The association between armed conflict,violence and mental health: a cross sectional study comparing two populations in Cundinamarca department,Colombia

Background

Exposure to violence in general and to armed conflict in particular has been consistently associated with an increased prevalence of mental illness. Colombia has sustained an internal armed conflict for decades and is considered one of the most violent countries in the world. However, certain areas have been more exposed to the conflict than others.

Methods

This is a cross sectional study comparing two communities from different villages in the department of Cundinamarca, Colombia. One, Guasca, was directly impacted by armed conflict. The other one; Guatavita has never been affected by armed conflict. We applied two different instruments: the PHQ scale and a short standardized interview in order to estimate the prevalence of major psychiatric disorders and their link to violent events. Forty-two volunteers from each village were evaluated through a personal interview using these two instruments.

Findings

Of the population surveyed in Guatavita, 2.4% reported direct exposure to violence compared to 23.8% from Guasca. In the population exposed directly to violent events, the prevalence of all disorders was greater than in the non-exposed population with an OR of 1.46 (95% CI 0.3809 - 5.5989) for anxiety; 4.54 (95% CI 1.1098 - 18.5984) for depression; 6.0 (95% CI 1.2298 - 30.2263) for somatization disorder; and 4.4 (95% CI 1.2037 - 16.0842) for alcohol abuse.

Interpretation

There is a statistically significant association between the history of armed conflict, violence and the presence of mental illnesses, particularly depression, somatization disorder and alcohol abuse. Special attention should be paid to the detection, prevention and treatment of these disorders when dealing with populations exposed to violence and to armed conflict in particular.

     

Armed conflict,alcohol misuse,decision-making,and intimate partner violence among women in Northeastern Uganda: a population level study

Background

Relations among and interactions between exposure to armed conflict, alcohol misuse, low socioeconomic status, gender (in)equitable decision-making, and intimate partner violence (IPV) represent serious global health concerns. Our objective was to determine extent of exposure to these variables and test pathways between these indicators of interest.

Methods

We surveyed 605 women aged 13 to 49 who were randomly selected via multistage sampling across three districts in Northeastern Uganda in 2016. We used Mplus 7.4 to estimate a moderated structural equation model of indirect pathways between armed conflict and intimate partner violence for currently partnered women (n?=?558) to evaluate the strength of the relationships between the latent factors and determine the goodness-of-fit of the proposed model with the population data.

Results

Most respondents (88.8%) experienced conflict-related violence. The lifetime/ past 12 month prevalence of experiencing intimate partner violence was 65.3%/ 50.9% (psychological) and 59.9%/ 43.8% (physical). One-third (30.7%) of women’s partners reportedly consumed alcohol daily. The relative fit of the structural model was superior (CFI?=?0.989; TLI?=?0.989). The absolute fit (RMSEA?=?0.029) closely matched the population data. The partner and joint decision-making groups significantly differed on the indirect effect through partner alcohol use (a₁b₁?=?0.209 [0.017: 0.467]).

Conclusions

This study demonstrates that male partner alcohol misuse is associated with exposure to armed conflict and intimate partner violence—a relationship moderated by healthcare decision-making. These findings encourage the extension of integrated alcohol misuse and intimate partner violence policy and emergency humanitarian programming to include exposure to armed conflict and gendered decision-making practices.

     

The impact of conditional cash transfers on child health in low- and middle-income countries: a systematic review

Objectives

The review aimed to assess the effectiveness of conditional cash transfers (CCTs) in improving child health in low- and middle-income countries.

Methods

Seven electronic databases were searched for papers: MEDLINE, EMBASE, PubMed, PsychINFO, BIOSIS Previews, Academic Search Complete, and CSA Sociological Abstracts. The included studies comprised of randomised controlled trials and controlled before-and-after studies evaluating the impact of CCTs on child health. Due to the substantial heterogeneity of the studies, a narrative synthesis was conducted on the extracted data.

Results

Sixteen studies predominantly from Latin American countries met the inclusion criteria. The outcomes reported by the studies in relation to CCTs’ effectiveness in improving child health were reduction in morbidity risk, improvement in nutritional outcomes, health services utilisation, and immunisation coverage.

Conclusions

The review suggests that to a large extent, CCTs are effective in improving child health by addressing child health determinants such as access to health care, child and maternal nutrition, morbidity risk, immunisation coverage, and household poverty in developing countries particularly middle-income countries. Of importance to both policy and practice, it appears that CCTs require effective functioning of health care systems to effectively promote child health.     

Helping Children Exposed to War and Violence: Perspectives from an International Work Group on Interventions for Youth and Families

Background

This paper outlines conclusions from a three-day workgroup hosting the eight authors as well as others with expertise in the evaluation and treatment of youth exposed to war and violence.

Objective

The purpose of this meeting was to bring multiple perspectives together to identify components that comprise effective psychosocial interventions for child victims of war and community violence across cultures. The meeting also sought to identify gaps in the existing treatment approaches.

Method

In the meeting, personal experiences and previous research were discussed to develop a wide-ranging intervention approach, determine a cohesive definition for “indirect” exposure, and identify successful methods of intervention delivery for youth exposed to acts of war and violence.

Results and Conclusions

Key components of intervention for youth exposed to war/violence, important outcome measures, and cultural differences that may influence effective intervention were identified. A clearer definition of “indirect” exposure was also developed. Finally, a nine-phase model was developed to provide guidelines for establishing partnerships between trauma teams and other organizations or schools to implement and disseminate treatment for this population.     

Equity of primary care service delivery for low income “sicker” adults across 10 OECD countries

Background

Despite significant investments to support primary care internationally, income-based inequities in access to quality health care are present in many high-income countries. This study aims to determine whether low- and middle-income groups are more likely to report poor quality of primary care (PC) than high-income groups cross-nationally.

Methods

The 2011 Commonwealth Fund Telephone Survey of Sicker Adults is a cross-sectional study across eleven countries. Respondents were recruited from randomly selected households. We used data from surveys conducted in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States. We identified all questions relating to primary care performance, and categorized these into five dimensions: 1) access to care, 2) coordination 3) patient-centered care, and 4) technical quality of care. We used logistic regression with low and middle-income as the comparison groups and high-income as the referent.

Results

Fourteen thousand two hundred sixty-two respondents provided income data. Countries varied considerably in their extent of income disparity. Overall, 24.7% were categorized as low- and 13.9% as high-income. The odds of reporting poor access to care were higher for low- and middle-income than high-income respondents in Canada, New Zealand and the US. Similar results were found for Sweden and Norway on coordination; the opposite trend favoring the low- and middle-income groups was found in New Zealand, United Kingdom, and the United States. The odds of reporting poor patient-centered care were higher for low-income than high-income respondents in the Netherlands, Norway, and the US; in Australia, this was true for low- and middle-income respondents. On technical quality of care, the odds of reporting poor care were higher for the low- and middle-income comparisons in Canada and Norway; in Germany, the odds were higher for low-income respondents only. The odds of reporting poor technical quality of care were higher for high-income than low-income respondents in the Netherlands.

Conclusion

Inequities in quality PC for low and middle income groups exist on at least one dimension in all countries, including some that in theory provide universal access. More research is needed to fully understand equity in the PC sector.

     

A Challenging Job: Physical and Sexual Violence Towards Group Workers in Youth Residential Care

Background

Residential or group care social workers appear to be at increased risk for experiencing physical violence at work. However, little is known about sexual harassment in addition to physical victimization of social workers in youth residential or group care.

Objective

We investigated the prevalence of physical and sexual victimization of youth care workers in residential care and tested whether characteristics of the group care workers and the type of care facility influenced this prevalence.

Methods

One hundred seventy-eight participants reported whether they had experienced verbal threat, physical threat, physical violence, verbal sexual harassment, and physical sexual harassment by one or more of the youth they worked with in a 1-year period.

Results

Eighty-one percent of the group workers experienced violence. Most incidents were verbal threats, but about half of the participants experienced physical violence. Youth care workers from secure care were most at risk for experiencing physical and verbal violence and workers from juvenile detention facilities were most at risk for experiencing sexual harassment. Rates of violence were increased for participants working with children with a mild intellectual disability. Gender of the youth care workers was not related to the rate of victimization, but age was: younger group workers reported more incidents than older group workers.

Conclusions

The high levels of violence in residential youth care indicate that residential care is not the best workplace for professionals nor the best rearing setting for youth. Alternative care settings, such as treatment in a family-type environment, should be explored.     

Priorities for research into human resources for health in low- and middle-income countries

Objective

To identify the human resources for health (HRH) policy concerns and research priorities of key stakeholders in low- and middle-income countries; to assess the extent to which existing HRH research addresses these concerns and priorities; and to develop a prioritized list of core research questions requiring immediate attention to facilitate policy development and implementation.

Methods

The study involved interviews with key informants, including health policy-makers, researchers and community and civil society representatives, in 24 low- and middle-income countries in four regions, a literature search for relevant reviews of research completed to date, and the assessment of interview and literature search findings at a consultative multinational workshop, during which research questions were prioritized.

Findings

Twenty-one research questions emerged from the key informant interviews, many of which had received little or no attention in the reviewed literature. The questions ranked as most important at the consultative workshop were: (i) To what extent do incentives work in attracting and retaining qualified health workers in underserviced areas? (ii) What is the impact of dual practice and multiple employment? and (iii) How can incentives be used to optimize efficiency and the quality of health care?

Conclusion

There was a clear consensus about the type of HRH policy problems faced by different countries and the nature of evidence needed to tackle them. Coordinated action to support and implement research into the highest priority questions identified here could have a major impact on health worker policies and, ultimately, on the health of the poor.     

Short and longer-term psychological consequences of Operation Cast Lead: documentation from a mental health program in the Gaza Strip

Background

There is growing recognition of the psychological impact of adversity associated with armed conflict on exposed civilian populations. Yet there is a paucity of evidence on the value of mental health programs in these contexts, and of the chronology of psychological sequelae, especially in prolonged conflicts with repeated cycles of extreme violence. Here, we describe changes in the psychological profile of new patients in a mental health program after the military offensive Cast Lead, in the context of the prolonged armed conflict involving the Gaza Strip.

Methods

This study analyses routinely collected program data from a Médecins Sans Frontières mental health program in the Gaza Strip spanning 2007?C2011. Data consist of socio-demographic as well as clinical baseline and follow-up data on new patients entering the program. Comparisons were made through Chi square and Fisher??s exact tests, univariate and multivariate logistic and linear regression.

Results

PTSD, depression and other anxiety disorders were the most frequent psychopathologies, with 21% having multiple diagnoses. With a median of nine sessions, clinical improvement was recorded for 83% (1122/1357), and more common for those with separation anxiety, acute and posttraumatic disorders as principal diagnosis (855/1005), compared to depression (141/183, p<0.01). Noted changes proximal to Operation Cast Lead were: a doubling in patient case load with a broader socio-economic background, shorter interval from an identified traumatic event to seeking care, and a rise in diagnoses of acute and posttraumatic stress disorders. Sustained changes included: high case load, more distal triggering events, and increase in diagnoses of other anxiety disorders (especially for children 15 years and younger) and depression (especially for patients 16 years and older).

Conclusion

Evolving changes in patient volume, diagnoses and recall period to triggering events suggest a lengthy and durable effect of an intensified exposure to violence in a context of prolonged conflict. Our findings suggest that mental health related humanitarian relief in protracted conflicts might need to prepare for an increase in patients with changing profiles over an extended period following an acute flare-up in violence.     

Hospital payment systems based on diagnosis-related groups: experiences in low- and middle-income countries

Objective

This paper provides a comprehensive overview of hospital payment systems based on diagnosis-related groups (DRGs) in low- and middle-income countries. It also explores design and implementation issues and the related challenges countries face.

Methods

A literature research for papers on DRG-based payment systems in low- and middle-income countries was conducted in English, French and Spanish through Pubmed, the Pan American Health Organization’s Regional Library of Medicine and Google.

Findings

Twelve low- and middle-income countries have DRG-based payment systems and another 17 are in the piloting or exploratory stage. Countries have chosen from a wide range of imported and self-developed DRG models and most have adapted such models to their specific contexts. All countries have set expenditure ceilings. In general, systems were piloted before being implemented. The need to meet certain requirements in terms of coding standardization, data availability and information technology made implementation difficult. Private sector providers have not been fully integrated, but most countries have managed to delink hospital financing from public finance budgeting.

Conclusion

Although more evidence on the impact of DRG-based payment systems is needed, our findings suggest that (i) the greater portion of health-care financing should be public rather than private; (ii) it is advisable to pilot systems first and to establish expenditure ceilings; (iii) countries that import an existing variant of a DRG-based system should be mindful of the need for adaptation; and (iv) countries should promote the cooperation of providers for appropriate data generation and claims management.     

Satellite-aided survey sampling and implementation in low- and middle-income contexts: a low-cost/low-tech alternative

Background

The increasing availability of online maps, satellite imagery, and digital technology can ease common constraints of survey sampling in low- and middle-income countries. However, existing approaches require specialised software and user skills, professional GPS equipment, and/or commercial data sources; they tend to neglect spatial sampling considerations when using satellite maps; and they continue to face implementation challenges analogous to conventional survey implementation methods. This paper presents an alternative way of utilising satellite maps and digital aides that aims to address these challenges.

Results

The case studies of two rural household surveys in Rajasthan (India) and Gansu (China) compare conventional survey sampling and implementation techniques with the use of online map services such as Google, Bing, and HERE maps. Modern yet basic digital technology can be integrated into the processes of preparing, implementing, and monitoring a rural household survey. Satellite-aided systematic random sampling enhanced the spatial representativeness of the village samples and entailed savings of approximately £4000 compared to conventional household listing, while reducing the duration of the main survey by at least 25 %.

Conclusion

This low-cost/low-tech satellite-aided survey sampling approach can be useful for student researchers and resource-constrained research projects operating in low- and middle-income contexts with high survey implementation costs. While achieving transparent and efficient survey implementation at low costs, researchers aiming to adopt a similar process should be aware of the locational, technical, and logistical requirements as well as the methodological challenges of this strategy.

     

Value innovation: an important aspect of global surgical care

Introduction

Limited resources in low- and middle-income countries (LMICs) drive tremendous innovation in medicine, as well as in other fields. It is not often recognized that several important surgical tools and methods, widely used in high-income countries, have their origins in LMICs. Surgical care around the world stands much to gain from these innovations. In this paper, we provide a short review of some of these succesful innovations and their origins that have had an important impact in healthcare delivery worldwide.

Review

Examples of LMIC innovations that have been adapted in high-income countries include the Bogotá bag for temporary abdominal wound closure, the orthopaedic external fixator for complex fractures, a hydrocephalus fluid valve for normal pressure hydrocephalus, and intra-ocular lens and manual small incision cataract surgery. LMIC innovations that have had tremendous potential global impact include mosquito net mesh for inguinal hernia repair, and a flutter valve for intercostal drainage of pneumothorax.

Conclusion

Surgical innovations from LMICs have been shown to have comparable outcomes at a fraction of the cost of tools used in high-income countries. These innovations have the potential to revolutionize global surgical care. Advocates should actively seek out these innovations, campaign for the financial gains from these innovations to benefit their originators and their countries, and find ways to develop and distribute them locally as well as globally.     

Results of the Global Youth Tobacco Survey and implementation of WHO Framework Convention on Tobacco Control in former Soviet Union countries

Objectives

We used data from the Global Youth Tobacco Survey (GYTS) to monitor articles of the World Health Organization Framework Convention on Tobacco Control in Former Soviet Union (FSU) countries.

Methods

The GYTS is a school-based survey, which uses a two-stage sample design to produce representative, independent, cross-sectional estimates. The GYTS was conducted in 10 out of 12 FSU countries from 1999 to 2008.

Results

The prevalence of ever smoking and current smoking, smoking initiation, and exposure to second-hand smoking decreased over time. Overall, willingness to stop smoking, supporting smoking bans, and receiving information about the dangers of smoking increased over time.

Conclusions

Overall, our study shows that FSU countries had positive changes in tobacco-use prevalence and perception among youth over time. Our findings should be used as baseline measures for future tobacco-control interventions aimed at reducing tobacco use among youth. Moreover, our results call for the enforcement of restricting advertising for tobacco products.     

Schutz vor Zoster

Background

Discussions on health sector reform in low-income and middle-income countries increasingly focus on the recognition of private-sector health care providers.

Aim

A review of recent literature presents trends of private stakeholder involvement as well as the potential for private sector participation in health system development and primary health care in these countries.

Results

Appropriate incentive structures may encourage private sector investments in health care as well as in service delivery in an efficient way and at reasonable cost – not only for the better-off. The role of government lies with regulation, health politics, and stewardship for health system financing. This approach may constitute an important contribution to achieving the goal of universal access to health care in the 21st century.     

SUPPORT Tools for evidence-informed Policymaking in health 11: Finding and using evidence about local conditions

Background

Little is known about the process of knowledge translation in low- and middle-income countries. We studied policymaking processes in Mozambique, South Africa and Zimbabwe to understand the factors affecting the use of research evidence in national policy development, with a particular focus on the findings from randomized control trials (RCTs). We examined two cases: the use of magnesium sulphate (MgSO₄) in the treatment of eclampsia in pregnancy (a clinical case); and the use of insecticide treated bed nets and indoor residual household spraying for malaria vector control (a public health case).

Methods

We used a qualitative case-study methodology to explore the policy making process. We carried out key informants interviews with a range of research and policy stakeholders in each country, reviewed documents and developed timelines of key events. Using an iterative approach, we undertook a thematic analysis of the data.

Findings

Prior experience of particular interventions, local champions, stakeholders and international networks, and the involvement of researchers in policy development were important in knowledge translation for both case studies. Key differences across the two case studies included the nature of the evidence, with clear evidence of efficacy for MgSO₄ and ongoing debate regarding the efficacy of bed nets compared with spraying; local researcher involvement in international evidence production, which was stronger for MgSO₄ than for malaria vector control; and a long-standing culture of evidence-based health care within obstetrics. Other differences were the importance of bureaucratic processes for clinical regulatory approval of MgSO₄, and regional networks and political interests for malaria control. In contrast to treatment policies for eclampsia, a diverse group of stakeholders with varied interests, differing in their use and interpretation of evidence, was involved in malaria policy decisions in the three countries.

Conclusion

Translating research knowledge into policy is a complex and context sensitive process. Researchers aiming to enhance knowledge translation need to be aware of factors influencing the demand for different types of research; interact and work closely with key policy stakeholders, networks and local champions; and acknowledge the roles of important interest groups.     

Gender-based violence in conflict and displacement: qualitative findings from displaced women in Colombia

Introduction

Gender-based violence (GBV) is prevalent among, though not specific to, conflict affected populations and related to multifarious levels of vulnerability of conflict and displacement. Colombia has been marked with decades of conflict, with an estimated 5.2 million internally displaced persons (IDPs) and ongoing violence. We conducted qualitative research to understand the contexts of conflict, displacement and dynamics with GBV. This as part of a multi-phase, mixed method study, in collaboration with UNHCR, to develop a screening tool to confidentially identify cases of GBV for referral among IDP women who were survivors of GBV.

Methods

Qualitative research was used to identify the range of GBV, perpetrators, contexts in conflict and displacement, barriers to reporting and service uptake, as well as to understand experiences of service providers. Thirty-five female IDPs, aged 18 years and older, who self-identified as survivors of GBV were enrolled for in-depth interviews in San Jose de Guaviare and Quibdo, Colombia in June 2012. Thirty-one service providers participated in six focus group discussions and four interviews across these sites.

Results

Survivors described a range of GBV across conflict and displacement settings. Armed actors in conflict settings perpetrated threats of violence and harm to family members, child recruitment, and, to a lesser degree, rape and forced abortion. Opportunistic violence, including abduction, rape, and few accounts of trafficking were more commonly reported to occur in the displacement setting, often perpetrated by unknown individuals. Intrafamilial violence, intimate partner violence, including physical and sexual violence and reproductive control were salient across settings and may be exacerbated by conflict and displacement. Barriers to reporting and services seeking were reported by survivors and providers alike.

Conclusions

Findings highlight the need for early identification of GBV cases, with emphasis on confidential approaches and active engagement of survivors in available, quality services. Such efforts may facilitate achievement of the goals of new Colombian laws, which seek to prevent and respond to GBV, including in conflict settings. Ongoing conflict and generalized GBV in displacement, as well as among the wider population, suggests a need to create sustainable solutions that are accessible to both IDPs and general populations.

     

Fruit and vegetable consumption and sports participation among UK Youth

Objectives

UK guidelines for youth recommend daily physical activity and five portions of fruit and vegetables per day. This study examined the prevalence and clustering of meeting recommendations among 10- to 15-year old.

Methods

Data for 3,914 youth, from the first wave of Understanding Society: the UK Household Longitudinal Study, were analysed. Clustering was assessed using the observed/expected ratio method.

Results

A minority of youth met both recommendations, and these behaviours were clustered. The odds of meeting both recommendations were lower for older youth and for Pakistani and Bangladeshi youth; boys in lower income households were less likely to meet both recommendations.

Conclusions

Most youth met neither recommendation and the behaviours clustered with variations by ethnicity and socioeconomic conditions.     

Physical inactivity and associated factors among university students in 23 low-, middle- and high-income countries

Objectives

The aim of this study was to determine estimates of the prevalence and social correlates of physical inactivity among university students in 23 low-, middle- and high-income countries.

Method

The International Physical Activity Questionnaire was used to collect data from 17,928 undergraduate university students (mean age 20.8, SD = 2.8) from 24 universities in 23 countries.

Results

The prevalence of physical inactivity was 41.4 %, ranging from 21.9 % in Kyrgyzstan to 80.6 % in Pakistan. In multivariate logistic regression, older age (22–30 years), studying in a low- or lower middle-income country, skipping breakfast and lack of social support were associated with physical inactivity. In men, being underweight, being overweight or obese, not avoiding fat and cholesterol, not having severe depression symptoms, low beliefs in the health benefits of physical activity, low personal control and knowledge of exercise-heart link, and in women, not trying to eat fibre, low personal mastery and medium personal control were additionally associated with physical inactivity.

Conclusion

Four in each ten students are physically inactive, calling for strategic interventions by relevant professionals in higher educational institutions.