Fragile Contexts Research Articles

The Gendered Experience of Close to Community Providers during COVID-19 Response in Fragile Settings: A Multi-Country Analysis

Many countries, and particularly those including fragile contexts, have a shortage of formal health workers and are increasingly looking to close-to-community (CTC) providers to fill the gap. The experiences of CTC providers are shaped by context-embedded gender roles and relations. This qualitative research study in Lebanon, Nepal, Myanmar and Sierra Leone explored the gendered experiences of CTC providers during the COVID-19 pandemic in fragile settings. We used document review, in-depth interviews or focus group discussions with CTC providers, and key informant interviews with local stakeholders to generate in-depth and contextual information. The COVID-19-associated lockdowns and school closures brought additional stresses, with a gendered division of labour acutely felt by women CTC providers. Their work is poorly or not remunerated and is seen as risky. CTC providers are embedded within their communities with a strong willingness to serve. However, they experienced fractures in community trust and were sometimes viewed as a COVID-19 risk. During COVID-19, CTC providers experienced additional responsibilities on top of their routine work and family commitments, shaped by gender, and were not always receiving the support required. Understanding their experience through a gender lens is critical to developing equitable and inclusive approaches to support the COVID-19 response and future crises.

Minoritised communities and Hong Kong’s ‘summer of uprising’: attitudes and engagement without citizenship

ABSTRACT Hong Kong experienced unprecedented political and social turmoil starting in June 2019. The original impetus was a proposed law that would have enabled the extradition of Hong Kong residents to Mainland China. The focus of previous work relating to the consequent social movement that opposed the law has been on the engagement of the dominant Chinese population. Little attention has been paid to the attitudes or experiences of Hong Kong’s minoritised communities. This paper, therefore, shifts the focus of research to those communities, who are resident in Hong Kong but many of them are not Chinese citizens. The interviews with twenty-five study participants revealed multiple views of the social movement ranging from those who were in full support to those who were wary of the social movement because of its potential to impinge on an already fragile social context. The conundrum of providing education for the city’s ‘non-citizens’ is discussed.

A Synecdoche of Catalanness in Australia: The Visual Politics of the Casal Català in Sydney

ABSTRACT This article examines the formation of Catalanness within the parameters of the new surge of Catalan independentism in the 2010s. It specifically looks at the Casal Català of New South Wales in Sydney as an illustrative example, through which the visual symbols of Catalan independentism function synecdochically as part of the whole of what it is to be Catalan in Australia. This is what will be termed the visual politics of the Casal Català in Sydney. Having this in mind, the article lastly explores in what ways the symbols used by the Casal Català are effective markers of Catalan commonsense in an extremely fragile diasporic context.

The Deepening Politics of Fragmentation in Uganda: Understanding Violence in the Rwenzori Region

AbstractIn November 2016, Uganda’s armed forces raided the Rwenzururu kingdom palace in Kasese Municipality, arresting and detaining the king and other kingdom officials on treason and other charges. This was the climax to a puzzling wave of violence that was then unfolding in the Rwenzori Region. We consider this violence an unintended consequence of the deepening politics of fragmentation, which takes two forms: “kingdomization” and “districtization.” Through fragmentation, Uganda’s ruling elites seek to weaken subnational concentrations of power, resources, and legitimacy wielded by otherwise coalesced, potentially strong, subnational authority structures and sociopolitical groups. Fragmentation fractures preexisting intra-regional unity, generates new conflicts, and reopens old wounds, leading to violent encounters at the sub-national level, between regional sub-groups, and with the central state. This unfolding of violent encounters involving both state and non-state actors has important ramifications for managing national security within socially fragile contexts and a politically fragmented polity.

Sustainable Entrepreneurship and Protected Areas: Influences of Embeddedness in a Semi-remote Context

This study examines the interaction between sustainable entrepreneurs and their socio-ecological environment. Previous studies postulate that fragile socio-ecological contexts by and large promote sustainable entrepreneurial practices. By being embedded in place, nature and culture, and communities, the entrepreneurs are able to revitalise semi-remote areas and drive development. However, how being embedded in fragile socio-ecological influences sustainable entrepreneurial activities is less understood. Using an exploratory qualitative study, we collected data from 15 sustainable entrepreneurs, operating in a protected area. We found that the entrepreneurs exhibited different forms of embeddedness. Embeddedness was either social, spatial or both. Further, the form of embeddedness determined the activities the sustainable entrepreneurs engaged in (adaptive versus transformative). Our study exemplifies that in addition to previously identified positive influences, the interaction between sustainable entrepreneurs and context in the form of embeddedness, results in certain negative influences on sustainable entrepreneurial activities, such as conforming.

The determinants of the quality of clinical management among diabetic and hypertensive patients in a context of fragility: A cross-sectional survey from Lebanon.

IntroductionThe management of NCDs is a growing challenge in low- and middle-income settings with the increasing prevalence and the associated demands that such conditions make on health systems. Fragile settings both exacerbate the risk of NCDs and undermine systems capacity. Lebanon is a setting where strategies to address rising NCDs burden have faced particularly acute contextual challenges.MethodsWe conducted a cross-sectional survey with patients accessing non-communicable disease across 11 primary care centers within the Greater Beirut and Beqaa areas. Response were received from 1,700 patients. We generated a Clinical Management Index Score as a measure of quality of care, and scores related to a range of socio-demographic characteristics and other context specific variables.ResultsSignificantly higher clinical management index scores (better quality of care) were associated with patients living in the semi-urban/rural context of Beqaa (compared to Greater Beirut), having health insurance coverage, aged above 60, having high levels of educational attainment, and making partial or full payment for their treatment. Relatively lower index scores (poorer quality of care) were associated with Syrian nationality (compared to Lebanese) and with patients suffering from diabetes or hypertension (compared to comorbid patients).ConclusionThe study identified a wide margin for improving quality of NCDs care in fragile contexts with particular gaps identified in referral to ophthalmology, accessing all prescribed medication and receiving counseling for smoking cessation. Additionally, findings indicate a number of predictors of comparatively poor quality of care that warrant attention, notably with regard to Syrian nationality/legal status, lack of health coverage, seeking free health provision and lower educational attachment. Although these are all relevant risk factors, the findings call on donor agencies, NGOs and provider institutions to design targeted programs and activities that especially ensure equitable delivery of services to diabetic and hypertensive patients with compounded vulnerability as a result of a number of these factors.

Does inter-border conflict influence the views of task sharing among community health volunteers in Nigeria? A qualitative study

BackgroundVolunteer community health workers are increasingly being engaged in Nigeria, through the World Health Organization’s task sharing strategy. This strategy aims to address gaps in human resources for health, including inequitable distribution of health workers. Recent conflicts in rural and fragile border communities in northcentral Nigeria create challenges for volunteer community health workers to meet their community's increasing health needs. This study aimed to explore the perception of volunteers involved in task sharing to understand factors affecting performance and delivery in such contexts.MethodsThis was a qualitative study conducted in fragile border communities in north central Nigeria. Eighteen audio recorded, semi-structured interviews with volunteers and supervisors were performed. Their perceptions on how task sharing and allocation of tasks affect performance and delivery were elucidated. The transactional social framework was applied during the thematic analysis process to generate an explanatory account of the research data, which was analysed using NVivo software.ResultsPromotive and preventive tasks were shared among the predominantly agrarian respondents. There was a structured task allocation process that linked the community with the health system and mainly cordial relationships were in place. However, there were barriers related to ethnoreligious crises and current conflict, timing of task allocations, gender inequities in volunteerism, shortage of commodities, inadequate incentives, dwindling community support and negative attitudes of some volunteers.ConclusionThe perception of task sharing was mainly positive, despite the challenges, especially the current conflict. In this fragile context, reconsideration of non-seasonal task allocations within improved community-driven selection and security systems should be encouraged. Supportive supervision and providing adequate and timely renumeration will also be beneficial in this fragile setting.

The Evolutionary Trends and Convergence of Cereal Yield in Europe and Central Asia

The state of food security in the world, including that of Europe and Central Asia (ECA), was highlighted in 2020 by the outbreak of the COVID-19 pandemic, when the fact that the food security status of millions of people in ECA, particularly the most vulnerable and those living in fragile contexts, would deteriorate if swift action was not taken as soon as possible became apparent. Improving cereal yield is the key for the ECA to achieve the Sustainable Development Goal (SDG) Target 2.1 to end hunger by 2030. Impressive cereal yield growth has been witnessed within the ECA from 1991 to 2020, but there is still significant variation across the five sub-regions. This paper aimed to analyze the evolutionary trends and convergence of cereal yield in countries of the ECA from 1991 to 2020 for four major cereals: wheat, maize, barley and oats. The findings show that there is strong evidence of σ-convergence and absolute and conditional β-convergence for cereal yield in the ECA, which indicates that countries with low yield in the initial stages have totally experienced higher growth rate, and yield in countries farther away from the steady-state have to have faster growth rate to converge to the steady-state. The presence of club convergence is also identified in terms of geographic location and income level, simultaneously. Therefore, cereal yield in the ECA has converged to the whole and to different groups at the same time, which provides some evidence of agricultural technology spillover effect in the region.

Cholera diagnosis in human stool and detection in water: A systematic review and meta-analysis.

BackgroundCholera continues to pose a problem for low-resource, fragile and humanitarian contexts. Evidence suggests that 2.86 million cholera cases and 95,000 deaths due to cholera are reported annually. Without quick and effective diagnosis and treatment, case-fatality may be 50%. In line with the priorities of the Global Task Force on Cholera Control, we undertook a systematic review and meta-analysis of diagnostic test accuracy and other test characteristics of current tests for cholera detection in stool and water.MethodsWe searched 11 bibliographic and grey literature databases. Data was extracted on test sensitivity, specificity and other product information. Meta-analyses of sensitivity and specificity were conducted for tests reported in three or more studies. Where fewer studies reported a test, estimates were summarised through narrative synthesis. Risk of Bias was assessed using QUADAS-2.ResultsSearches identified 6,637 records; 41 studies reporting on 28 tests were included. Twenty-two tests had both sensitivities and specificities reported above 95% by at least one study, but there was, overall, wide variation in reported diagnostic accuracy across studies. For the three tests where meta-analyses were possible the highest sensitivity meta-estimate was found in the Cholera Screen test (98.6%, CI: 94.7%-99.7%) and the highest specificity meta-estimate in the Crystal VC on enriched samples (98.3%, CI: 92.8%-99.6%). There was a general lack of evidence regarding field use of tests, but where presented this indicated trends for lower diagnostic accuracy in field settings, with lesser-trained staff, and without the additional process of sample enrichment. Where reported, mean test turnaround times ranged from over 50% to 130% longer than manufacturer’s specification. Most studies had a low to unclear risk of bias.ConclusionsCurrently available Rapid Diagnostic Tests can potentially provide high diagnostic and detection capability for cholera. However, stronger evidence is required regarding the conditions required to secure these levels of accuracy in field use, particularly in low-resource settings.RegistrationPROSPERO (CRD42016048428).

First aid guidelines for fragile contexts: Contextualization & Adaptation

Topic: In situations of remoteness to medical care, disaster or conflict, first aid provision is important but challenging. Education for learners in such contexts needs to be adapted according to resources available. This paper explores the educational approach and adaptations recommended by the 2020 IFRC First Aid, Resuscitation and Education Guidelines and provides a review of them. As a specialist in fragile and harsh contexts, the ICRC has contributed insight which enables the new guidelines to reflect challenges faced by those providing first aid education in peacetime and in war, and in other situations of adversity. Context: First Aid in armed conflicts, disasters and remote settings Adaptation: Educators need to adjust both the first aid skills and the way of teaching to the realities of those providing first aid. In some instances, safety and security of the first aider and the person requiring help should be prioritized over providing care. In remote settings or places where medical assistance is unlikely to be expedient, or in situations where effective first aid might not be possible, the psychological wellbeing of the first aid provider is also important and educators need to prepare their learners for such occurrences. Within the 2020 International First Aid Guidelines, authors tried to reflect the specific circumstances faced by first aiders in fragile settings, aiming to put the learner at the center and adapt the education to their needs and the realities of the resources available to them. Discussion: First aid educators around the world have to understand that guidelines are provided as an evidence-based guiding document which need to be adapted by the educator to the realities faced by the learner. It is their role to give learners the permission and confidence to act as best they can and provide options for delivering alternative care where resources or circumstances are limiting. Conclusions: The specific circumstances of armed conflict, disasters and remote settings will require the first aid educators and first aiders to adapt the scientific evidence of the first aid guidelines to their realities, and in some instances, place safety and security ahead of first aid provision. To increase the likelihood of successful implementation of evidence-based first aid techniques and practice, first aid education must consider aspects of context that promote and/or hinder implementation in these settings. Important, but not yet explicit enough in the new guidelines, is the permission needed to be given to first aid educators to create an authentic, intelligent and humanitarian approach to first aid learning. The goal is to encourage people to be creative and adapt to harsh realities using available resources without being distracted by theories which they cannot apply.

Factors Influencing Effective Remote Monitoring Approaches for Non-Governmental Organizations in Highly Insecure Settings in Yemen

This study aims to examine the factors influencing the effective remote monitoring approach for NGOs in highly insecure settings in Yemen. Using a structured survey instrument, this study gathered data from 63 staff members who work and carry the monitoring function in 12 targeted NGOs. The study’s findings confirmed that ‘human capacity’ is the most significant factor among the research’s four factors. Information Communication Technology has a positive impact in enhancing the accuracy and quality of collecting, analyzing, and disseminating the monitoring data in a short time and at a low cost. However, the findings show that the ‘organization guidance’ factor has no significant impact on the effective RM approaches in fragile and insecure contexts in Yemen. The outcomes of this research can be used to improve the quality and effectiveness of the monitoring function in general. This research shows that the Remote Monitoring (RM) approach is an alternative method used by several NGOs in Yemen to remain active and to ensure accountability and transparency to their donors, beneficiaries, and governments while reducing the risk faced by their partners and staff.

Determinants of rural hand-pump functionality through maintenance provision in the Central African Republic

While preventive maintenance services have emerged as promising interventions to improve the continuity of water service delivery, the operational and contextual requirements for sustained functionality within maintenance models are not well understood. This paper uses data analysis to better understand factors influencing the success of rural water service delivery within the circuit rider maintenance model in fragile contexts. Incorporating operational data from a large scale circuit rider hand-pump maintenance program in the Central African Republic, mixed-effect logistic regression models were used to identify determinants of water point functionality and payment compliance. Models were informed by data from over 16,000 maintenance visits across nine years. Faster response time, proximity to urban centers, and proximity to other hand-pumps emerged as significant factors for improving water point functionality, while proximity to maintenance program headquarters, pump functionality, and frequency of maintenance visits significantly influenced payment compliance. The observed high functionality rates of hand-pumps serviced by the maintenance program indicates the potential benefits of professionalized maintenance through the circuit rider model at promoting water system reliability in fragile contexts. Despite adaptability and resilience in implementation of the circuit rider model, insecurity and conflict remain barriers to sustaining service delivery in the Central African Republic.

Slanted Narratives, Social Media, and Foreign Influence in Libya

In fragile contexts such as Libya where social media penetration is high, foreign social media outlets with political interests can use social media platforms to influence the country's politics. In this study, we assess how social media content varies by the country of the information producer. We create a dataset of Facebook posts about a strongman’s recent attack on Tripoli (N=16,662). We find that more than half of the posts originated from outside Libya and that posts from countries aligned with the Tripoli-based government are biased in that direction and posts from countries aligned with the eastern-based strongman are biased toward his forces. However, many Pages are not slanted: the correlations are instead driven by a smaller number of hyperpartisan Pages. Our findings have implications for our understanding of how social media content -- especially from abroad -- shapes citizen perceptions of the legitimacy of competing political actors.

Geomorphology and geotourism for a sustainable development of the Daunia Mts, Southern Italy

ABSTRACT Landscape preservation strongly depends on exploration and knowledge of its history and evolution. The acquisition and the analysis of geological and geomorphological features are basic and useful tools to identify the touristic potential and the anthropic impact of a territory. This study aims to enhance the knowledge of the natural and cultural heritage of an area of the Daunia Mts between the towns of Alberona and Faeto, Southern Italy, marked by neglect and abandonment, through the drafting of a geomorphological map and the proposal of geotourist itineraries and routes. The results highlight the potential competitiveness and attractiveness of the study area by contributing to the promotion of a sustainable development of a marginal territory. Such data may encourage a form of fruition that promotes knowledge, appreciation, and environmental awareness, in a fragile territorial context.

Sustainable entrepreneurship and legitimacy building in protected areas: Overcoming distinctive barriers through activism

AbstractSustainable entrepreneurs operating in protected areas face distinctive barriers that place additional emphasis on the need to build legitimacy. To date, how they do this has not been entirely explored. This paper addresses this need through an exploratory study of sustainable entrepreneurs in a transnational protected area. The results indicate that sustainable entrepreneurs in protected areas face barriers that can be broadly classified as cognition spanning, locale and sector‐related barriers. The findings highlight that a key way sustainable entrepreneurs overcome these distinctive barriers is by building legitimacy through activism. Activism became instrumental in building legitimacy with varied stakeholders and actors. This is all geared towards overcoming barriers during the sustainable entrepreneurship process. The findings add to existing literature on the role of legitimacy building in sustainable entrepreneurship by detailing the different forms of legitimacy and how they are built through activism. The paper concludes with propositions about the conditions necessary for sustainable entrepreneurs to build legitimacy in fragile socioecological contexts through activism.

Analysing care policies and practices in times of austerity and conflict: the case of the Occupied Palestinian Territory (OPT)

ABSTRACT In fragile and conflict-affected contexts, the COVID-19 pandemic hit communities much harder than elsewhere by adding another layer of vulnerability to their already precarious circumstances. Around the world, many pandemic recovery plans were devoid of gender-sensitivity, such as lacking explicit recognition of, or introduction of, substantive steps, supporting women’s quest for improved care services. In the Occupied Palestinian Territory (OPT), where the pandemic coincided with other crises such as the occupation, an escalated military offensive (May 2021 in Gaza), heatwaves due to climate change, and a longstanding economic crisis, pandemic recovery is particularly challenging. This paper examines the channels through which Palestinian women’s multi-layered vulnerabilities continue to worsen despite the Palestinian Authority’s pandemic recovery measures. It does so by documenting the plethora of ways in which women’s wellbeing is hampered by critical factors such as informal modes of employment, patriarchal social norms, unpaid care responsibilities, and the longstanding absence of any social protections. The policy analysis reveals that there is widespread fragmentation in the design of pandemic recovery policies which attempt to address their highly complex and multi-layered challenges. Using the case of women in the OPT as an example, it proposes several policy recommendations to help address Palestinian women’s unique vulnerabilities even within their existing limitations.

India’s ‘soft power’ play with BIMSTEC nations: observing education diplomacy as an instrument of foreign policy

South Asia as a region has a deficient Human Resource base, which jeopardizes its developmental ambitions and socioeconomic progress. Due to the fragile geopolitical context of the region, low spending for human development and increased expenditures for militarism sustain such a state of affairs in the subregion. As a result, large educational interventions are needed in the region. Education is the stumbling block to progress. Education and culture have always served as vital lines of communication between India and the BIMSTEC member states like Bhutan, Bangladesh, Myanmar, etc. India became the world's second-largest provider of higher education after independence, and it continued to attract students from the BIMSTEC countries. The chapter will examine several aspects of educational collaboration between India and the BIMSTEC countries in this context. This collaboration in the field of education will allow India to use soft-power diplomacy to strengthen its relations with its BIMSTEC partner.

Outpatient use patterns and experiences among diabetic and hypertensive patients in fragile settings: a cross-sectional study from Lebanon

ObjectivesAssess and describe the health service use and delivery patterns for non-communicable disease (NCD) services in two contrasting fragility contexts and by other principal equity-related characteristics including gender, nationality and...

Ethical research landscapes in fragile and conflict-affected contexts: understanding the challenges

As the prevalence of conflict and fragility continue to rise around the world, research is increasingly heralded as a solution. However, current ethical guidelines for working in areas suffering from institutional and social fragility, insecurity or violent conflict have been heavily critiqued as highly abstract; focussed only on data collection; detached from the realities of academia in the Global South; and potentially extractive. This article seeks to respond to that assessment by spotlighting some of the most prevalent challenges researchers face in the pursuit of ethical working practices. It explores the material and epistemic injustices that often shape and underpin research structures and relationships in these contexts. The paper draws on the authors’ experiences of research in conflict-affected and fragile contexts over the last fifteen years and on workshop discussions with researchers based in fragile and conflict-affected contexts conducted in Amman, Bogotá and Dhaka in 2019-2020. The paper works from the premise that achieving ethical research in fragile spaces is not dependent solely on activity at the site of research, but also on decisions made across the entire ecosystem of a research project. It therefore interrogates the full research landscape, from funding models, to research design (including research topics, partnerships, methods, participant selection, and researcher positionality), to dissemination plans and ethical gatekeeping. The paper critically reflects on inequities in the processes of knowledge production about conflict and fragility and the key ethical challenges that researchers encounter. It highlights the need for further guidance, support and accountability to ensure ethical research practices.

Social determinants of psychological distress in Sierra Leone

PurposeGrowing evidence demonstrates that daily stressors such as family violence, unemployment, and living conditions play an important part in causing psychological distress. This paper investigates the impact of distressing events and day-to-day living conditions on psychological distress in the fragile context of Sierra Leone.MethodsA cross-sectional survey was conducted with 904 adults (454 men, 450 women) in 5 districts of Sierra Leone. The survey questionnaire comprised the Sierra Leone Psychological Distress scale and measures of demographic variables and personal characteristics, current life circumstances and potentially distressing events.ResultsMultiple regression results identified three factors to be the greatest contributors to psychological distress: family conflict (β = 0.185, p < 0.001) and inability to afford basic needs (β = 0.175, p < 0.001). Gender differences were evident: factors predicting men’s psychological distress included severe sickness or injury (β = 0.203, p < 0.001) and being unable to afford basic needs (β = 0.190, p < 0.001); for women, predicting factors were family conflict (β = 0.212, p < 0.001), perceived poor health (β = 0.192, p < 0.001) and inability to afford basic needs (β = 0.190, p < 0.001).ConclusionInitiatives to promote good mental health and psychosocial wellbeing in Sierra Leone should focus on enhancing income-generating and employment opportunities, promoting access to education, and strengthening family relationships.