Humanitarian Crisis Settings Research Articles

The Spaces In Between: Understanding Children’s Creative Expression in Temporary Shelters for Asylum Seekers

On arrival in a host country, asylum‐seeking children face uncertainty and stress that may compound past traumatic experiences of war and violence. This article is based on a participatory action research project, Welcome Haven, that aims to promote the wellbeing and mental health of asylum‐seeking families in Montreal, Canada, through psychosocial workshops. Since 2023, our interdisciplinary team has conducted arts‐based workshops to support asylum‐seeking children lodged in hotels that function as temporary accommodations, funded by the federal government. This study examines the drawings and narratives of participating children (ages 5–17) to understand how children communicate and make sense of their experiences through artmaking. Following a participatory action research framework using arts‐based approaches, we use narrative and thematic analysis to analyze our (a) ethnographic field notes, (b) notes from our intervention team meetings, which functioned as peer supervision for facilitators, and (c) photographs of children’s artwork. Our findings suggest that children use drawings to share and externalize their personal stories and to express fears and hopes for the future. Importantly, children’s expression happened not only on the page and through stories, but in the space between facilitators and children, and in their manner of sharing or protecting their art. The challenges of conducting research and creating therapeutic alliances in these spaces are explored. This research has important implications for understanding children affected by war and those in humanitarian crisis settings, including reception centers and shelters in high‐income countries.

Psychometric Validation of the Domestic Violence Questionnaire in Swahili Among Congolese Female Survivors of Domestic Violence

The Domestic Violence Questionnaire (DVQ) is a measure that captures physical, sexual, economic, and psychological violence perpetrated against women. A team of local academicians and intervention experts evaluated several tools for domestic and gender-based violence, concluding that the DVQ fitted best in the context of evaluating the Living Peace intervention in conflict-affected eastern DRC. The purpose of this validation study was to: (1) validate the factor structure of the Swahili version of the DVQ, (2) to evaluate its convergent and divergent validity, and (3) to examine its internal consistency reliability. The factor structure was evaluated using Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) while concurrent validity and internal consistency reliability were evaluated using Pearson correlation and Cronbach’s alpha coefficients, respectively. The study participants were women, partners of men that participated in the Living Peace program, a community-based intervention program that works on promoting positive masculinity among men that are perceived to be violent by their community. Data were obtained from two independent purposive samples of 704 participants for EFA and 878 participants for CFA, selected from 60 villages in North and South Kivu, DRC. The results indicated that five and three-factor structures could be meaningfully interpreted in EFA, each with 66% explained variance. For comparative purposes, CFA was conducted on the two newly created factor models and the original factor model. All models reach good fit indexes, with the three-factor model demonstrating the best fit. Its standardized factor loadings ranged from 0.57 to 0.91. The internal consistency was α = .90 for the total scale and ranged from α = .75 to .926 per dimension. Finally, scores of DVQ were negatively correlated with mental well-being ( r = −0.23, p < .001), and positively with depression ( r = .435, p < .001), as hypothesized. The Swahili version of DVQ has excellent psychometric properties and can be applied to evaluate the physical, sexual, economic and psychological violence in victims of domestic violence in humanitarian crisis settings.

Implementation and Delivery of Oral Cholera Vaccination Campaigns in Humanitarian Crisis Settings among Rohingya Myanmar nationals in Cox's Bazar, Bangladesh.

Over 700,000 Myanmar nationals known as the 'Rohingyas' fled into Cox's Bazar, Bangladesh, in late 2017. Due to this huge displacement into unhygienic areas, these people became vulnerable to communicable diseases including cholera. Assessing the risk, the Government of Bangladesh (GoB), with the help of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) and other international partners, decided to take preventive measures, one of which is the execution of oral cholera vaccination (OCV) campaigns. This paper describes the implementation and delivery of OCV campaigns during humanitarian crises in Bangladesh. Seven rounds of OCV campaigns were conducted between October 2017 and December 2021. The OCV campaigns were conducted by applying different strategies. Approximately 900,000 Rohingya Myanmar nationals (RMNs) and the host population (amounting to 528,297) received OCV across seven campaigns. In total, 4,661,187 doses of OCVs were administered, which included 765,499 doses for RMNs, and 895,688 doses for the host community. The vaccine was well accepted, and as a result, a high level of coverage was achieved, ranging from 87% to 108% in different campaigns. After successful pre-emptive campaigns in Cox's Bazar humanitarian camps, no cholera outbreaks were detected either in the RMN or host communities.

Bacterial and viral etiology of acute respiratory infection among the Forcibly Displaced Myanmar Nationals (FDMNs) in fragile settings in Cox's Bazar- a prospective case-control study.

The leading infectious cause of death in children worldwide is lower acute respiratory infection (LARI), particularly pneumonia. We enrolled a total of 538 acute respiratory infection (ARI) cases according to WHO criteria and age-sex matched 514 controls in the Forcibly Displaced Myanmar National (FDMN) refugee camps in Cox's Bazar, Bangladesh, between June 2018 and March 2020 to investigate the role of bacteria, viruses, and their co-infection patterns and observe Streptococcus pneumoniae (S. pneumoniae) serotype distribution. According to the etiological findings, children ≤5 years of age have a higher bacterial positivity (90%) and viral positivity (34%) in nasopharyngeal samples (NPS) compared to those >5 years of age, in both ARI cases as well as for the control group. Among the bacteria, S. pneumoniae was predominant in both cases and controls (85% and 88%). Adenovirus (ADV)(34), influenza virus A and B (IFV-A, B)(32,23), and respiratory syncytial virus (RSV)(26) were detected as the highest number among the viruses tested for the ARI cases. The total number of viruses was also found higher in ≤5 years of age group. Within this group, positive correlation was observed between bacteria and viruses but negative correlation was observed between bacteria. Both single and co-infection for viruses were found higher in the case group than the control group. However, co-infection was significantly high for Streptococcus aureus (S. aureus) and Haemophilus influenzae b (H. influenza b) (p<0.05). Additionally, semi-quantitative bacterial and viral load was found higher for the ARI cases over control considering Cycle threshold (Ct)≤30. Pathogen identification from blood specimens was higher by qRT-PCR than blood culture (16% vs 5%, p<0.05). In the S. pneumoniae serotype distribution, the predominant serotypes in ARI cases were 23F, 19A, 16F, 35B, 15A, 20 and 10F, while 11A, 10A, 34, 35A and 13 serotypes were predominant in the control group. Pathogen correlation analysis showed RSV positively correlated with human metapneumovirus (HMPV), S. aureus and H. influenza b while S. pneumoniae was negatively correlated with other pathogens in ≤5 years age group of ARI cases. However, in >5 years age group, S. aureus and H. influenza b were positively correlated with IFVs, and S. pneumoniae was positively correlated with HMPV and ADV. Logistic regression data for viruses suggested among the respondents in cases were about 4 times more likely to be RSV positive than the control. Serotype distribution showed 30% for PCV10 serotypes, 41% for PCV13 and 59% for other serotypes. Also, among the 40 serotypes of S. pneumoniae tested, the serotypes 22F, Sg24, 9V, 38, 8, and 1 showed strong positive correlation with viruses in the case group whereas in the control group, it was predominant for serotypes 14, 38, 17F and 39 ARI cases were prevalent mostly in monsoon, post-monsoon, and winter periods, and peaked in September and October. Overall these region-specific etiological data and findings, particularly for crisis settings representing the FDMNs in Cox's Bazar, Bangladesh, is crucial for disease management and disease prevention control as well as immunization strategies more generally in humanitarian crisis settings.

The effect of internal displacement due to armed conflict on tuberculosis treatment outcomes in northwest Syria, 2019–2020

BackgroundNorthwest Syria accounts for over 4 million people of whom more than half are internally displaced persons (IDPs). More than 1 million IDPs reside in camps and many more live in settings which are overcrowded and poorly ventilated. Suboptimal social living conditions leave these populations susceptible to tuberculosis (TB) morbidity and mortality. This study aimed to assess the effect of internal displacement due to armed conflict on the risk of unsuccessful treatment outcomes among TB patients in northwest Syria. MethodsAll patients registered to start TB treatment at three centres in northwest Syria between the 1st June 2019 to the 31st December 2020 were included. Unsuccessful TB treatment outcome was defined as a composite outcome combining the WHO TB treatment outcomes of treatment failure, loss to follow-up, and death. We assessed the association between internal displacement and unsuccessful TB treatment outcomes using multivariable logistic regression. We also explored the risk of an unsuccessful treatment outcome by internal displacement setting (camp, village or city). ResultsOf the total 737 registered patients included in the analysis, 400 (54%) were documented as internally displaced. The median age of IDPs was 30 (IQR: 21.5–48) and the median age of residents was 34 (IQR:22–50). A significantly higher percentage of those who were IDPs had an unsuccessful treatment outcome compared to residents (40% vs 18%, p<0.001). After adjustment for confounders, the relative risk of having unsuccessful TB treatment was two-fold higher in internally displaced TB patients compared to residents (95% CI: 1.5–2.6). IDPs living in villages had a 30% lower risk of an unsuccessful treatment outcome compared to IDPs living in camps (RR 95% CI: 0.50–0.91), and IDPs living in cities had a 13% lower risk of an unsuccessful treatment outcome (RR 95% CI: 0.57–1.18). ConclusionThis is one of few studies which aims to quantify the effect of internal displacement on TB treatment outcomes during times of conflict. Our findings starkly highlight how social determinants contribute to poor TB outcomes and act as a starting point for much needed research on how best to manage TB in humanitarian crisis settings.

The nutritional benefits of cash transfers in humanitarian crises: evidence from Yemen

At the World Humanitarian Summit in 2016 the long-standing divide between humanitarian and development approaches was challenged with a call for responses that both meet immediate needs and protect human capital for eventual recovery. In this regard, the use of cash transfers in humanitarian settings is an emerging trend; however, it has been limited by a lack of evidence on how well cash transfers improve nutritional outcomes given the challenges of conducting rigorous evaluations in a crisis context. This study makes use of a cluster randomized control trial that was left in place when a pilot cash-plus intervention evolved during the civil conflict into a major program within the Yemen Emergency Crisis Response program. The results provide uniquely rigorous evidence of the potential for long-run nutritional benefits of cash transfers in humanitarian crisis settings. The “Cash for Nutrition” intervention provides cash transfers as well as nutritional training to targeted households with young children in Yemen in the context of what is considered the world’s worst humanitarian crisis. Differences-in-differences estimates indicate that the intervention significantly increased purchases of non-staple foods which translated into large positive impacts on child dietary diversity scores. Impacts on consumption patterns and dietary diversity are significant for the full sample and strongest among the poorest tercile of households where the transfers are largest relative to baseline household food budgets. In this poorest sub-group we also find large and statistically significant program impacts on height-for-age z-scores of 0.3. These results support the increased use of cash transfers and provide a benchmark for comparison with more traditional food distribution and supplementation strategies for supporting child nutrition in protracted crisis contexts.

A case analysis of partnered research on palliative care for refugees in Jordan and Rwanda

BackgroundThis case analysis describes dilemmas and challenges of ethical partnering encountered in the process of conducting a research study that explored moral and practical dimensions of palliative care in humanitarian crisis settings. Two contexts are the focus of this case analysis: Jordan, an acute conflict-induced refugee situation, and Rwanda, a protracted conflict-induced refugee setting. The study’s main goal was to better understand ways humanitarian organizations and health care providers might best support ethically and contextually appropriate palliative care in humanitarian contexts. An unintended outcome of the research was learning lessons about ethical dimensions of transnational research partnerships, which is the focus of this case analysis.DiscussionThere exist ongoing challenges for international collaborative research in humanitarian conflict-induced settings. Research partnerships were crucial for connecting with key stakeholders associated with the full study (e.g., refugees with life limiting illness, local healthcare providers, aid organization representatives). While important relationships were established, obstacles limited our abilities to fully attain the type of mutual partnership we aimed for. Unique challenges faced during the research included: (a) building, nurturing and sustaining respectful and equitable research partnerships between collaborators in contexts of cultural difference and global inequality; (b) appropriate ethics review and challenges of responding to local decision-maker’s research needs; and (c) equity and fairness towards vulnerable populations. Research strategies were adapted and applied to respond to these challenges with a specific focus on (d) research rewards and restitution.ConclusionsThis case analysis sheds light on the importance of understanding cultural norms in all research roles, building relationships with decision makers, and developing teams that include researchers from within humanitarian crisis settings to ensure that mutually beneficial research outcomes are ethical as well as culturally and contextually relevant.

A systematic review of the burden of hypertension, access to services and patient views of hypertension in humanitarian crisis settings

IntroductionGlobally, a record number of people are affected by humanitarian crises caused by conflict and natural disasters. Many such populations live in settings where epidemiological transition is underway. Following the...

Newborn and Child Health Care in Humanitarian Crisis Settings: Piloting of Training Package for Primary Health Care Workers in Rural Nepal

Introduction:The community-based integrated management of newborn and childhood illness (CBIMNCI) training package has been widely used throughout Nepal. Adding a component of disaster response and management to this program would greatly impact the community, and could improve the knowledge and skills of community workers for the management of children during a disaster.Aim:Describe the development and implementation of a community-based training for children in disasters.Methods:Using expertise from emergency and pediatric emergency physicians, pediatricians, and psychiatrists, we developed a two-day training and facilitator manual covering topics such as trauma, resuscitation, burn, drowning, disaster, nutrition, and care of the newborn. The information and manuals were presented to the Nepal Division of Child Health for approval. Four pilot trainings were conducted in Bardia and Bardibas in Nepal in September 2017, including knowledge and skill-based sessions. Knowledge was tested pre- and post-training using multiple choice questions (MCQ) and self-reflections. Skills were evaluated by direct observation and marked using a Likert scale. Confidence was assessed using a confidence matrix before and after the course. Overall feedback was taken at the end of the session.Results:Of 82 participants, 74 participants from four trainings were included for analysis. Post-test Cronbach’s alpha for MCQ was 0.82 and the confidence matrix was 0.86. Mean score for the pre-test MCQ was 6.12 (SD 2.22) compared to the post-test mean of 10.97 (SD 2.97), which was a statistically significant improvement (p&lt;0.05). Trainees reported that the trauma teaching was helpful. They felt that it improved confidence regarding trauma and disasters.Discussion:Adding this training to current CBIMNCI can be an effective tool to reach out to primary health care workers, and provide further knowledge and skills on care of children during a disaster or humanitarian crisis.

Control of infectious disease during pregnancy among pastoralists in South Sudan: A case for investment into mobile clinics

Given their high intermittent mobility, proximity to cattle as well as underlying cultural practices, pastoralists are among groups with high exposure to infectious diseases. Living under adverse environmental conditions while in search for pasture can result in malaria and other environmental pathogenic diseases. Proximity to cattle and consumption of raw untreated milk from cows result in Treponema infections and bovine TB. Furthermore, widespread practice of polygamous relations increases the risk of sexually transmitted infections. Compounded with this, especially in humanitarian crisis settings with weaker health systems, pregnant pastoralists are under-served resulting in an escalation of the impact of infectious diseases which affects pregnant women and their developing foetus via vertical transmission. Using South Sudan as a case study, this paper argues that it is essential to control infectious diseases among pregnant pastoralists, through exploring various ambulatory health services especially mobile clinics. In addition, the paper calls for an increased investment into mobile clinics for pregnant pastoralists as a way of achieving global responsibility of ensuring universal health coverage.

Palliative care in humanitarian crises: a review of the literature

This paper presents findings from a systematic review of the literature (2005–2017) on palliative care in humanitarian crises (e.g., disasters, armed conflicts, epidemics). This review set out to describe palliative care needs, practices, barriers, and recommendations in humanitarian crisis settings. It contributes to current discussions within the field of humanitarian healthcare aimed at clarifying whether or not and how best to respond to palliative care needs in humanitarian crises.Analysis of 95 peer-reviewed and gray literature documents reveal a scarcity of data on palliative care needs and interventions provided in crises, challenges of care provision particularly due to inadequate pain relief resources and guidelines, a lack of consensus on the ethics of providing or limiting palliative care as part of humanitarian healthcare response, and the importance of contextually appropriate care. These findings suggest that more research and open discussion on palliative care in humanitarian crises are needed. This review contributes to defining palliative care needs in humanitarian crises, building consensus on humanitarian healthcare organizations’ ethical responsibilities towards individuals and families with palliative needs, and developing realistic and context-appropriate policies and guidelines.

Pharmacists in humanitarian crisis settings: Assessing the impact of pharmacist-delivered home medication management review service to Syrian refugees in Jordan.

Refugees all over the world are facing several health-related problems. Chronic diseases among Syrian refugees in Jordan are high. The Home Medication Management Review (HMMR) service could be ideal to optimize refugees' health management. To assess the impact of the HMMR service on the type and frequency of Treatment Related Problems (TRPs) among Syrian refugees living in Jordan. This prospective randomized single blinded intervention-control study was conducted in three main cities in Jordan, between May and October 2016. Syrian refugees with chronic conditions were recruited and randomized into intervention and control groups. The HMMR service was conducted for all patients to identify TRPs at baseline. Data were collected via two home visits for all study participants. Clinical pharmacist's recommendations were written in a letter format to the physicians managing the patients in the intervention group only. Physicians' approved recommendations were conveyed to the patients via the pharmacist. Interventions at the patient level were delivered by the pharmacist directly. Patients were reassessed for their TRPs and satisfaction 3 months after baseline. Syrian refugees (n = 106) were recruited with no significant differences between the intervention (n = 53) and control groups (n = 53). A total of 1141 TRPs were identified for both groups at baseline, with a mean number of 10.8 ± 4.2 TRPs per patient. At follow-up, there was a significant decrease in the number of TRPs among the intervention group (P < 0.001, paired sample t-test) but not among the control group (P = 0.116). Physicians' approval rate of the pharmacist's recommendations was high (82.9%), and more than 70.0% of refugees in the intervention group reported high satisfaction with the HMMR service. Identified TRPs are high amongst Syrian refugees living in Jordan. The HMMR service significantly reduced the number of TRPs, and was highly accepted by the physicians. Refugees reported high satisfaction with this service.

Evaluations of outcomes for children and youth from NGO-supported microeconomic interventions: a research synthesis

Economic strengthening (ES) approaches are increasingly applied in resource-poor environments, including in humanitarian crisis settings, in order to achieve a wide variety of socio-economic goals. At the same time, randomized control trial (RCT) methodology has become more prevalent in evaluations of ES and other microeconomic interventions. This review is a systematic research synthesis of randomized impact evaluations of NGO-implemented interventions in low-income countries that work to build income and/or economic assets either of the caregiver, the household, or the individual child, adolescent, or youth, where the evaluation looked at any child-level or youth-level outcomes. The papers evaluate interventions that work to build household or individual income and/or assets, such as conditional and unconditional cash and asset transfers, savings, and training. We find a wide variety of direct and indirect interventions that can potentially affect children. Most of the statistically significant findings from these studies are good for children across a range of outcome measures; however among the studies included here, there is no discernible pattern of any particular intervention category (skills training, savings, etc.) being more effective than any other at achieving better outcomes for children. In many outcome categories, researchers could find no short-term impact on children from ES programming at all. Unintended negative effects for children were found in over 20 per cent of the studies in our document set. By focusing on RCT evaluations of non-governmental programmes, we provide information about the highest quality evaluations of interventions that may be feasible to implement for programmers interested in this topic.

Development of a brief screening tool for women's mental health assessment in refugee settings: A psychometric evaluation.

The detection of common mental disorders in humanitarian crisis settings requires a screening tool that is feasible to use as well as sensitive and specific. The Self-Report Questionnaire, developed by the World Health Organization in 1994 to detect presence or absence of common mental health disorders, has frequently been used among conflict-affected and refugee populations. Our goal was to identify a highly predictive and reliable subset of items to serve as a screening tool that can be used in busy, over-crowded, and low-resource primary health care settings to identify women who need mental health attention. We analyzed the responses on a version of the Self-Report Questionnaire expanded to include two suicidality items from 810 displaced women living in refugee camps in Rwanda. Screening items were selected and evaluated for predictive ability using logistic regression in a cross-validation process, sensitivity and specificity using receiver operating characteristic curve analysis, and internal consistency analysis. A five-item screening tool resulted. Those items are "Do you feel unhappy?", Do you feel easily nervous, tense, or worried?", "Have you lost interest in things?", "Do you have trouble thinking clearly?" and "Has the thought of ending your life been on your mind?". The Self-Report Questionnaire-5 may be an important tool for identifying common mental disorders as well as suicide ideation and behaviors when assessing mental health among women in crisis situations. Further evaluation of this tool is warranted.