of anticipatory action in complex crises: acting in advance of flooding in South Sudan.

Little evidence exists on the design and implementation of anticipatory action (AA) in complex crises. This article examines a 2022 United Nations 'early action' pilot in South Sudan in advance of extreme flooding. As a case study of efforts to act in a complex crisis, it contributes to learning on assisting conflict-affected and displaced populations in advance of extreme weather events. The research points towards the possibility and value of implementing forecast-informed early action in complex contexts with limited forecast skills and multiple hazards when trigger-based AA is not possible. It also argues for the need to link AA implemented in complex crises to development and peacebuilding actors and processes. More broadly, examining the perceptions and processes of AA in the form of early action, rather than a formal AA framework, is highly relevant for the AA community as attention is increasingly placed on providing AA in countries affected by fragility and conflict.

The long-lasting effect of armed conflicts deaths on the living: Quantifying family bereavement.

Armed conflicts escalate combatant and civilian mortality and produce considerable levels of family bereavement. Yet, we know little about the prevalence of bereavement in conflict-affected populations. The violent loss of kin affects individuals across several dimensions, including trauma, mental health, socioeconomic status, and caregiving, especially during childhood and old age. Here, we propose a method to quantify population-level loss of parents and offspring in conflict-affected populations. Our analyses demonstrate that bereavement levels consistently surpass fatality rates in 16 conflict-affected settings. Using demographic projections, we show that these populations will continue to experience considerable levels of bereavement in the coming decades, independent of the future development of the respective conflicts. This quantification underscores bereavement as a profound yet understudied consequence of conflict with potentially far-reaching implications lingering long after the conflict's end.

Marital quality in a context of displacement: the role of union formation characteristics among Syrian refugee and Jordanian youth

Marital quality is an important determinant of well-being and is related to how unions are formed. Both processes of union formation and marital relationships may be influenced by stressful conditions, including insecurity and displacement. We leverage unique representative data on young Syrian refugees in Jordan to learn more about the interplay between displacement, union formation characteristics and marital quality. Through comparisons with youth from the Jordanian host population, we assess the role of key contextual predictors of marital quality, such as consanguinity and young people’s role in choosing their spouse, with a focus on gender differences. We measure marital quality with six separate items capturing aspects of equality, respect and interpersonal communication and a unidimensional scale identified through exploratory factor analysis. Results show that consanguinity, marital duration and number of children are generally unrelated to marital quality in both populations. In contrast, involvement in spouse choice emerges as the strongest predictor, with both Syrians and Jordanians in family-arranged unions experiencing lower-quality marriages. Among Syrians, women suffer more from lower marital quality, especially when arranged unions happen at a young age, and marriages formed after displacement to Jordan appear more fragile. The study is one of the first to explore predictors of marital quality in a non-Western, conflict-affected population. The findings emphasise the importance of the demographic study of family dynamics in situations of insecurity and displacement moving beyond a narrow focus on marriage timing to cover a wider range of marriage outcomes related to family well-being.

War-Related Life Course Stress and Late-Life Subjective Age in Northern Vietnam.

The role of early life stressors in subjective aging is weakly understood, especially in low- to middle-income countries. This paper investigated how early life stressors encountered in armed conflict influence subjective age among Vietnamese older adults who experienced war over decades of their early life. We analyzed survey data from the 2018 Vietnam Health and Aging Study involving 2,447 Vietnamese older adults who encountered diverse war-related stressors in early adulthood. The analytical sample (N = 2,341) included 50.9% women and 49.1% men, with an average age of 69.8. 41.1% are military veterans. We conducted survey-adjusted multinomial logistic regression analyses with mediation to predict the probability of feeling younger or older than one's chronological age. We examined how childhood adversity (i.e., childhood hunger and low parental SES) and wartime stressors (i.e., war-related violence, malevolent environment, and military service) influenced late-life subjective age, both directly and as mediated by late-life mental, functional, and physical health. We found significant associations between early adulthood war-related stressors and subjective age. Formal military service significantly lessened the relative risk of feeling subjectively old, and more plentiful wartime violence exposures significantly increased the risk of feeling younger than one's chronological age. Violence exposure's effects were both direct and indirect through functional and mental health. Conversely, greater exposure to wartime malevolent conditions (e.g., shortages of clean water and evacuations) and multiple episodes of severe hunger in childhood increased the risk of feeling older, effects both direct and mediated by late-life functional and mental health. Results suggest wartime stressors, especially war's malevolent environments and severe childhood hunger, experienced in many conflict-affected populations globally, have the potential to subjectively "age" survivors. Yet, not all war exposures are equal, and some may yield psychological and socioeconomic resources that support healthy aging.

Changes in mental health stigma among healthcare professionals and community representatives in Northern Sri Lanka during an mhGAP intervention study.

Research indicates that exposure to conflict, natural disasters, and internal displacement can increase mental health conditions. Since the end of the civil conflict within Sri Lanka, the country has worked to increase access to mental health services to meet the needs of conflict-affected populations, however, gaps remain. To address this, integration of mental health services into primary care can reduce the strain on growing specialized care. As part of a larger study primary care practitioners (doctors), public health professionals (nurses, midwives), and community representatives (teachers, social workers) were trained to deliver mental health services in primary care across the heavily impacted Northern Province. The aim was to reduce mental health stigma among enrolled healthcare workers and community representatives by 50%. Stigma was measured across all participant groups at six time points: pre- and post- initial training at baseline, pre- and post- refresher training 3-months after initial training, and pre- and post- refresher training 6-months after initial training. Results indicate a small improvement in average stigma scores at the 6-month refresher point for primary care practitioners, and no meaningful difference in average scores across time points for public health professionals or community representatives. World Health Organization mhGAP training appears to reduce stigma among primary care practitioners and could be an effective strategy to counteract mental health stigma in low resource settings. Future research should investigate underlying mechanisms of stigma reduction to improve delivery of mental health services in primary care and community settings.

HDP Nexus Outcomes and the Integration of Peace Elements: The Case of Iraq after the ISIL Conflict

ABSTRACT Although new policy frameworks such as the humanitarian-development-peace (HDP) nexus are emerging to better respond to increasingly complex and protracted conflicts and humanitarian crises, analysis of their impact remains limited. We analyse the case of Iraq in the aftermath of the ISIL conflict with data that measures the impact of interventions from across the nexus domains. Results show that humanitarian and development outcomes improved steadily over time, while peace outcomes remained poor and relatively unchanged. Improvement in the ‘soft’ security elements of peace related to social cohesion and coexistence were superseded by a deterioration in ‘hard’ security elements linked to protection of civilians and security configurations over time. These findings are explained by the lack of integration of hard security elements into an otherwise comprehensive international response along HDP Triple Nexus components. Separate hard security interventions rather had a critically different scope focused primarily on counterterrorism without further encompassing the wider range of security issues facing conflict-affected populations, including those internally displaced seeking to return, nor did they consider the diffusion of local powers and actors in this regard. This has left particularly vulnerable displaced and conflict-affected communities without remedy as priorities in the country shift.

Ripe for better post-war governance? The impact of the 2016 peace agreement on the reestablishment of health services in Colombia

A peace agreement represents a chance for the state to renew its social contract with the conflict-affected population. Conflict may reoccur if their expectations of a peace dividend are disappointed. However, in the existing literature there is a lack of focus on post-war public services and the challenges to re-establishing effective state governance, especially in areas with significant rebel presence. Much of the literature still assumes that conflict zones are ripe for better governance and the post-war impact of rebel governance remains largely unanalysed. Drawing on original survey data, interviews and focus groups, this mixed-methods article analyses the impact of the 2016 Colombian peace agreement on health services in areas with high conflict intensity and sustained rebel presence. In the most conflict-affected areas, it finds an increase in demand for health services but no improvement in the perceived quality of this care. In fact, in municipalities hosting FARC reintegration camps, which were specially targeted for improved healthcare, we find a decline in both demand and perceived quality. Three key obstacles are identified: 1) favourable views of wartime healthcare services provided by the FARC; 2) difficulties establishing state presence locally; 3) high expectations and mistrust of government provisions. This demonstrates the lasting impact of wartime rebel governance, and the challenges it poses to post-war state legitimacy, and adds to our knowledge of the underlying mechanisms of uneven state capacity. It thereby makes an important and original contribution to our understanding of peacebuilding obstacles and to the growing literature on rebel governance.

Unpacking gender-specific risk and protective factors for mental health status among Congolese refugees in Uganda

ABSTRACT Background: Research indicates refugees from the Democratic Republic of Congo (DRC), particularly females, have a higher incidence of mental health problems compared to the global norm for conflict-affected populations. Objective: This study aimed to unpack gender differences in the mental health of Congolese refugees by examining specific risk (trauma exposure, adaptation challenges, and discrimination) and protective factors (marital status, literacy, and social resources) in relation to posttraumatic stress symptoms (PTSS) and depression. Method: Utilizing systematic random sampling, we surveyed 667 adult refugees (370 females, 297 males) in the Kyaka II refugee settlement in Western Uganda. A multi-group path analysis was conducted, initially allowing for variance between genders and subsequently comparing a constrained model, where paths were set equal across groups. Results: The unconstrained model presented an excellent fit to the data. When paths were set to be equal across groups, the decline in model fit, confirmed by a chi-square difference test, indicated differences in the model for males and females. A series of Z-tests were used to compare individual paths. Experiencing discrimination was a stronger risk factor for depression among men, whereas a history of rape was more strongly associated with depression for females. Being literate and a member of a social group in the settlement were stronger protective factors for depression among men, whereas living with a partner and a felt sense of connection to their community was more important for women. Associations between risk and protective factors and PTSS were more similar across groups, only membership in a group was significantly moderated by gender; with group membership being more impactful for males. Conclusion: The results highlight similarities and differences in predictors of distress for male and female Congolese refugees and point to potential avenues for tailoring programming to be gender sensitive.

Measuring refugees’ capabilities: translation, adaptation, and valuation of the OxCAP-MH into Juba Arabic for use among South Sudanese male refugees in Uganda

BackgroundForcibly displaced populations are highly vulnerable to psychosocial distress and mental disorders, including alcohol misuse. In an ongoing trial that seeks to develop a transdiagnostic intervention addressing psychological distress and alcohol use disorders among conflict-affected populations, we will carry out a cost-effectiveness evaluation using a capability-based Oxford Capabilities Mental Health (OxCAP-MH) measure. The OxCAP-MH is a 16-item questionnaire developed from the Capability Approach, that covers multiple domains of functioning and welfare. The aim of the current paper is to present the results of the translation, cultural adaptation and valuation of the OxCAP-MH into Juba Arabic for South Sudanese refugees living in Uganda.We adhered to the official Translation and Linguistic Validation process of the OxCAP-MH. To carry out the translation, the Concept Elaboration document, official English version of the OxCAP-MH, and the Back-Translation Review Template were used. Four independent translators were used for forward and back translations. The reconciled translated version was then piloted in two focus group discussions (N = 16) in Rhino refugee settlement. A most important to least important valuation of the sixteen capability domains covered in the OxCAP-MH was also done.ResultsThe Juba Arabic version of the OxCAP-MH was finalized following a systematic iterative process. The content of the Juba Arabic version remained unchanged, but key concepts were adapted to ensure cultural acceptability, feasibility, and comprehension of the measure in the local context of Rhino refugee settlement. Most participants had low levels of literacy and required support with filling in the tool. Participants suggested an additional capability that is currently not reflected in the OxCAP-MH, namely access to food. Furthermore, discussions around the valuation exercise of the sixteen domains led to two separate importance scales, which showed relevant differences.ConclusionsIn this context, the OxCAP-MH was considered culturally acceptable. The valuation exercise proved cognitively demanding. Participants voiced confusion over how to answer the questions on the OxCAP-MH instrument due to low levels of literacy. These concerns invite consideration for future research to consider how measures such as the OxCAP-MH can be made more accessible to individuals with low literacy rates in resource poor settings.

Experiences of trauma, stress, and resilience in indigenous mental health workers operating among refugee and conflict-affected populations on the Thai–Myanmar border: A descriptive phenomenological analysis.

Experiences of trauma, stress, and resilience in indigenous mental health workers operating among refugee and conflict-affected populations on the Thai–Myanmar border: A descriptive phenomenological analysis.

A Low-Cost, Integrated Immunization, Health, and Nutrition Intervention in Conflict Settings in Pakistan-The Impact on Zero-Dose Children and Polio Coverage.

Pakistan is one of two countries globally still endemic for poliovirus. While increasing immunization coverage is a concern, providing equitable access to care is also a priority, especially for conflict-affected populations. Recognizing these challenges, Naunehal, an integrated model of maternal, newborn, and child health (MNCH), immunization, and nutrition services delivered through community mobilization, mobile outreach, and private-sector engagement was implemented in conflict-affected union councils (UCs) with high poliovirus transmission, including Kharotabad 1(Quetta, Balochistan) and Bakhmal Ahmedzai (Lakki Marwat, Khyber Pakhtunkhwa). A quasi-experimental pre-post-design was used to assess the impact of the interventions implemented between April 2021 and April 2022, with a baseline and an endline survey. For each of the intervention UCs, a separate, matched-control UC was identified. At endline, the proportion of fully immunized children increased significantly from 27.5% to 51.0% in intervention UCs with a difference-in-difference (DiD) estimate of 13.6%. The proportion of zero-dose children and non-recipients of routine immunization (NR-RI) children decreased from 31.6% to 0.9% and from 31.9% to 3.4%, respectively, with a significant decrease in the latter group. Scaling up and assessing the adoption and feasibility of integrated interventions to improve immunization coverage can inform policymakers of the viability of such services in such contexts.

Trends in mental health before and after the onset of the COVID-19 pandemic: a longitudinal survey of a conflict-affected population in Colombia

BackgroundFocusing on the Meta region in Colombia, we investigated the relationship between mental health, the COVID-19 pandemic, and social determinants of health influenced by over five decades of civil conflict. We studied the post-2016 peace agreement trends in mental health for the population of Meta, before and after the local onset of the pandemic.MethodWe conducted three rounds of a longitudinal health survey in years 2018 with N = 1309 (Women = 709; Men = 600); 2019 with N = 1106 (Women = 597; Men = 509); and 2020 with N = 905 (Women = 499; Men = 406). We measured mental health through the Self-Report Questionnaire (SRQ-20), investigating population trends in the average SRQ score and SRQ-positive frequency (SRQ + , indicating positive tendency towards experiencing mental health disorders).ResultsBetween 2018 and 2020, there were reductions in the mean SRQ-20 score by 1.74 points (95% CI -2.30 to -1.18) and in SRQ + frequency by 15 percentage points (95% CI -21.0 to -9.0) for the Meta population. Yet specific subgroups have become more vulnerable to mental illness during the pandemic, for example older age groups (e.g., increase in mean SRQ score among over 60 s by 2.49 points, 95% CI 0.51 to 4.46) and people living with children younger than five years-old (e.g., increase in mean SRQ score by 0.64 points, 95% CI 0.07 to 1.20). Increased mental health vulnerability among specific subgroups may be related to differences in the likelihood of knowing people who tested positive for COVID-19 or died from itf having been in quarantine.ConclusionOur findings support the importance of public policies in Colombia (and other low- and middle-income countries) that address the social determinants of mental illness whose influence was likely exacerbated by the pandemic, including persistent job insecurity leading to work and financial pressures, and inadequate support networks for isolated individuals and vulnerable caregivers.

COVID-19 Induced Ethnographic Distance: Remote Fieldwork, Ethical Challenges and Knowledge Production in Conflict-Affected Environments

Post-conflict ethnographic research thrives on bodily immersion in a field site to interact and observe how conflict-affected people navigate and make sense of their world. Therefore, ethnography and distance or ethnographic distance is an oxymoron. Physical immersion in the field has the advantage of generating situated knowledge as the researcher comes to know his situation/location in the field in relation to the social location, conditions, and identities of the researched and all those involved in the knowledge production. Hence, physical presence is desirable for the study of conflict-affected populations. However, when being in the field is dangerous or impossible, the researcher can adapt without losing the key insights that physical immersion provides. COVID-19 research travel restrictions made it impossible for me to travel to Uganda, a post-conflict setting, to conduct fieldwork for my doctoral studies. I had to re-scope my original research design to conduct remote fieldwork. This raised additional ethical challenges associated with fieldwork in such settings. This article reflects on my experience collaborating with two local research assistants (RAs) to conduct remote fieldwork in Northern Uganda. First, my overall ethical responsibility was based on a commitment not to transfer all the risks to the RAs. I formulated my ethical decisions around payment, workload, and the wellbeing of the RAs. Second, remote fieldwork meant that the RAs were the brokers, interviewers, interpreters, transcribers, and translators. These expanded roles significantly impacted the knowledge production processes. To account for this, I asked the RAs to write reflexive statements to situate themselves in the research. I discussed their reflexive statements around their roles as brokers, interviewers and language translators/interpreters and how each impacted knowledge production. The analysis shows that COVID-19 accelerated the localisation of peacebuilding research and provided an opportunity to re-think issues of power relations, local capacity, and gatekeeping.

Setting research priorities for prevention and response to child marriage in communities in the Arab region: findings from a multi-stage Delphi study involving practitioners across the region

Globally, more than 12 million girls under the age of 18 are forced to marry every year. Progress on ending child marriage in the Arab region is slowing, and risks being reversed, due to an increase in conflict-affected populations and widespread economic crisis. The aim of this paper is to consider the research priorities across the region to inform effective and accelerated child marriage prevention and response programming within the Arab region. Seventy-three specialists supporting child marriage prevention and response programming in the Arab region engaged with up to three phases of an online Delphi consultation process on research gaps and the research environment between July 2019 and December 2021. Proposals of research gaps were elicited, reviewed, and rated by participants to confirm a shared learning agenda. Participants identified 50 different research gaps across 7 main areas, reaching a high level of consensus support for 23 of 50 statements. Clear consensus was reached in relation to an increased need to produce and use evidence to support programme development, and further research on specific drivers and consequences of child marriage. The least consensus was found in relation to how research can inform prevention and response efforts within the law and legal system. The results provide the foundation of a child marriage research agenda for the Arab region which takes into account regional distinctiveness and builds on the global momentum for child marriage research. Mechanisms are in place to do this through the Regional Action Forum, and other networks across the region.

“Actually, the psychological wounds are more difficult than physical injuries:” a qualitative analysis of the impacts of attacks on health on the personal and professional lives of health workers in the Syrian conflict

IntroductionAttacks on healthcare in armed conflict have far-reaching impacts on the personal and professional lives of health workers, as well as the communities they serve. Despite this, even in protracted conflicts such as in Syria, health workers may choose to stay despite repeated attacks on health facilities, resulting in compounded traumas. This research explores the intermediate and long-term impacts of such attacks on healthcare on the local health professionals who have lived through them with the aim of strengthening the evidence base around such impacts and better supporting them.MethodsWe undertook purposive sampling of health workers in northwest and northeast Syria; we actively sought to interview non-physician and female health workers as these groups are often neglected in similar research. In-depth interviews (IDIs) were conducted in Arabic and transcribed into English for framework analysis. We used an a priori codebook to explore the short- and long-term impacts of attacks on the health workers and incorporated emergent themes as analysis progressed.ResultsA total of 40 health workers who had experienced attacks between 2013 and 2020 participated in IDIs. 13 were female (32.5%). Various health cadres including doctors, nurses, midwives, pharmacists, students in healthcare and technicians were represented. They were mainly based in Idlib (39.5%), and Aleppo (37.5%) governorates. Themes emerged related to personal and professional impacts as well as coping mechanisms. The key themes include firstly the psychological harms, second the impacts of the nature of the attacks e.g. anticipatory stress related to the ‘double tap’ nature of attacks as well as opportunities related to coping mechanisms among health workers.ConclusionViolence against healthcare in Syria has had profound and lasting impacts on the health workforce due to the relentless and intentional targeting of healthcare facilities. They not only face the challenges of providing care for a conflict-affected population but are also part of the community themselves. They also face ethical dilemmas in their work leading to moral distress and moral injury. Donors must support funding for psychosocial support for health workers in Syria and similar contexts; the focus must be on supporting and enhancing existing context-specific coping strategies.