Conflict-affected Populations Research Articles

Health system governance in settings with conflict-affected populations: a systematic review.

Health system governance has been recognized as critical to strengthening healthcare responses in settings with conflict-affected populations. The aim of this review was to examine existing evidence on health system governance in settings with conflict-affected populations globally. The specific objectives were (1) to describe the characteristics of the eligible studies; (2) to describe the principles of health system governance; (3) to examine evidence on barriers and facilitators for stronger health system governance; and (4) to analyse the quality of available evidence. A systematic review methodology was used following Preferred Reporting Items for Systematic Review and Meta-Analysis criteria. We searched six academic databases and used grey literature sources. We included papers reporting empirical findings on health system governance among populations affected by armed conflict, including refugees, asylum seekers, internally displaced populations, conflict-affected non-displaced populations and post-conflict populations. Data were analysed according to the study objectives and informed primarily by a governance framework from the literature. Quality appraisal was conducted using an adapted version of the Mixed Methods Appraisal Tool. Of the 6511 papers identified through database searches, 34 studies met eligibility criteria. Few studies provided a theoretical framework or definition for governance. The most frequently identifiable governance principles related to participation and coordination, followed by equity and inclusiveness and intelligence and information. The least frequently identifiable governance principles related to rule of law, ethics and responsiveness. Across studies, the most common facilitators of governance were collaboration between stakeholders, bottom-up and community-based governance structures, inclusive policies and longer-term vision. The most common barriers related to poor coordination, mistrust, lack of a harmonized health response, lack of clarity on stakeholder responsibilities, financial support and donor influence. This review highlights the need for more theoretically informed empirical research on health system governance in settings with conflict-affected populations that draws on existing frameworks for governance.

Family Socialization and Experiences of Early Childhood Programs in the Rohingya Camps: Study Protocol

Objective of Protocol: The primary objective of this protocol is to record the process of conceptualizing a semi-structured interview protocol, training enumerators on the protocol, collecting data, translating findings into English, and analyzing data in English and Bengali, in a study of family socialization among a stateless and conflict-affected population, Rohingya refugees, in Cox’s Bazar, Bangladesh. Research Questions of Study: (1) What are the socialization goals that mothers have for their children, and how do they perceive these goals in relation to their future or current roles as caregivers? (2) What are parents’ experiences with their children’s participation in Humanitarian Play Labs (education/child care provisions in the camps), and what are their perceptions of how their child’s participation in the programs has influenced their child/family? (3) What were the experiences of parents with their children as they migrated from Myanmar to Bangladesh? Design of Study: The design of the study involved a qualitative grounded theory approach based on an analysis of the participants’ responses to a semi-structured interview protocol. Study population: Participants included a purposive sample of 28 mother/father dyads in the Rohingya camps in Cox’s Bazar.

Feasibility and relatability of cultural adaptation amongst conflict-affected populations

Cultural aspects, such as cultural values and specific stressors, need to be considered in intervention development of care.11Resnicow, K. (1999). Cultural sensitivity in public health: defined and demystified. Ethnicity & Disease. One study looked at the relevance and necessity of cultural adaptation in mental health interventions, and the results were conclusive. They found that for populations the intervention was not designed for, treatment was less effective than for the target population.22Benish, S.G. (2011). Culturally adapted psychotherapy and the legitimacy of myth: a direct-comparison meta analysis. Journal of Counselling Psychology. Existing mental health programs well established in developed countries, with a low-threshold for quality care and a flexible delivery of the care, have shown to be less effective for marginalized populations and refugees, where linguistic and cultural barriers still exist. These barriers include limited understanding of treatment, a lack of knowledge on the healthcare systems in host countries, and the lack of interpreters or programs available in their native language.33Marrone, S. (2007). Understanding barriers to health care: a review of disparities in health care services among indigneous populations. International Journal of Circumpolar Health. A promising approach for culturally-informed treatment are short skills-training interventions, designed to help participants better cope with stress and build up resilience to successfully deal with new challenges. START NOW is an evidence-based integrative skills training program and an effective treatment for vulnerable adolescents in demanding situations. We designed a total of eleven characters and fifthteen storylines that reflect the negative experiences commonly experienced by the target beneficiaries, and then conducted content testing to identify the most relatable among them. By conducting content testing, we can culturally adapt the START NOW program to meet the needs of Persian and Afghans migrants, informed by the very community that the program seeks to help. The results identified the six most relatable characters and twelve most relatable storylines, which will go on to feature in START NOW intervention sessions, and improve outcomes in testing the adapted program's efficacy with participants in Switzerland. This study provided a greater understanding of the challenges and emotions experienced by Persian and Afghan migrants, and enables us to design an effective, culturally-relevant treatment to address symptoms of poor mental health amongst this population. We can now replicate this process when adapting evidence-based treatments for other populations in need.

Food systems science for peace and security: Is research for development key for achieving systematic change?

This paper uses CGIAR research as an example to demonstrate the potential of food systems science to contribute to conflict prevention and peacebuilding. Conflict often arises through a complex process whose triggers and consequences are closely interconnected in feedback loops and linked to climate variability, environmental degradation and food insecurity. Conflicts are often approached from a symptomatic rather than a holistic perspective. We (i) review the literature on climate security to identify conflict pathways and related drivers. This serves as the basis for mapping CGIAR and partner research related to climate security through a portfolio review (ii) and facilitated multidisciplinary expert panel discussions (iii). We then define cross-cutting priorities for the future direction of climate security debates, policies and programmes and link them to the new One CGIAR strategy. Conflicts pathways related to food systems, migration and weak governance were among the most studied conflict drivers found in the literature. The same drivers are also frequently studied by CGIAR and addressed by conveying knowledge and tools on disaster- risk reduction, climate change adaptation and livelihood resilience, among others. Four cross-cutting priorities for peacebuilding emerged from the panel discussions: (1) integrating food systems science into policy conversations; (2) bridging the gap between food systems science and security through data and new technologies; (3) financing to build sustainable livelihoods for conflict-affected populations; and (4) multidisciplinary partnerships. CGIAR, its many partners and partner research and development initiatives, are well positioned to demonstrate the potential of food systems science to contribute to peacebuilding.

Challenges of delivering reproductive health services to forced displaced populations

BackgroundOf the 80 million forced displaced persons worldwide, women and children bear greater morbidity and mortality, especially in conflict-affected regions. This is due to disruption in health service provision, breakdown of social institutions and increase in sexual and gender-based violence. Reproductive health (RH) service delivery as part of humanitarian health cluster services is outlined in the Minimum Initial Service Package (MISP). This study explores the challenges of delivering RH services to forced-displaced populations, focussing on field level stakeholders in humanitarian settings.MethodsQualitative semi-structured interviews were conducted with stakeholders from non-governmental and United Nations agencies involved in delivering RH services to conflict-affected populations. Additionally, a scoping review, using the Arksey and O'Malley framework, of the literature was also conducted reviewing challenges of delivering RH programmes to women in forced displaced populations. An inductive and deductive thematic approach was used in data analysis.ResultsEleven key informants (KIs) were interviewed from six conflict-affected countries including Syria, Afghanistan and Libya. Main emerging themes were: 1. Poor awareness of international guidelines (including the MISP) 2. Service provision barriers including lack of human resources 3. Attitudes towards SRH and women's rights 4. Disruption of health services due to COVID-19.ConclusionsThis study has highlighted the main challenges that the humanitarian actors delivering RH programmes in conflict-affected settings face. Implementation of international guidelines remains a key barrier. Key policy recommendations would be to standardise training for all RH providers, prioritise training in the MISP and address cultural attitudes towards RH. Further research exploring the use of WHO's essential medicines for RH and the long-term impact of COVID-19 on forced displaced females needs to be conducted.Key messages Providing basic essential reproductive health services to conflict affected populations remains a challenge, including implementation of standardised international guidance through the MISP.One key policy recommendation would be to prioritise training in MISP for conflict-affected humanitarian settings to ensure it is offered as part of the essential package.

A systematic review evaluating HIV prevalence among conflict-affected populations, 2005-2020.

Historically, there has been concern that conflict may exacerbate the HIV epidemic. We conducted a systematic review to examine HIV prevalence in conflict-affected populations compared to district-level or countrywide HIV prevalence. Following PRISMA guidelines, studies presenting original HIV prevalence data published between 2005 and 2020 were drawn from PubMed, Scopus, and Embase. Data extracted included HIV prevalence, methods, dates, location, and population type. Studies were assessed for bias. Ten met criteria for data extraction; all focused on populations in sub-Saharan African. Most of the studies reported on mixed population settings while one was in a refugee camp. Six reported HIV prevalence higher than district- or country-level prevalence, while four reported lower HIV prevalence. Seven demonstrated moderate-to-high likelihood of bias in sampling, and five used methods limiting their comparability with local HIV prevalence. The relationship between armed conflict and HIV prevalence remains difficult to evaluate and likely varies by socioeconomic indicators.

It’s the Little Things: The Role of International Interveners in the Social (re)Construction of the International Peace Architecture

ABSTRACT Much peace and conflict scholarship groups individual international interveners together as ‘the international’, treating them more as an ideational structure – the international peace architecture – than as individual agents. This article brings foreign policy analysis scholarship into conversation with constructivist scholarship to propose analytical questions that can be used to study the role that individual international interveners play in socially constructing the international peace architecture. It proposes questions at both the micro scale of individual international interveners and the meso scale of the international peace architecture, that is, the organisations that make peacebuilding policy and practice peacebuilding work. Analysis guided by these questions could inform future considerations of what peacebuilding means, who is a suitable candidate for performing peacebuilding work, the way that peacebuilding is practiced, and ultimately on the security of the conflict-affected populations in which peacebuilding interventions are conducted.

Patterns of conflict-related trauma exposure and their relation to psychopathology: A person-centered analysis in a population-based sample from eastern DRC

Populations in war-torn regions are exposed to a wide array of traumatic events that can cause an enormous psychological burden. Individual characteristics influence the likelihood of being exposed to certain events, pointing to systematic interindividual differences in trauma exposure. However, there is a dearth of studies examining potential patterns of trauma exposure in war regions. In this cross-sectional epidemiological study, we applied a person-centered approach to identify patterns in the exposure to conflict-related traumatic events and determine their impact on commonly reported mental health problems in a population-based sample (N ​= ​1000) from the eastern Democratic Republic of Congo. We implemented multi-stage random cluster sampling to randomly select adults from 100 villages. Of 1000 adults (Mage ​= ​43.19 years) included in the study, 50% were female. Results showed high prevalence of PTSD (17.0%), depression (27.8%), anxiety (25.4%) and suicidality (15.1%) following exposure to conflict-related traumatic events since 2002. Latent Class Analysis identified three distinct classes of trauma exposure: Class 1 “low-trauma-exposure” (51.4%, n ​= ​514) was characterized by the lowest probabilities of trauma exposure. Class 2 “non-physical-trauma” (39.1%, n ​= ​391) consisted of individuals with a high probability for exposure to non-physical trauma types only. Class 3 “interpersonal-trauma” (9.5%, n ​= ​95) had the overall highest probability of exposure to traumatic events and was the only class affected by interpersonal-trauma types. Class membership was related to gender, age and place of living. Vulnerability to mental health problems increased from low-trauma-exposure to non-physical-trauma to interpersonal-trauma class. Our findings indicate that the exposure to traumatic events in conflict-affected populations underlies distinct patterns, with interpersonal trauma as a distinguishing marker. Vulnerability to psychopathology varies with trauma patterns, revealing patterns that include both non-physical and interpersonal traumata as most detrimental for mental health. Identification of underlying trauma patterns and their effects may improve mental health care in war-affected populations.

EHealth for service delivery in conflict: a narrative review of the application of eHealth technologies in contemporary conflict settings.

The role of eHealth in conflict settings is increasingly important to address geographic, epidemiologic and clinical disparities. This study categorizes various forms of eHealth usage in conflict and aims to identify gaps in evidence to make recommendations for further research and practice. The analysis was carried out via a narrative hermeneutic review methodology. Articles that fulfilled the following screening criteria were reviewed: (1) describing an eHealth intervention in active conflict or ongoing insurgency, (2) an eHealth intervention targeting a conflict-affected population, (3) an e-learning platform for delivery in conflict settings and (4) non-interventional descriptive reviews relating to eHealth in conflict. Of the 489 papers eligible for screening, 46 merited final inclusion. Conflict settings described include Somalia, Sudan, Afghanistan, Syria, Iraq, Pakistan, Chechnya, Gaza and the Democratic Republic of Congo. Thirty-six studies described specific eHealth initiatives, while the remainder were more generic review papers exploring general principles. Analysis resulted in the elucidation of three final categories of current eHealth activity in conflict-affected settings: (1) eHealth for clinical management, (2) e-learning for healthcare in conflict and (3) eHealth for information management in conflict. Obvious disparities in the distribution of technological dividends from eHealth in conflict are demonstrated by this review. Conflict-affected populations are predominantly subject to ad hoc and voluntary initiatives delivered by diaspora and civil society organizations. While the deployment of eHealth technologies in conflict settings is increasingly normalized, there is a need for further clarification of global norms relating to practice in this context.

Health-related quality of life of a conflict-affected population in Colombia

PurposeWe assessed the validity of the EQ-5D instrument; explored correlations between area of residence’s conflict intensity and individual health-related quality of life (HRQoL); and identified factors associated with HRQoL in a conflict-affected population in Colombia.MethodsWe conducted a household survey among residents of the Meta province, collecting longitudinal information about HRQoL (EQ-5D-3L instrument), health, demographic and socio-economic indicators, for years 2014 (pre-2016 peace accord), 2018 (post-peace accord) and 2019 (follow-up). After examining EQ-5D’s validity, we analysed panel data using multivariate random effects models to explore associations between area conflict levels (and other factors) and HRQoL. We scrutinised these results further through multivariate linear regressions using cross-sectional data, and provided preliminary estimates of quality-adjusted life years (QALYs) gained since the Colombian peace accord.ResultsIn total, 1309 individuals provided information for years 2014 and 2018; 1106 individuals were followed-up in 2019. Mean EQ-5D scores in 2014, 2018 and 2019 were 0.898, 0.846 and 0.902, respectively. The tests confirmed the validity of EQ-5D. Our estimations indicated a dose–response relationship between conflict levels and HRQoL: people in lightly and heavily affected areas had 0.019 and 0.037 lower EQ-5D scores (respectively) than people in non-affected areas. Other relevant factors included age, marital status, education, assets and health status. We estimated QALY gain of 0.0343 per individual and 20,752 for all Meta adults since the peace accord.ConclusionWe found EQ-5D to be a valid instrument for HRQoL measurement in a conflict-affected population. Area conflict intensity was negatively associated with individual HRQoL.

Delivering maternal and neonatal health interventions in conflict settings: a systematic review

BackgroundWhile much progress was made throughout the Millennium Development Goals era in reducing maternal and neonatal mortality, both remain unacceptably high, especially in areas affected by humanitarian crises. While valuable...

A Complex Intervention for Alcohol Misuse Among Conflict-Affected Populations in Uganda and Ukraine: Study Protocol for the Qualitative Components in the CHANGE Trial

Qualitative research is increasingly being integrated within the development and evaluation phases of trials of complex health interventions. Qualitative research can complement effectiveness data and provide insights around how context and implementation impact the results of the trial and to what extent interventions fit implementation contexts after evaluation. Several qualitative studies have been conducted at different stages of trials of mental health and psychosocial support interventions for populations affected by adversity such as armed conflict and disasters. However, these qualitative components are usually implemented as disjointed components within the trial. The current protocol aims to provide a shared framework detailing the qualitative components of the CHANGE project trial: a program of work to address alcohol misuse and associated mental health comorbidities among conflict-affected populations in Uganda and Ukraine. In particular, the objectives of the current protocol are (i) to identify the specific qualitative questions and methods that will be undertaken in CHANGE; (ii) characterize the different methodological approaches to analyzing the data; and (iii) explain how each qualitative component within the different work-packages will cumulatively add value to each other over the duration of the CHANGE project. The current protocol will represent a useful template for the integration of serial qualitative research components within complex health interventions in humanitarian settings. Each qualitative components described will undergo formal ethics approval by ethics boards in the United Kingdom, Uganda, and Ukraine. Multiple mechanisms will be in place to ensure rigor and trustworthiness of the research by meeting the criteria of credibility, transferability, dependability, and confirmability.

Understanding the health needs of internally displaced persons: A scoping review

We seek to strengthen understanding of the health needs of internally displaced persons (IDPs) in contexts of conflict or violence. Based upon a scoping review, our paper identified limited evidence on IDP health, but nevertheless indicates that IDPs tend to experience worse health outcomes than other conflict-affected populations across a range of health issues; and this is due to the particularly vulnerable situation of IDPs relative to these other populations, including reduced access to health services. Further research is required to better understand these needs and the interventions that can most effectively address these needs.

Experiences of mental health and functioning among conflict-affected populations: A qualitative study with military veterans and displaced persons in Ukraine.

Objective: This article reports findings from a qualitative study that sought to identify and describe psychosocial and mental health consequences of conflict among internally displaced persons (IDPs) and military veterans in Ukraine. The study was the first phase of a clinical intervention trial and was designed to understand local experiences of mental health problems and function, inform the selection and adaptation of local measures, and guide the modification, and implementation of a psychotherapy intervention that could support conflict-affected persons. Method: Free-list interviews (FLs), key informant interviews (KIIs), and focus group discussions (FDGs) were conducted with IDPs, military veterans, and providers working with these two groups. A total of 227 respondents were interviewed from two study regions in eastern Ukraine-Zaporizhia and Kharkiv-including 136 IDPs and 91 military veterans. Results: Both IDPs and veterans were described as experiencing high levels of psychological stress symptoms, including depression, isolation, anxiety, and intrusive memories. Although IDPs and veterans were exposed to different traumas, they both identified struggles with social adaptation, including feeling isolated and misunderstood by their communities. Both groups also described relational conflict within and outside the family. Social support mechanisms were considered essential for recovery, and positive social interaction was described as a key example of healthy functioning. Conclusion: Findings suggest a need for community-based programming that facilitates social adaptation, supports social network building, and helps engage conflict-affected people into mental health services. Programs that promote greater awareness, interaction, and understanding among the general public, military veterans, and IDPs are also warranted. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Displaced, Dispossessed and Silenced: The Need for Suicide Prevention and Response for Conflict-affected Populations

Displaced, Dispossessed and Silenced: The Need for Suicide Prevention and Response for Conflict-affected Populations

REAL-LIFE APPROACHES EMPLOYED BY RECOGNIZED GOVERNMENTS TO ENSURE HEALTH COVERAGE OF CITIZENS IN FRAGILE SETTINGS, INCLUDING THE POPULATION OF THE DISPUTED TERRITORIES, STRUGGLING FOR INDEPENDENCE

The aim: To review real-life approaches employed by recognized governments to ensure health coverage of citizens in fragile settings, including the population of the disputed territories, struggling for independence. Materials and methods: Content analysis of documents, the peer-reviewed articles, open-access databases, policy documents and original sources were utilized in order to archive the study aim. Multidimensional approach to source selection was chosen for objective assessment of the current policy- and decision-making practices. Conclusions: Protracted nature of conflict leads to health system fragility resulting in adverse effects on conflict-affected population health coverage. Health policy in such settings is often externally-driven due to lack of capacities of recognized government and reliance on external funding. Safety and political concerns impede imposition of the context-specific durable solutions for the universal health coverage. Recognized governments lack access to real data to perform evidence-based decision-making.Conventional decision-making based on external demand leads to permanent underperformance of health governance.

\u201cHaving more women humanitarian leaders will help transform the humanitarian system\u201d: challenges and opportunities for women leaders in conflict and humanitarian health

BackgroundIt is estimated that over 40% of the half a million humanitarian workers who provide frontline care during emergencies, wars and disasters, are women. Women are at the forefront of improving health for conflict-affected populations through service delivery, education and capacity strengthening, advocacy and research. Women are also disproportionately affected by conflict and humanitarian emergencies. The growing evidence base demonstrating excess female morbidity and mortality reflects the necessity of evaluating the role of women in leadership driving health research, policy and programmatic interventions in conflict-related humanitarian contexts. Despite global commitments to improving gender equality, the issue of women leaders in conflict and humanitarian health has been given little or no attention. The aim of this paper focuses on three domains: importance, barriers and opportunities for women leaders in conflict and humanitarian health. Following thematic analysis of the material collected, we discuss the following themes: barriers of women’s leadership domain at societal level, and organisational level, which is subcategorized into culture and strategy. Building on the available opportunities and initiatives and on inspirational experiences of the limited number of women leaders in this field, recommendations for empowering and supporting women’s leadership in conflict health are presented.MethodsA desk-based literature review of academic and grey sources was conducted followed by thematic analysis.ResultsThere is very limited evidence on women leaders in conflict and humanitarian health. Some data shows that women have leadership skills that help to support more inclusive solutions which are incredibly important in this sector. However, deeply imbedded discrimination against women at the organisational, cultural, social, financial and political levels is exacerbated in conflict which makes it more challenging for women to progress in such settings.ConclusionAdvocating for women leaders in conflict and health in the humanitarian sector, governmental bodies, academia and the global health community is crucial to increasing effective interventions that adequately address the complexity and diversity of humanitarian crises.

Displaced security? The relationships, routines and rhythms of peacebuilding interveners

This article considers what treating individual international interveners engaged in peacebuilding work as referent objects can tell us about emplaced security. This is important because individual interveners are diverse, embodied agents who can impact the agency, peace and security of conflict-affected populations. It argues that applying an ontological security lens can provide a partial explanation for why interveners develop narratives and perform practices, including why they sometimes identify and behave in counterproductive, and even damaging, ways. The final section considers why an analytical focus on place is valuable, noting that place-based experiences and place-identities are formative of ontological security. It argues that treating interveners as a referent object provides opportunities to rethink the tendency to focus on home as the key site of emplacement in the ontological security literature. Building on this, it argues that examining the emplaced security of interveners invites us to examine the political nature and consequences of interveners’ physical and ontological security-seeking narratives and practices, including their creation of the material and ideational structures of intervention spaces and places.

Planning the scale up of brief psychological interventions using theory of change

BackgroundA large mental health treatment gap exists among conflict-affected populations, and Syrian refugees specifically. Promising brief psychological interventions for conflict-affected populations exist such as the World Health Organization’s Problem Management Plus (PM+) and the Early Adolescent Skills for Emotions (EASE) intervention, however, there is limited practical guidance for countries of how these interventions can be taken to scale. The aim of this study was to unpack pathways for scaling up PM+ and EASE for Syrian refugees.MethodsWe conducted three separate Theory of Change (ToC) workshops in Turkey, the Netherlands, and Lebanon in which PM+ and EASE are implemented for Syrian refugees. ToC is a participatory planning process involving key stakeholders, and aims to understand a process of change by mapping out intermediate and long-term outcomes on a causal pathway. 15–24 stakeholders were invited per country, and they participated in a one-day interactive ToC workshop on scaling up.ResultsA cross-country ToC map for scale up brief psychological interventions was developed which was based on three country-specific ToC maps. Two distinct causal pathways for scale up were identified (a policy and financing pathway, and a health services pathway) which are interdependent on each other. A list of key assumptions and interventions which may hamper or facilitate the scaling up process were established.ConclusionToC is a useful tool to help unpack the complexity of scaling up. Our approach highlights that scaling up brief psychological interventions for refugees builds on structural changes and reforms in policy and in health systems. Both horizontal and vertical scale up approaches are required to achieve sustainability. This paper provides the first theory-driven map of causal pathways to help support the scaling-up of evidence-based brief psychological interventions for refugees and populations in global mental health more broadly.

COVID-19 as a global challenge: towards an inclusive and sustainable future

COVID-19 is a global challenge that demands researchers, policy makers, and governments address multiple dimensions which go far beyond the implications of this pandemic for health and wellbeing. Just as the UN Sustainable Development Goals call for focus on the connections between development policy sectors, the pandemic has exposed the complex global interdependencies that underpin economies and highlighted fault lines in societal structures that perpetuate ethnic, economic, social, and gender inequalities.Here,wehighlightthepandemic’semerging potential consequences for achieving sustainable development with respect to the six global challenge areas we collectively address at the UK Research and Innovation’s Global Challenges Research Fund:1 food systems; education; cities and sustainable infrastructure; security, protracted conflict, refugee crises, and forced displacement; environmental resilience; and global health. As the immediate health consequences of the pandemic unfold and begin to be superseded by the impact of public health containment measures, we call for a refocusing of research and action not only to mitigate these impacts but to build sustainability and strengthened resilience into future recovery.