Conflict-affected Populations Research Articles

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

Abstract Background and Objectives 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. Research Design and Methods 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. Results 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. Discussion and Implications 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.

Forcibly 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. The 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. In 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.

Cango Lyec (Healing the Elephant): HIV Prevalence and Vulnerabilities Among Adolescent Girls and Young Women in Postconflict Northern Uganda.

Adolescent girls and young women younger than 25 years (AGYW) account for disproportionate HIV infections in sub-Saharan Africa. Impacts of war in Northern Uganda continue to affect HIV-related health and wellbeing of young people postconflict. Prevalence and incidence of HIV infection were estimated, and factors associated with HIV prevalence among sexually active AGYW in Northern Uganda were investigated. Cango Lyec is a cohort involving conflict-affected populations in Northern Uganda. Nine randomly selected communities in Gulu, Nwoya, and Amuru districts were mapped. House-to-house census was conducted. Consenting participants aged 13-49 years were enrolled over 3 study rounds (2011-2015), of whom 533 were AGYW and had ever had sex. Data were collected on trauma, depression, and sociodemographic-behavioral characteristics. Venous blood was taken for HIV and syphilis serology. Multivariable logistic regression determined baseline factors associated with HIV prevalence. HIV prevalence among AGYW was 9.7% (95% CI: 7.3 to 12.6). AGYW living in Gulu (adjusted risk ratio, aRR: 2.48; 95% CI: 1.12 to 5.51) or Nwoya (aRR: 2.65; 95% CI: 1.03 to 6.83) were more likely than in Amuru to be living with HIV. Having self-reported genital ulcers (aRR: 1.93; 95% CI: 0.97 to 3.85) or active syphilis (aRR: 3.79; 95% CI: 2.35 to 6.12) was associated with increased risk of HIV infection. The likelihood of HIV was higher for those who experienced sexual violence in the context of war (aRR: 2.37; 95% CI: 1.21 to 4.62) and/or probable depression (aRR: 1.95; 95% CI: 1.08 to 3.54). HIV incidence was 8.9 per 1000 person-years. Ongoing legacies of war, especially gender violence and trauma, contribute to HIV vulnerability among sexually active AGYW. Wholistic approaches integrating HIV prevention with culturally safe initiatives promoting sexual and mental health in Northern Uganda are essential.

Prevention and promotion effects of Self Help Plus: secondary analysis of cluster randomised controlled trial data among South Sudanese refugee women in Uganda

IntroductionEvidence-based and scalable prevention and promotion focused mental health and psychosocial support interventions are needed for conflict-affected populations in humanitarian settings. This study retrospectively assessed whether participation in Self Help...

Alcohol and other drug use patterns and services in an integrated refugee settlement in Northern Zambia: a formative research study

BackgroundEvidence on patterns of alcohol and other drug (AOD) use and how to effectively deliver services to address AOD use in humanitarian settings is limited. This study aimed to qualitatively explore the patterns of AOD use among Congolese refugees in Mantapala Refugee Settlement and members of the surrounding host community and identify potential appropriate intervention and implementation approaches to address AOD use disorders among conflict-affected populations.MethodsFifty free listing interviews, 25 key informant interviews, and four focus group discussions were conducted among refugees, host community members, humanitarian implementing agency staff, and refugee incentive workers. These participants were selected based on their knowledge of AOD use and related problems in the settlement and the surrounding host community in northern Zambia.ResultsCannabis and home-brewed alcohol were the substances that were perceived to be most commonly used and have the greatest impact on the community. Participants reported that self-medication, boredom, and relief of daily stressors associated with lack of housing, safety, and employment were reasons that people used AODs. Participants recommended that programming include components to address the underlying causes of AOD use, such as livelihood activities. Stigma due to the criminalization of and societal ideals and religious beliefs regarding AOD use was identified as a substantial barrier to accessing and seeking treatment.ConclusionsOur study’s findings indicate the need for services to address AOD use in Mantapala Refugee Settlement. Interventions should consider the social and structural determinants of AOD use.

How do the emotional and embodied experiences of international interveners influence their understanding and practice of peacebuilding?

What happens if international interveners feel emotions that they consider unsanctioned, unwanted and unprofessional? What if they enact and manage their emotions in ways that they – or others – deem unacceptable? If international interveners face anxiety about being ‘too emotional’ or not feeling or expressing the ‘right’ emotions, does this challenge their sense of identity? And what consequences could this have for peacebuilding and the conflict-affected population in which they were working? Building on the growing body of critical peace and conflict scholarship that has analysed international interveners at the micro-scale, this article analyses how individual interveners’ emotional and embodied experiences influence their understanding and practice of peacebuilding. Based on a discourse analysis of the memoirs of 10 international interveners, this article identifies two primary interpretive repertoires that the interveners employed and argues that they generated two ideal-type subject positions: the intervener as objective, rational, technocratic ‘expert’ and the intervener as irrational, fallible, vulnerable ‘human’. These subject positions determined the feeling rules that the interveners followed and the dilemmas they faced. This, in turn, affected how the interveners perceived the conflict-affected societies in which they were working, and how they understood and practised peacebuilding.

Challenges of COVID-19 prevention during protracted conflicts: differential adherence to preventive measures in "contact line" regions in eastern Ukraine.

Despite the epidemiological importance of social vulnerabilities in compliance with preventive measures, little is known about the disproportional nature of preventive behaviors in crisis-affected populations. We examined adherence to COVID-19 preventive behaviors, focusing on social distancing measures in the conflict-affected regions in eastern Ukraine. From a multisectoral needs assessment conducted in 2020 using a household interview of a stratified simple random sample, we included 1,617 rural and urban households located in the government-controlled area. We performed multivariable binary logistic regression analysis with latent class analysis (LCA) to identify unmeasured patterns of classification of preventive measures using data from a cross-sectional survey. The conflict-affected populations showed difficulty in complying with COVID-19 preventive measures due to losses of housing, partners, and access to food resources due to conflicts. Among the various preventive measures, wearing a face mask (88.1%) and washing hands more regularly (71.4%) were the most frequently reported. Compliance with social distancing was significantly lower in those who experienced the direct impacts of conflicts indicated by damaged accommodation or being widowed. Three different groups who showed distinctive patterns of employing COVID-19 preventive measures were identified via the LCA model, which were "highly complying group", "moderately complying group", and "face masks only group". The group membership was associated with a respondent's poverty status. The findings show the difficulty in compliance with COVID-19 preventive measures among conflict-affected populations indicating secondary impacts of the conflicts on preventive health behaviors. To mitigate the health impacts of conflicts, immediate attention is needed to address barriers to COVID-19 preventive measures among conflict-affected populations in Ukraine. This study suggests the need for public health strategies to improve preventive health behaviors in conflict-affected populations under pandemics or large-scale outbreaks.

Providing person-centered palliative care in conflict-affected populations in the Middle East: What matters to patients with advanced cancer and families including refugees?

Universal health coverage highlights palliative care as an essential component of health services. However, it is unclear what constitutes person-centered care in populations affected by conflict, as they may have specific concerns in the dimensions of physical, emotional, social, and spiritual wellbeing. This study aimed to identify what matters to patients with advanced cancer and family caregivers in Jordan including refugees, to inform appropriate person-centered assessment and palliative care in conflict-affected populations. Cross-sectional face-to-face, semi-structured interviews were conducted at two sites in Amman. Adult patients with advanced cancer and family caregivers were purposively sampled to maximize diversity and representation. Interviews were digitally audio recorded, anonymized, and transcribed verbatim for thematic analysis. Four themes were generated from 50 patients (22 refugees; 28 Jordanians) and 20 caregivers (7 refugees; 13 Jordanians) (1). Information, communication, and decision-making. Truth-telling and full disclosure from clinicians was valued, and participants expressed concerns that information was not shared in case patients would disengage with treatment. (2) Priorities and concerns for care and support. Participants' top priority remained cure and recovery (which was viewed as possible). Other priorities included returning to their "normal" life and their "own" country, and to continue contributing to their family. (3) Role of spirituality and Islam. Most participants had strong faith in God and felt that having faith could comfort them. For refugees whose social network was fractured due to being away from home country, prayer and Quran reading became particularly important. (4) Unmet support needs of family caregivers. Family caregivers were affected physically and emotionally by worrying about and caring for the patients. They needed support and training, but often could not access this. Truth-telling is highly valued and essential to achieving person-centered care and informed decision-making. This study also reveals specific concerns in conflict-affected populations, reflecting the experience of prior losses and fracturing of existing social networks and support. The role of religion is crucial in supporting refugee communities, and consideration should be paid to the needs of patients and caregivers when caring for a patient at home without access to their communities of origin and the support they accessed.

Humanitarian Food Assistance and Nutrition Outcomes among Refugees: A Historical Perspective

Background: Humanitarian interventions are done after a significant disruption of people’s daily life which in turn affect their food security and nutrition needs. Food assistance has become a key element of humanitarian aid to conflict-affected populations. Hunger and undernutrition can significantly worsen during situations of prolonged conflicts and where institutional capacities are weak. Humanitarian food aid provided in the form of food or non-food items for people affected by famine, drought, or natural disaster is intended to feed, shelter, and provide legal protection. Malnutrition in children is related to insufficient food intake, poor food quality, and severe or repeated infectious diseases. Therefore, humanitarian food assistance is given to ensure sufficient, safe, and nutritious food is consumed to prevent malnutrition and prevent death.
 Objectives: This paper seeks to understand the following specific objectives; to explore the evolution of humanitarian food assistance or food aid; to gain an understanding of the contemporary views on humanitarian food assistance; to explore the comparative views on humanitarian food assistance, and to find out the implications of shifting from Food Aid to Food Assistance.
 Study Design/Method: Secondary data collection method was used and both published and official documents were reviewed based on the objectives of this paper, and relevant information was picked. The review provides evidence on the benefits as well as gaps related to humanitarian food assistance interventions and their relationship with the nutrition status of children below the age of five years.
 Results: Food in-kind directly impacts positively on the nutrition status of households and influences the coping mechanisms of the affected populations. In Mali, a study found food transfers exert a protective effect on food-insecure populations in conflict situations and increased micro-nutrient availability. Another study found improvement in nutrition status among children in Myanmar, Kenya, Niger, and South Sudan. While global acute malnutrition (GAM) in Myanmar declined from 6.6% to 2.6% and from 7.5% to 4.7%, in Niger, GAM rates declined from 21.3% to 13.6%, and 11.4% to 7.3% in Kenya and South Sudan, a decline of 6% GAM. Also, a study on the “impact of cash transfers on food consumption in humanitarian settings found cash transfer” is an appropriate and effective modality in humanitarian settings for meeting the needs of vulnerable populations.
 Conclusion: The strategic shift from food aid to food assistance has the potential to enhance effectiveness in addressing hunger because there is increased use of non-food aid in operational modalities and other initiatives to enhance local production and purchase, and the use of vouchers and cash transfers in humanitarian response.

Cancer diagnosis in areas of conflict.

To date, many Arab countries within the Middle East are facing political, financial, and social instability from war and conflicts. These conflicts have led to severe resources shortages and sometimes complete breakdowns in cancer care and diagnosis. Cancer diagnosis at early stages is the most vital step in achieving optimal cancer care and outcomes. Shortages in cancer diagnostic services have meant that many people within areas of conflict are ultimately deprived of these services in their own countries. Therefore, many of these cancer sufferers must bear travel expenses to neighboring countries in order to seek these services. A lack of prevention, screening, and diagnostic services for this population is known to deepen the cancer care deficit within these areas. Additionally, the financial burden of traveling abroad alongside the need to secure childcare and time off work can be overwhelming. As a result, patients within areas of conflict are frequently diagnosed at later stages and are less likely to receive optimal management plans. Though conflict-affected regions encounter many similar challenges in delivering quality cancer care, pronounced region-specific differences do exist. Therefore, it is important to build a roadmap that can provide tailored solutions to deficits in instruments, manpower, and facilities for each and every region involved. Keeping in mind the importance of collaboration and coordination on national and international levels to address the ground disparity in cancer diagnostic services, the main objective of this review article is to examine the significant problems, shortages, and difficulties in providing cancer diagnosis with a focus on imaging to conflict-affected populations in the Middle East (mainly Iraq, Syria, Yemen, and Sudan). Finally, we discuss how access to cancer diagnostic imaging services has been impacted by these conflicts.