Innovative Strategies for Remotely Sampling Hard-to-Reach Populations: Assessing Phone Versus Internet Respondent-Driven Sampling Approaches Among Venezuelan Refugees and Migrants in Colombia.

It is challenging to quantitatively measure the health vulnerability and risk factors of refugees and migrants residing outside of formal settlement settings. For hard-to-reach populations without available sampling frames, researchers have increasingly turned to novel sampling and statistical methods, like respondent-driven sampling (RDS). "Standard" RDS is typically conducted face-to-face at fixed sites. However, during the coronavirus disease 2019 (COVID-19) pandemic, face-to-face survey methods and recruitment approaches posed high potential risk of virus transmission and infection, making remote RDS approaches optimal. In this paper, we explore the feasibility of implementing telephone and Internet RDS strategies to assess challenges faced by Venezuelan refugees and migrants in the city of Bogotá, Colombia's capital, and the department of Norte de Santander, the main Venezuelan-Colombian border crossing site. We describe RDS assumptions, survey design, formative research, and the implementation of both strategies and present diagnostics for determining whether assumptions are met. Phone-based recruitment strategies in both locations and the Internet strategy in Bogotá achieved their calculated sample size; however, the Internet strategy in Norte de Santander did not. Most RDS assumptions were sufficiently met at sites where sample sizes were reached. These surveys provide valuable lessons for implementing innovative remote strategies with which to study hard-to-reach populations such as refugees and migrants.

Association between distress and displacement settings: a cross-sectional survey among displaced Yazidis in northern Iraq.

BACKGROUND: Globally 70.8 million people have been forcibly displaced from their homes and are at disproportionally high risk for trauma. At the time of this study, there was an estimated 1.6 million internally displaced persons (IDP) in Iraq, more than two-thirds of whom reside in private, urban settings. This study aims to understand the impact of post-displacement accommodation on mental well-being of the Yazidi minority group displaced in Iraq. METHODS: Multi-stage stratified sampling was used to randomly select IDPs in camp and out of camp settlements in northern Iraq. Standardized questionnaires evaluated factors including exposure to violence and self-reported distress symptoms (measured by Impact of Event Scale-Revised). A multi-variate linear model assessed the relationship between settlement setting and distress symptoms. RESULTS: One thousand two hundred fifty-six displaced Yazidi participants were included in the study: 63% in camps and 37% out of camps. After controlling for exposure to violence, social cohesion, unemployment, and access to basic services, IDPs in camps were predicted to have a 19% higher mean distress symptom score compared to those out of camps. CONCLUSIONS: This study provides a framework to investigate post-displacement accommodation as a potential intervention to improve well-being for displaced populations. With a shift towards new models of emergency and long-term housing, it is important to understand the potential and limitations of more decentralized models, and identify effective methods to maintain access to basic services while improving living conditions for both displaced populations and their host communities.

Dynamics of conflict during the Ebola outbreak in the Democratic Republic of the Congo 2018-2019.

BACKGROUND: The 2018-2019 Ebola virus disease (EVD) outbreak in North Kivu and Ituri provinces in the Democratic Republic of the Congo (DRC) is the largest ever recorded in the DRC. It has been declared a Public Health Emergency of International Concern. The outbreak emerged in a region of chronic conflict and insecurity, and directed attacks against health care workers may have interfered with disease response activities. Our study characterizes and quantifies the broader conflict dynamics over the course of the outbreak by pairing epidemiological and all available spatial conflict data. METHODS: We build a set of conflict variables by mapping the spatial locations of all conflict events and their associated deaths in each of the affected health zones in North Kivu and Ituri, eastern DRC, before and during the outbreak. Using these data, we compare patterns of conflict before and during the outbreak in affected health zones and those not affected. We then test whether conflict is correlated with increased EVD transmission at the health zone level. FINDINGS: The incidence of conflict events per capita is ~ 600 times more likely in Ituri and North Kivu than for the rest of the DRC. We identified 15 time periods of substantial uninterrupted transmission across 11 health zones and a total of 120 bi-weeks. We do not find significant short-term associations between the bi-week reproduction numbers and the number of conflicts. However, we do find that the incidence of conflict per capita was correlated with the incidence of EVD per capita at the health zone level for the entire outbreak (Pearson's r = 0.33, 95% CI 0.05-0.57). In the two provinces, the monthly number of conflict events also increased by a factor of 2.7 in Ebola-affected health zones (p value < 0.05) compared to 2.0 where no transmission was reported and 1.3 in the rest of the DRC, in the period between February 2019 and July 2019. CONCLUSION: We characterized the association between variables documenting broad conflict levels and EVD transmission. Such assessment is important to understand if and how such conflict variables could be used to inform the outbreak response. We found that while these variables can help characterize long-term challenges and susceptibilities of the different regions they provide little insight on the short-term dynamics of EVD transmission.

Risk Factors Associated With 7- Versus 30-Day Readmission Among Patients With Heart Failure Using the Nationwide Readmission Database.

BACKGROUND: The 30-day all-cause readmission for heart failure (HF) is a standard measure to evaluate hospital performance. A recent study found that a shorter period after discharge may be more indicative of hospital quality. OBJECTIVE: To compare risk factors for 7- versus 30-day readmission in patients with HF. DESIGN: This is a retrospective cohort using the 2014 Nationwide Readmissions Database. SUBJECTS: Patients 65 years and older with Medicare coverage discharged after HF admission. MEASURES: The 7- or 30-day all-cause readmissions were the outcomes of interest. HF-related readmissions were secondary outcomes. Covariates included patient characteristics, hospital characteristics, and admission-related information. Hierarchical logistic regression evaluated the association between covariates and readmissions. RESULTS: There were N=15,039 all-cause readmissions within 7 days after discharge and N=47,896 within 30 days. Surgical service was a risk factor for 30-day but not 7-day all-cause readmission (odds ratio=1.10, 95% confidence interval=1.05-1.16). Depression, rheumatoid arthritis, liver disease, drug abuse, lymphoma, and psychosis were associated with an increased risk of 30-day all-cause readmission but not 7-day. Longer lengths of stay also had a higher likelihood of all-cause readmission within 30 days compared with 7 days. In contrast, smaller hospital bed size was associated with an increased risk of 7-day all-cause readmission (odds ratio=1.06, confidence interval=1.01-1.12) but not 30-day. Sensitivity analysis with using a 3-day readmission interval showed similar results. CONCLUSIONS: Risk factors for hospital readmission are slightly different dependent on the measurement interval. In general, hospital-related factors were associated with shorter readmissions intervals while patient factors were more associated with longer intervals.

Environmental health effects attributed to toxic and infectious agents following hurricanes, cyclones, flash floods and major hydrometeorological events.

Extreme hydrometeorological events such as hurricanes and cyclones are increasing in frequency and intensity due to climate change and often associated with flash floods in coastal, urbanized and industrial areas. Preparedness and response measures need to concentrate on toxicological and infectious hazards, the potential impact on environmental health, and threat to human lives. The recognition of the danger of flood water after hurricanes is critical. Effective health management needs to consider the likelihood and specific risks of toxic agents present in waters contaminated by chemical spills, bio-toxins, waste, sewage, and water-borne pathogens. Despite significant progress in the ability to rapidly detect and test water for a wide range of chemicals and pathogens, there has been a lack of implementation to adapt toxicity measurements in the context of flash and hurricane-induced flooding. The aim of this review was to highlight the need to collect and analyze data on toxicity of flood waters to understand the risks and prepare vulnerable communities and first responders. It is proposed that new and routinely used technologies be employed during disaster response to rapidly assess toxicity and infectious disease threats, and subsequently take necessary remedial actions.

Real-world adherence for direct oral anticoagulants in a newly diagnosed atrial fibrillation cohort: does the dosing interval matter?

BACKGROUND: Differences in adherence may represent drug properties (e.g. dosing interval) or patient experiences while on treatment. Adherence to direct oral anticoagulants (DOACs) in nonvalvular atrial fibrillation (NVAF) is important to maintain effectiveness over the course of treatment. METHODS: This was a retrospective cohort study using 2009-2015 Truven Health MarketScan Databases. New initiators of dabigatran, rivaroxaban, and apixaban with NVAF were identified. Twelve months of continuous enrollment before treatment was required to assess demographics and medical history. Proportion of days cover (PDC) was used to measure adherence at 3, 6, 9 and 12-month. Gaps in therapy and treatment switches were also evaluated. Logistic regression was used to compare high adherence (PDC ≥0.80). RESULTS: A total of 14,864 dabigatran, 16,005 rivaroxaban, and 8078 apixaban users were identified. Apixaban users had the highest adherence overall, with mean PDC at 3, 6, 9, and 12-months of 0.83, 0.76, 0.72, and 0.69, while dabigatran had the lowest adherence of 0.78, 0.67, 0.61, and 0.57. Adherence to DOACs increased with increased stroke risk scores. Adherence was also higher when first days supplied was > 30 days compared to 30 days and when filled via mail order pharmacies. Switching was highest among dabigatran users. Apixaban users were the most likely to have high adherence versus dabigatran (OR = 1.73, 95% CI = 1.60-1.88) and versus rivaroxaban (OR = 1.24, 95% CI = 1.14-1.34) at 12-months. CONCLUSIONS: Apixaban users had the highest overall adherence despite twice-daily dosing versus once-daily dosing for rivaroxaban. These findings can be useful for formulary decision-making and when assessing treatment options.

Advancing disability-inclusive climate research and action, climate justice, and climate-resilient development.

Globally, more than 1 billion people with disabilities are disproportionately and differentially at risk from the climate crisis. Yet there is a notable absence of climate policy, programming, and research at the intersection of disability and climate change. Advancing climate justice urgently requires accelerated disability-inclusive climate action. We present pivotal research recommendations and guidance to advance disability-inclusive climate research and responses identified by a global interdisciplinary group of experts in disability, climate change, sustainable development, public health, environmental justice, humanitarianism, gender, Indigeneity, mental health, law, and planetary health. Climate-resilient development is a framework for enabling universal sustainable development. Advancing inclusive climate-resilient development requires a disability human rights approach that deepens understanding of how societal choices and actions-characterised by meaningful participation, inclusion, knowledge diversity in decision making, and co-design by and with people with disabilities and their representative organisations-build collective climate resilience benefiting disability communities and society at large while advancing planetary health.

Protective Behaviors Associated With Gender During the 2018-2020 Ebola Outbreak in Eastern Democratic Republic of the Congo.

Importance: In 2018 to 2020, the Democratic Republic of the Congo experienced the world's second largest Ebola virus disease (EVD) outbreak, killing 2290 individuals; women were disproportionately infected (57% of all cases) despite no evidence of differential biological EVD risk. Understanding how gender norms may influence exposure to EVD, intensity, and prognosis as well as personal protective behaviors against the virus is important to disease risk reduction and control interventions. Objective: To assess whether men and women differ in personal protective behaviors (vaccine acceptance, health-seeking behaviors, physical distancing) and the mediating role of EVD information and knowledge, perceived disease risk, and social relations. Design, Setting, and Participants: This cross-sectional, multistage cluster survey study of 1395 randomly selected adults was conducted in the Ebola-affected regions of North Kivu from April 20, 2019, to May 10, 2019. Path analyses were conducted using structural equation modeling to examine associations among study variables. Statistical analysis was conducted from August 2019 to May 2020. Main Outcomes and Measures: The main behavioral outcomes of interest were (1) vaccine acceptance, (2) formal health care seeking, and (3) self-protective behaviors. The primary factor of interest was self-reported gender identity. We also assessed sociodemographic factors. Results: Among the study's 1395 participants, 1286 (93%) had Nande ethnicity and 698 (50%) were women; the mean (SD) age was 34.5 (13.1) years. Compared with female participants, male participants reported significantly higher levels of education, wealth, and mobile phone access. There were associations found between gender and all EVD preventive behavioral outcomes, with evidence for mediation through EVD knowledge and belief in rumors. Men reported greater EVD knowledge accuracy compared with women (mean [SE] score for men: 12.06 [0.13] vs women: 11.08 [0.16]; P < .001), and greater knowledge accuracy was associated with increases in vaccine acceptance (ß = 0.37; P < .001), formal care seeking (ß = 0.39; P < .001), and self-protective behaviors (ß = 0.35; P < .001). Lower belief in rumors was associated with greater vaccine acceptance (ß = -0.30; P < .001), and greater EVD information awareness was associated with increased adoption of self-protective behaviors (ß = 0.23; P < .001). Conclusions and Relevance: This survey study found gender differences in adopting preventive protective behaviors against EVD. These findings suggest that it is critical to design gender-sensitive communication and vaccination strategies, while engaging women and their community as a whole in any response to infectious disease outbreaks. Research on the potential link between gender and sociodemographics factors associated with disease risk and outcomes is needed.

Assessing the impact of the COVID-19 pandemic among Venezuelan refugees and migrants in Colombia using respondent-driven sampling (RDS).

OBJECTIVES: To determine factors associated with adherence to COVID-19 mitigation measures, related symptoms and testing, as well as pandemic-related income loss among Venezuelan refugee and migrant adults in urban and border areas of Colombia. DESIGN: Phone-based respondent-driven sampling SETTING: Bogotá and Norte de Santander, Colombia. PARTICIPANTS: 605 adult Venezuelan refugees and migrants residing in Bogotá (n=305) and Norte de Santander (n=300), who arrived in Colombia after 2014 and completed the survey in August and September 2020. PRIMARY AND SECONDARY OUTCOME MEASURES: Full COVID-19 compliance (vs incomplete or no compliance), any COVID-19-related symptoms (vs none) and income loss due to isolation measures in Colombia (vs no income change or increase in income). RESULTS: Older age was associated with lower odds of compliance with physical distancing measures (0.94, 0.90-0.99; p=0.01) for those in Bogotá. Nearly 15% of refugees and migrants in both locations (81 of 605) experienced at least one symptom consistent with COVID-19. Having a health condition was associated with higher odds of experiencing COVID-19-related symptoms in Bogotá (4.00, 1.22-13.06; p=0.02) and Norte de Santander (6.99, 1.95-24.99; p=0.003). Around 8% in both locations (48 of 605) were tested for COVID-19. Around 90% in both locations (537 of 605) had trouble earning an income after the introduction of isolation measures, and the median reported monthly income decreased by half in Bogotá and by 30% in Norte de Santander. A higher level of education (3.46, 1.02-11.75; p=0.05) was associated with higher odds of income loss among participants in Norte de Santander. CONCLUSIONS: Results indicate high compliance with COVID-19 mitigation measures, low testing rates and high pandemic-related income loss among Venezuelan refugees and migrants in Colombia. This study provides insights into a hard-to-reach refugee and migrant population in Colombia; additional study on the effects of the pandemic on hidden populations is warranted.

Biosecurity at Cattle Farms: Strengths, Weaknesses, Opportunities and Threats.

Biosecurity is a key component of any animal and public health strategy and disease prevention and control programs. This study reviewed the main findings of different studies implemented from 2015 to 2021 to analyse the biosecurity situation at Belgian cattle farms, including attitudes and behaviours of cattle farmers and rural veterinarians regarding biosecurity measures. Specifically, the objective was to perform a SWOT (strengths, weaknesses, opportunities and threats) analysis of the situation and propose a new conceptual framework improving the level of biosecurity in the cattle sector. Biosecurity in cattle farming remains relatively low and faces multiple challenges. Its future improvement requires the different stakeholders to agree on shared goals and objectives and to carefully consider animal, public and environmental health, as well as socioeconomic and cultural factors. Further cost efficiency studies are required to identify the most important biosecurity measures and convince the stakeholders of their utility and benefits. Cattle farmers rely mainly on rural veterinarians for technical guidance and consider them as trustful informants. To be more effective in promoting these good practices, rural veterinarians need a proper guidance from the authorities, a proper training on biosecurity and communication, as well as an enabling environment.

Sense of coherence and its association with exposure to traumatic events, posttraumatic stress disorder, and depression in eastern Democratic Republic of Congo.

The Democratic Republic of Congo is the scene of some of the worst atrocities in recent history. However, in the face of traumatic experience, only a minority of people develops symptoms that impair their functioning. The sense of coherence proposed by Antonovsky (1987) is a theoretical construct reflecting an individual's overall wellbeing and ability to cope with stress. This study explores the relationships between sense of coherence, exposure to traumatic events, symptoms of posttraumatic stress disorder (PTSD), and depression. Results suggest an association between a high sense of coherence and high education levels, high income, and positive social relationships. Furthermore, the study found that sense of coherence is inversely correlated with cumulative exposure to violence and symptoms of PTSD and depression.

Association of exposure to violence and potential traumatic events with self-reported physical and mental health status in the Central African Republic.

CONTEXT: For decades, the Central African Republic (CAR) has experienced violence, economic stagnation, and institutional failure. The latest wave of violence erupted in 2001 and continues to this day in some areas. Yet there has been little attention to the conflict and even less research to document and quantify the conflict's human cost. OBJECTIVE: To study levels of violence in CAR, including mortality levels, and the association between exposure to violence and traumatic events with self-reported physical and mental health status. DESIGN, SETTING, AND PARTICIPANTS: Multistage stratified cluster random survey of 1879 adults 18 years or older in selected households conducted in 5 administrative units of CAR (3 in the south, which has been free from recent violence, and 2 in the north, in which violence continues) between October and December 2009. MAIN OUTCOME MEASURES: Mortality, morbidity, exposure to potential traumatic events, sense of insecurity, and meeting of symptom criteria for depression and anxiety using the Hopkins Symptom Checklist-25 with a cut-off score of 1.75. RESULTS: The crude mortality rate (CMR) was 4.9 deaths (95% confidence interval [CI], 4.6-5.1) per 1000 population per month and self-reported CMR due to violence was 0.8 deaths (95% CI, 0.6-1.0) per 1000 population per month. Thirty-five percent reported their physical health status as being good or very good while 29% described it as bad or very bad. Respondents in northern prefectures reported higher rates of mortality, exposure to trauma, and insecurity and lower levels of physical health and access to health services compared with those in the south. The estimated prevalences of symptoms of depression and anxiety were 55.3% (95% CI, 51.6%-59.0%) and 52.5% (95% CI, 48.1%-56.8%), respectively. Exposure to violence and self-reported physical health were statistically associated with mental health outcomes (P < .001). Anxiety symptom scores were higher for respondents in the northern prefectures than those in the south (t = 2.54, P = .01). CONCLUSION: A high proportion of adult respondents in CAR reported witnessing or having personally experienced traumatic events over the course of the conflicts, and more than half met symptom criteria for depression and anxiety.

Updating the Cost Effectiveness of Oral Anticoagulants for Patients with Atrial Fibrillation Based on Varying Stroke and Bleed Risk Profiles.

BACKGROUND: Previous investigations into the cost effectiveness of direct oral anticoagulants only considered individual stroke risk but not bleed risk even though bleeding is an important and potentially fatal side effect for anticoagulated patients. OBJECTIVE: This study aimed to evaluate the cost effectiveness of dabigatran, rivaroxaban, apixaban, and edoxaban vs warfarin in patients with atrial fibrillation with varying stroke/bleed risk profiles over a lifetime horizon. METHODS: A Markov micro-simulation was adapted to examine the lifetime costs and quality-adjusted survival of five anticoagulants from a US private payer's perspective. The study hypothetical cohort consisted of 10,000 patients with atrial fibrillation with age, CHA2DS2-VASc, and HAS-BLED scores similar to a commercially insured patient with atrial fibrillation cohort. Model input parameters including the efficacy and safety of each strategy, utilities, and cost were estimated from public sources, published literature, and analysis conducted in the IBM MarketScan database. Lifetime cost, quality-adjusted life-years, and incremental cost-effectiveness ratios were assessed for each treatment strategy. Subgroup analyses stratified by age, stroke risk score alone, bleed risk score alone and both were performed. Uncertainty was assessed by a deterministic sensitivity analysis and a probabilistic sensitivity analysis. RESULTS: The base-case analysis suggested dabigatran was the optimal treatment with an incremental cost-effectiveness ratio of $35,055 per quality-adjusted life-year relative to warfarin. Subgroup analyses stratified by age, stroke risk score, and bleed risk score alone were largely consistent with the base-case analysis. Subgroup analyses stratified by both stroke and bleed risk score showed edoxaban was the preferred treatment in patients with a low stroke and a low or medium bleed risk, and patients with a high stroke and low bleed risk. Apixaban was the preferred treatment in patients with a medium stroke and high bleed risk. Results of the deterministic sensitivity analysis indicate the model results were most sensitive to the drug cost and hazard ratio for stroke and bleeding event. Results of the probability sensitivity analysis showed dabigatran is cost effective vs. other treatments in 32.8% and 42.4% of iterations at a willingness to pay of $50,000/quality-adjusted life-year and a willingness to pay of $100,000/quality-adjusted life year, respectively. CONCLUSIONS: From a US private payer's perspective, dabigatran appears cost effective compared with other anticoagulants. This study indicated risk stratification especially considering both stroke and bleed risk simultaneously is important not only in clinical practice but also in health technology assessment exercises among patients with atrial fibrillation.

Predicting Cost-Effectiveness of Generic vs. Brand Dabigatran Using Pharmacometric Estimates Among Patients with Atrial Fibrillation in the United States.

Generic entry of newer anticoagulants is expected to decrease the costs of atrial fibrillation management. However, when making switches between brand and generic medications, bioequivalence concerns are possible. The objectives of this study were to predict and compare the lifetime cost-effectiveness of brand dabigatran with hypothetical future generics. Markov microsimulations were modified to predict the lifetime costs and quality-adjusted life years of patients on either brand or generic dabigatran from a US private payer perspective. Event rates for generics were predicted using previously developed pharmacokinetic-pharmacodynamic models. The analyses showed that generic dabigatran with lower-than-brand systemic exposure were dominant. Meanwhile, generic dabigatran with extremely high systemic exposure was not cost-effective compared with the brand reference. Cost-effectiveness of generic medications cannot always be assumed as shown in this example. Combined use of pharmacometric and pharmacoeconomic models can assist in decision making between brand and generic pharmacotherapies.

Incremental value of 2-dimensional speckle tracking strain imaging to wall motion analysis for detection of coronary artery disease in patients undergoing dobutamine stress echocardiography.

BACKGROUND: Interpretation of dobutamine stress echocardiogram (DSE) is often subjective and requires expert training. The purposes of this study was to determine optimal cutoff values for longitudinal, circumferential, and radial strains at peak DSE for detection of significant stenoses on coronary angiography and to investigate incremental value of combining strain measurements to wall motion analysis. METHODS: In this multicenter study, 102 patients underwent concomitant DSE and coronary angiography. Optimal cutoff values for mean global longitudinal (-20%), global circumferential (-26%), and mean radial (50%) strains at peak stress for detection of significant stenoses on coronary angiography were determined in a derivation group (n = 62) and tested in a prospectively recruited validation group (n = 40). RESULTS: Respective sensitivities for longitudinal, circumferential, radial strains, and expert wall motion score index (WMSI) were 84.2%, 73.9%, 78.3%, and 76%; respective specificities were 87.5%, 78.6%, 57.1%, and 92.9%; and respective accuracies were 85.2%, 75.7%, 70.3%, and 82.1%. Longitudinal strain analysis had comparable accuracy to WMSI (P = .70). However, combination longitudinal strain and WMSI had the highest sensitivity, specificity, and accuracy (100%, 87.5%, and 96.3% respectively), and its diagnostic accuracy was incremental to either longitudinal strain (P = .034) or WMSI alone (P = .008). CONCLUSION: Longitudinal strain analysis had higher diagnostic accuracy than circumferential and radial strains and was comparable to WMSI for detection of significant coronary artery disease. However, combination longitudinal strain and WMSI resulted in significant incremental increase in diagnostic accuracy.

Returning home: forced conscription, reintegration, and mental health status of former abductees of the Lord's Resistance Army in northern Uganda.

BACKGROUND: Since the late 1980s, the Lord's Resistance Army (LRA), a spiritualist rebel group in northern Uganda, has killed and mutilated thousands of civilians and abducted an estimated 52,000 to 75,000 people to serve as soldiers, porters, and sex slaves for its commanders. This study examines the types of violence to which former abductees have been exposed and the extent to which these acts have affected their psychological well-being. METHODS: This is a cross-sectional study of 2,875 individuals selected through a multi-stage stratified cluster sampling design conducted in 8 districts of northern Uganda. Multivariate logistic regressions were performed with symptoms for Post-traumatic Stress Disorder (PTSD) and depression as the main outcome measures. RESULTS: One-third of the respondents (33%) self-reported having experienced abduction (49% among the Acholi, the largest tribal group in northern Uganda). Over half (56%) of all the respondents and over two-thirds of those who experienced abduction met the criteria for symptoms of post-traumatic stress disorder (PTSD). Multivariate analysis shows that several factors increased the risk of former LRA abductees developing symptoms of PTSD. These factors included gender (females were more susceptible than males), being a member of the Acholi ethnic group, participating in or witnessing a cumulative number of traumatic events, and encountering difficulties re-integrating into communities after abduction. Factors associated with increased risk of meeting criteria for symptoms of depression included older age of males at the time of abduction, lower score on social relationship scale, high incidence of general traumatic event exposure, high incidence of forced acts of violence, and problems reintegrating into communities after abduction. CONCLUSION: Abduction and forced conscription of civilians has affected the psychological well-being of a significant number of northern Ugandans. The sources of psychological trauma are multiple, ranging from witnessing to being forced to commit violent acts, and compounded by prolonged exposure to violence, often for months or years. Community-based mental health care services and reintegration programs are needed to facilitate the reintegration of former abductees back into their communities.

Institutional trust and misinformation in the response to the 2018-19 Ebola outbreak in North Kivu, DR Congo: a population-based survey.

BACKGROUND: The current outbreak of Ebola in eastern DR Congo, beginning in 2018, emerged in a complex and violent political and security environment. Community-level prevention and outbreak control measures appear to be dependent on public trust in relevant authorities and information, but little scholarship has explored these issues. We aimed to investigate the role of trust and misinformation on individual preventive behaviours during an outbreak of Ebola virus disease (EVD). METHODS: We surveyed 961 adults between Sept 1 and Sept 16, 2018. We used a multistage sampling design in Beni and Butembo in North Kivu, DR Congo. Of 412 avenues and cells (the lowest administrative structures; 99 in Beni and 313 in Butembo), we randomly selected 30 in each city. In each avenue or cell, 16 households were selected using the WHO Expanded Programme on Immunization's random walk approach. In each household, one adult (aged ≥18 years) was randomly selected for interview. Standardised questionnaires were administered by experienced interviewers. We used multivariate models to examine the intermediate variables of interest, including institutional trust and belief in selected misinformation, with outcomes of interest related to EVD prevention behaviours. FINDINGS: Among 961 respondents, 349 (31·9%, 95% CI 27·4-36·9) trusted that local authorities represent their interest. Belief in misinformation was widespread, with 230 (25·5%, 21·7-29·6) respondents believing that the Ebola outbreak was not real. Low institutional trust and belief in misinformation were associated with a decreased likelihood of adopting preventive behaviours, including acceptance of Ebola vaccines (odds ratio 0·22, 95% CI 0·21-0·22, and 1·40, 1·39-1·42) and seeking formal health care (0·06, 0·05-0·06, and 1·16, 1·15-1·17). INTERPRETATION: The findings underscore the practical implications of mistrust and misinformation for outbreak control. These factors are associated with low compliance with messages of social and behavioural change and refusal to seek formal medical care or accept vaccines, which in turn increases the risk of spread of EVD. FUNDING: The Harvard Humanitarian Initiative Innovation Fund.

Exposure to war crimes and implications for peace building in northern Uganda.

CONTEXT: Since the late 1980s, the Lord's Resistance Army has waged war against the Ugandan People's Democratic Army and the people of northern Uganda. Ending the conflict and achieving peace have proven to be challenges. In this context, it is important to examine population-based data on exposure to war crimes to understand how survivors perceive mechanisms aimed at achieving a lasting peace. OBJECTIVES: To assess the level of exposure to war-related violence and the prevalence of posttraumatic stress disorder (PTSD) and depression symptoms in northern Uganda and to determine how these variables are associated with respondents' views about peace. DESIGN, SETTING, AND PARTICIPANTS: Multistage, stratified, random cluster survey of 2585 adults aged 18 years or older conducted in villages and camps for internally displaced persons in 4 districts of northern Uganda in April and May 2005. MAIN OUTCOME MEASURES: Rates and patterns of exposure to trauma; symptom criteria for PTSD, assessed via the PTSD Checklist-Civilian Version with a total severity score of 44; symptoms of depression, assessed via the Johns Hopkins Depression Symptom Checklist with a cutoff of 42; and opinions and attitudes about peace. RESULTS: Among the respondents, 1774 of 2389 (74.3%) met PTSD symptom criteria and 1151 of 2585 (44.5%) met depression symptom criteria. Four patterns of exposure to trauma were distinguished: those with low exposure (group 1; 21.4%), witnesses to war-related violence (group 2; 17.8%), those threatened with death and/or physically injured (group 3; 16.4%), and those abducted (group 4; 44.3%). Respondents in groups 3 and 4, who experienced the most traumatic exposures, were more likely to have PTSD symptoms compared with group 1 (group 3 vs group 1: odds ratio [OR], 7.04 [95% confidence interval {CI}, 5.02-9.87]; group 4 vs group 1: OR, 6.07 [95% CI, 4.77-7.71]). Groups 3 and 4 were also more likely to meet depression symptom criteria (group 3 vs group 1: OR, 5.76 [95% CI, 4.34-7.65]; group 4 vs group 1: OR, 4.00 [95% CI, 3.16-5.06]). Respondents who met the PTSD symptom criteria were more likely to identify violence as a means to achieve peace (OR, 1.31; 95% CI, 1.05-1.65). Respondents who met the depression symptom criteria were less likely to identify nonviolence as a means to achieve peace (OR, 0.77; 95% CI, 0.65-0.93). CONCLUSIONS: Our study found high prevalence rates for symptoms of PTSD and depression in a conflict zone. Respondents reporting symptoms of PTSD and depression were more likely to favor violent over nonviolent means to end the conflict.

The United Nations Material Assistance to Survivors of Cholera in Haiti: Consulting Survivors and Rebuilding Trust.

INTRODUCTION: In August 2016, the United Nations (U.N.) Secretary General acknowledged the U.N.'s role in the cholera epidemic that has beset Haiti since 2010. Two months later, the Secretary General issued a historic apology to the Haitian people before the U.N. General Assembly, for the organization's insufficient response to the cholera outbreak. These steps are part of the U.N.'s "new approach" to cholera in Haiti, which also includes launching a material assistance package for those most affected by cholera. METHODS: This paper draws on the authors' experience and findings from consultations with more than 60,000 victims and communities affected by disasters and violence in a dozen countries. We reviewed the literature on best practices for consultation with and outreach to communities affected by development and transitional justice programming, and reviewed our own findings from previous studies with a view to identifying recommendations for ensuring that the assistance package reflects the views of people affected by cholera. RESULTS: The assistance package program is an opportunity to rebuild the relationship between the victims and the United Nations. This can only be achieved if victims are informed and engaged in the process. This consultation effort is also an opportunity to answer a set of key questions related to the nature, structure, and implementation of the victims' assistance program, but also how the program may be designed to contribute to rebuilding Haitians' confidence in the U.N. as an institution that promotes peace, human rights, and development. DISCUSSION: We recommend that the consultations must be accompanied by an outreach effort that provides clear, accurate information on the assistance program, so that it begins to establish a dialogue between the U.N. and cholera victims. Finally, we conclude by offering a number of concrete next steps that the U.N. can take to kick start the consultation process.

Epidemiology of Chikungunya fever outbreak in Western Jamaica during July-December 2014.

OBJECTIVE: Our study describes the 2014 Chikungunya outbreak in Western Jamaica in terms of geographic distribution and trend of the outbreak over time, and evaluates clinical symptoms of the disease based on pre-existing conditions. METHODS: We conducted a retrospective, cross-sectional study of 609 clinically defined Chikungunya virus (CHIKV) fever cases that occurred in the four parishes of the Western Regional Health Authority of Jamaica from July 2014 to December 2014. Cases were not confirmed by laboratory tests but met clinical and epidemiological criteria of CHIKV fever. RESULTS: Our results show a propagated spread of CHIKV fever during the outbreak period with the peak at the end of October. Main urban cities, such as Montego Bay and Lucea, were identified as places that had high numbers of cases. Fever and arthralgia were the two most common clinical symptoms in CHIKV patients. Although a majority (80%) of infants aged <2 years had up to four symptoms (80%), the percentage of infants with higher numbers of symptoms (9-10) was higher than in older age groups. However, back pain was found to occur significantly more in older patients. Those with arthritis as a pre-existing condition were more likely to experience headache, asthenia, back pain, and periarticular edema. CONCLUSION: These findings can help public health officials develop more effective programs to prevent the spread of CHIKV outbreaks by focusing on crowded urban cities. The findings indicate that those who are likely to develop a higher number of symptoms, such as young infants and people with pre-existing conditions, such as arthritis, should be more closely monitored to better manage the disease outcome.