Child marriage among displaced populations - a 2019 study in Kurdistan Region of Iraq.

BACKGROUND: Many of the factors that increase risk of child marriage are common among refugees and internally displaced persons (IDPs). We sought to address the gaps in knowledge surrounding child marriage in displaced and host populations in the Kurdistan Region of Iraq (KRI). METHODS: A multistage cluster sample design was employed collecting data of KRI host communities, Iraqi IDPs, and Syrian refugees. Interviews were conducted in eligible households, requiring at least one adult female and one female adolescent present, addressing views of marriage, demographics and socioeconomic factors. Household rosters were completed to assess WHO indicators, related to child marriage including completed child marriage in females 10-19 and completed risk of previously conducted child marriages in females 20-24. RESULTS: Interviews were completed in 617 hosts, 664 IDPs, and 580 refugee households, obtaining information on 10,281 household members and 1,970 adolescent females. Overall, 10.4% of girls age 10-19 were married. IDPs had the highest percentage of married 10-19-year-old females (12.9%), compared to the host community (9.8%) and refugees (8.1%). Heads of households with lower overall education had higher percentages of child marriage in their homes; this difference in prevalence was most notable in IDPs and refugees. When the head of the household was unemployed, 14.5% of households had child marriage present compared to 8.0% in those with employed heads of household. Refugees and IDPs had larger percentages of child marriage when heads of households were unemployed (refugees 13.1%, IDPs 16.9%) compared to hosts (11.9%). When asked about factors influencing marriage decisions, respondents predominately cited family tradition (52.5%), family honor (15.7%), money/resources (9.6%), or religion (8.0%). Over a third of those interviewed (38.9%) reported a change in influencing factors on marriage after displacement (or after the arrival of refugees in the area for hosts). CONCLUSIONS: Being an IDP in Iraq, unemployment and lower education were associated with an increase in risk for child marriage. Refugees had similar percentages of child marriage as hosts, though the risk of child marriage among refugees was higher in situations of low education and unemployment. Ultimately, child marriage remains a persistent practice worldwide, requiring continued efforts to understand and address sociocultural norms in low socioeconomic and humanitarian settings.

Migration and health: a global public health research priority.

BACKGROUND: With 244 million international migrants, and significantly more people moving within their country of birth, there is an urgent need to engage with migration at all levels in order to support progress towards global health and development targets. In response to this, the 2nd Global Consultation on Migration and Health- held in Colombo, Sri Lanka in February 2017 - facilitated discussions concerning the role of research in supporting evidence-informed health responses that engage with migration. CONCLUSIONS: Drawing on discussions with policy makers, research scholars, civil society, and United Nations agencies held in Colombo, we emphasize the urgent need for quality research on international and domestic (in-country) migration and health to support efforts to achieve the Sustainable Development Goals (SDGs). The SDGs aim to 'leave no-one behind' irrespective of their legal status. An ethically sound human rights approach to research that involves engagement across multiple disciplines is required. Researchers need to be sensitive when designing and disseminating research findings as data on migration and health may be misused, both at an individual and population level. We emphasize the importance of creating an 'enabling environment' for migration and health research at national, regional and global levels, and call for the development of meaningful linkages - such as through research reference groups - to support evidence-informed inter-sectoral policy and priority setting processes.

Burden of out-of-hospital cardiac arrest in Karachi, Pakistan: Estimation through the capture-recapture method.

OBJECTIVE: To assess the application of capture-recapture method as a potential strategy to estimate the incidence of out-of-hospital cardiac arrest. METHODS: This cross-sectional study was carried out from January to April 2013 in Karachi and comprised three public general hospitals, one public cardiac hospital, one private general hospital and two ambulance services. Two-sample capture-recapture method was used: first capture was through cardiac arrest data from two major emergency medical services and second capture was from the five teaching hospitals. Records from the hospitals and ambulance services were compared on 7 variables; name, age, gender, date and time of arrest, cause of arrest and destination hospital. Matched and unmatched cases were used in the equation to estimate the incidence of out-of-hospital cardiac arrest. RESULTS: Of the 630 out-of-hospital cardiac arrest cases reported, 191(30.3%) related to the emergency medical services records and 439(69.7%) to hospital records. The capture-recapture identified only 9(1.4%) matched cases even with the least restrictive criteria and estimated the annual out-of-hospital cardiac arrest incidence as 166/100,000 population (95% confidence interval: 142.9 to 189.6). CONCLUSIONS: Capture-recapture method could be a potential alternative for providing population level data in the absence of organised health information systems.

Longitudinal Effects of Acculturation on Alcohol Use among Vietnamese and Cambodian Immigrant Women in the USA.

AIMS: Recent studies indicate that alcohol use is increasing among Asian American populations and that acculturation impacts alcohol use among immigrants in the USA. We investigated the longitudinal relationship between three domains of acculturation (traditionalism, biculturalism, assimilation) and alcohol use among 302 Vietnamese and Cambodian women in Washington State. METHODS: Data were obtained from the Cross Cultural Families Project (CCF), a 5-year longitudinal investigation of a random sample of Vietnamese and Cambodian immigrant families living in Washington State. Alcohol use was measured with a three item scale assessing frequency and quantity of use, and binge drinking. Acculturation was measured with the Suinn-Lew Asian Self-Identity Acculturation Scale. Linear mixed effects regression models were estimated to assess the impact of acculturation on alcohol use among the overall sample and among a sub-sample of only women who consumed any alcohol. RESULTS: A majority of the sample, 73.2%, reported no alcohol use. In the overall sample, none of the three acculturation domains were significantly associated with drinking. Among a sub-sample of only those who reported any alcohol use, however, a greater degree of traditional cultural identification (ß = -0.94, SE= 0.44, P= 0.03) and a greater degree of biculturalism (ß = -1.33, SE= 0.53, P =0.01) were associated with lower levels of use. CONCLUSIONS: Our findings suggest that acculturation did not impact alcohol use prevalence but that it did affect the drinking pattern among alcohol consumers. Clinicians should be cognizant that certain aspects of cultural identification are important contributors to drinking behavior among alcohol consumers in these populations.

Ambulance use in Pakistan: an analysis of surveillance data from emergency departments in Pakistan.

BACKGROUND: The utilization of ambulances in low- and middle-income countries is limited. The aim of this study was to ascertain frequency of ambulance use and characteristics of patients brought into emergency departments (EDs) through ambulance and non-ambulance modes of transportation. METHODS: The Pakistan National Emergency Departments Surveillance (Pak-NEDS) was a pilot active surveillance conducted in seven major tertiary-care EDs in six main cities of Pakistan between November 2010 and March 2011. Univariate and multivariate logistic regression was performed to investigate the factors associated with ambulance use. RESULTS: Out of 274,436 patients enrolled in Pak-NEDS, the mode of arrival to the ED was documented for 94. 9% (n = 260,378) patients, of which 4.1% (n = 10,546) came to EDs via ambulances. The mean age of patients in the ambulance group was significantly higher compared to the mean age of the non-ambulance group (38 ± 18.4 years versus 32.8 ± 14.9 years, p-value < 0.001). The most common presenting complaint in the ambulance group was head injury (12%) while among non-ambulance users it was fever (12%). Patients of all age groups were less likely to use an ambulance compared to those >45 years of age (p-value < 0.001) adjusted for gender, cities, hospital type, presenting complaint group and disposition. The adjusted odds ratio of utilizing ambulances for those with injuries was 3.5 times higher than those with non-injury complaints (p-value < 0.001). Patients brought to the ED by ambulance were 7.2 times more likely to die in the ED than non-ambulance patients after adjustment for other variables in the model. CONCLUSION: Utilization of ambulances is very low in Pakistan. Ambulance use was found to be more among the elderly and those presenting with injuries. Patients presenting via ambulances were more likely to die in the ED.

A transdiagnostic community-based mental health treatment for comorbid disorders: development and outcomes of a randomized controlled trial among Burmese refugees in Thailand.

BACKGROUND: Existing studies of mental health interventions in low-resource settings have employed highly structured interventions delivered by non-professionals that typically do not vary by client. Given high comorbidity among mental health problems and implementation challenges with scaling up multiple structured evidence-based treatments (EBTs), a transdiagnostic treatment could provide an additional option for approaching community-based treatment of mental health problems. Our objective was to test such an approach specifically designed for flexible treatments of varying and comorbid disorders among trauma survivors in a low-resource setting. METHODS AND FINDINGS: We conducted a single-blinded, wait-list randomized controlled trial of a newly developed transdiagnostic psychotherapy, Common Elements Treatment Approach (CETA), for low-resource settings, compared with wait-list control (WLC). CETA was delivered by lay workers to Burmese survivors of imprisonment, torture, and related traumas, with flexibility based on client presentation. Eligible participants reported trauma exposure and met severity criteria for depression and/or posttraumatic stress (PTS). Participants were randomly assigned to CETA (n = 182) or WLC (n = 165). Outcomes were assessed by interviewers blinded to participant allocation using locally adapted standard measures of depression and PTS (primary outcomes) and functional impairment, anxiety symptoms, aggression, and alcohol use (secondary outcomes). Primary analysis was intent-to-treat (n = 347), including 73 participants lost to follow-up. CETA participants experienced significantly greater reductions of baseline symptoms across all outcomes with the exception of alcohol use (alcohol use analysis was confined to problem drinkers). The difference in mean change from pre-intervention to post-intervention between intervention and control groups was -0.49 (95% CI: -0.59, -0.40) for depression, -0.43 (95% CI: -0.51, -0.35) for PTS, -0.42 (95% CI: -0.58, -0.27) for functional impairment, -0.48 (95% CI: -0.61, -0.34) for anxiety, -0.24 (95% CI: -0.34, -0.15) for aggression, and -0.03 (95% CI: -0.44, 0.50) for alcohol use. This corresponds to a 77% reduction in mean baseline depression score among CETA participants compared to a 40% reduction among controls, with respective values for the other outcomes of 76% and 41% for anxiety, 75% and 37% for PTS, 67% and 22% for functional impairment, and 71% and 32% for aggression. Effect sizes (Cohen's d) were large for depression (d = 1.16) and PTS (d = 1.19); moderate for impaired function (d = 0.63), anxiety (d = 0.79), and aggression (d = 0.58); and none for alcohol use. There were no adverse events. Limitations of the study include the lack of long-term follow-up, non-blinding of service providers and participants, and no placebo or active comparison intervention. CONCLUSIONS: CETA provided by lay counselors was highly effective across disorders among trauma survivors compared to WLCs. These results support the further development and testing of transdiagnostic approaches as possible treatment options alongside existing EBTs. TRIAL REGISTRATION: ClinicalTrials.gov NCT01459068 Please see later in the article for the Editors' Summary.

Measuring impact: a cross-sectional multi-stage cluster survey to assess the attainment of durable solutions in post-tsunami Aceh, Indonesia.

BACKGROUND: There exists little agreement on the choice of indicators to be used to assess the impact of humanitarian assistance. The 2004 Indian Ocean tsunami led to significant mortality and displacement in Aceh Province, Indonesia, as well as a nearly unprecedented humanitarian response. Six years after the disaster we conducted an impact assessment of humanitarian services rendered in Aceh using a comprehensive set of rights-based indicators and sought to determine modifiable predictors of improved outcomes in disaster-affected households. METHODS: A sample of 597 returned and non-returned households in Banda Aceh and Meulaboh was selected using a multistage stratified cluster survey design. We employed principle components analysis and the Framework on Durable Solutions for Internally Displaced Persons to develop a comprehensive and rights-based approach to humanitarian impact measurement using multivariate regression models. RESULTS: The attainment of durable solutions was equivalent in both returned households 100.1 [CI] 97.63-102.5) and households that integrated elsewhere (99.37 [CI] 95.43-103.3, P = 0.781). Standard of living as well as education and health facility satisfaction increased significantly whereas monthly income decreased after the tsunami, from 2585241 IDR ([CI] 2357202-2813279 IDR) to 2038963 ([CI] 1786627-2291298 IDR, P < 0.001). Shelter (P = 0.007) and legal assistance (P < 0.001) were both significantly associated with positive durable solutions outcomes, whereas prolonged displacement duration was significantly associated with poorer outcomes (P < 0.001). Livelihood assistance received after one year was associated with higher odds of increasing or maintaining pre-tsunami income levels (OR = 3.02, P = 0.008), whereas livelihood assistance received within one year was associated with lower odds of attaining pre-tsunami income (OR = 0.52, P = 0.010). CONCLUSIONS: We find that after adjusting for pre-tsunami conditions and tsunami-related damages, the impact of sectoral responses can be assessed. The duration of displacement was the strongest negative predictive factor for the attainment of durable solutions, suggesting that measures to reduce displacement time may be effective in mitigating the long-term effects of disaster on households. The durable solutions framework is a novel and effective impact measurement tool and can be used to identify factors amenable to intervention and inform future disaster recovery efforts.

Challenges of COVID-19 prevention during protracted conflicts: differential adherence to preventive measures in "contact line" regions in eastern Ukraine.

Objectives: Despite the epidemiological importance of social vulnerabilities in compliance with preventive measures, little is known about the disproportional nature of preventive behaviors in crisis-affected populations. We examined adherence to COVID-19 preventive behaviors, focusing on social distancing measures in the conflict-affected regions in eastern Ukraine. Methods: From a multisectoral needs assessment conducted in 2020 using a household interview of a stratified simple random sample, we included 1,617 rural and urban households located in the government-controlled area. We performed multivariable binary logistic regression analysis with latent class analysis (LCA) to identify unmeasured patterns of classification of preventive measures using data from a cross-sectional survey. Results: The conflict-affected populations showed difficulty in complying with COVID-19 preventive measures due to losses of housing, partners, and access to food resources due to conflicts. Among the various preventive measures, wearing a face mask (88.1%) and washing hands more regularly (71.4%) were the most frequently reported. Compliance with social distancing was significantly lower in those who experienced the direct impacts of conflicts indicated by damaged accommodation or being widowed. Three different groups who showed distinctive patterns of employing COVID-19 preventive measures were identified via the LCA model, which were "highly complying group", "moderately complying group", and "face masks only group". The group membership was associated with a respondent's poverty status. Conclusion: The findings show the difficulty in compliance with COVID-19 preventive measures among conflict-affected populations indicating secondary impacts of the conflicts on preventive health behaviors. To mitigate the health impacts of conflicts, immediate attention is needed to address barriers to COVID-19 preventive measures among conflict-affected populations in Ukraine. This study suggests the need for public health strategies to improve preventive health behaviors in conflict-affected populations under pandemics or large-scale outbreaks.

Incidence of child marriage among refugees and internally displaced persons in the Middle East and South Asia: evidence from six cross-sectional surveys.

OBJECTIVE: To examine incidence of child marriage among displaced and host populations in humanitarian settings. DESIGN: Cross-sectional surveys. SETTING: Data were collected in Djibouti, Yemen, Lebanon and Iraq in the Middle East and in Bangladesh and Nepal in South Asia. PARTICIPANTS: Adolescent girls aged 10-19 in the six settings and age cohort comparators. OUTCOME MEASURES: Cumulative incidence of marriage by age 18. RESULTS: In Bangladesh and Iraq, the hazard of child marriage did not differ between internally displaced populations (IDPs) and hosts (p value=0.25 and 0.081, respectively). In Yemen, IDPs had a higher hazard of child marriage compared with hosts (p value<0.001). In Djibouti, refugees had a lower hazard of child marriage compared with hosts (p value<0.001). In pooled data, the average hazard of child marriage was significantly higher among displaced compared with host populations (adjusted HR (aHR) 1.3; 95% CI 1.04 to 1.61).In age cohort comparisons, there was no significant difference between child marriage hazard across age cohorts in Bangladesh (p value=0.446), while in Lebanon and Nepal, younger cohorts were less likely to transition to child marriage compared with older comparators (p value<0.001). Only in Yemen were younger cohorts more likely to transition to child marriage, indicating an increase in child marriage rates after conflict (p value=0.034). Pooled data showed a downward trend, where younger age cohorts had, on average, a lower hazard of child marriage compared with older cohorts (aHR 0.36; 95% CI 0.29 to 0.4). CONCLUSIONS: We did not find conclusive evidence that humanitarian crises are associated with universal increases in child marriage rates. Our findings indicate that decision-making about investments in child marriage prevention and response must be attuned to the local context and grounded in data on past and current trends in child marriage among communities impacted by crisis.

North Korean refugee health in South Korea (NORNS) study: study design and methods.

BACKGROUND: Understanding the health status of North Korean refugees (NKRs), and changes in health during the resettlement process, is important from both the humanitarian standpoint and the scientific perspective. The NOrth Korean Refugee health iN South Korea (NORNS) study aims to document the health status and health determinants of North Korean refugees, to observe various health outcomes as they occur while adapting to the westernized lifestyle of South Korea, and to explain the mechanisms of how health of migrants and refugees changes in the context of new environmental risks and opportunities. METHODS: The NORNS study was composed of an initial survey and a follow-up survey 3.5 years apart. Participants were recruited voluntarily among those aged 30 or more living in Seoul. The survey consists of a health questionnaire and medical examination. The health questionnaire comprises the following six domains: 1) demographic and migration information 2) disease history, 3) mental health, 4) health-related lifestyle, 5) female reproductive health, and 6) sociocultural adaptation. The medical examination comprises anthropometric measurements, blood pressure and atherosclerosis, and various biochemical measurements. Prevalence of several diseases able to be diagnosed from the medical examination, the changes between the two surveys, and the association between the outcome and other measurements, such as length of stay and extent of adaptation in South Korea will be investigated. Furthermore, the outcome will be compared to a South Korean counterpart cohort to evaluate the relative health status of NKRs. DISCUSSION: The NORNS study targeting adult NKRs in South Korea is a valuable study because various scales and medical measurements are employed for the first time. The results obtained from this study are expected to be utilized for developing a health policy for NKRs and North Korean people after unification. Additionally, since NKRs are an immigrant group who are the same race and have the same genetic characteristics as South Koreans, this study has the characteristics of a unique type of migrant health study.

A qualitative study of DRG coding practice in hospitals under the Thai Universal Coverage scheme.

BACKGROUND: In the Thai Universal Coverage health insurance scheme, hospital providers are paid for their inpatient care using Diagnosis Related Group-based retrospective payment, for which quality of the diagnosis and procedure codes is crucial. However, there has been limited understandings on which health care professions are involved and how the diagnosis and procedure coding is actually done within hospital settings. The objective of this study is to detail hospital coding structure and process, and to describe the roles of key hospital staff, and other related internal dynamics in Thai hospitals that affect quality of data submitted for inpatient care reimbursement. METHODS: Research involved qualitative semi-structured interview with 43 participants at 10 hospitals chosen to represent a range of hospital sizes (small/medium/large), location (urban/rural), and type (public/private). RESULTS: Hospital Coding Practice has structural and process components. While the structural component includes human resources, hospital committee, and information technology infrastructure, the process component comprises all activities from patient discharge to submission of the diagnosis and procedure codes. At least eight health care professional disciplines are involved in the coding process which comprises seven major steps, each of which involves different hospital staff: 1) Discharge Summarization, 2) Completeness Checking, 3) Diagnosis and Procedure Coding, 4) Code Checking, 5) Relative Weight Challenging, 6) Coding Report, and 7) Internal Audit. The hospital coding practice can be affected by at least five main factors: 1) Internal Dynamics, 2) Management Context, 3) Financial Dependency, 4) Resource and Capacity, and 5) External Factors. CONCLUSIONS: Hospital coding practice comprises both structural and process components, involves many health care professional disciplines, and is greatly varied across hospitals as a result of five main factors.

DRG coding practice: a nationwide hospital survey in Thailand.

BACKGROUND: Diagnosis Related Group (DRG) payment is preferred by healthcare reform in various countries but its implementation in resource-limited countries has not been fully explored. OBJECTIVES: This study was aimed (1) to compare the characteristics of hospitals in Thailand that were audited with those that were not and (2) to develop a simplified scale to measure hospital coding practice. METHODS: A questionnaire survey was conducted of 920 hospitals in the Summary and Coding Audit Database (SCAD hospitals, all of which were audited in 2008 because of suspicious reports of possible DRG miscoding); the questionnaire also included 390 non-SCAD hospitals. The questionnaire asked about general demographics of the hospitals, hospital coding structure and process, and also included a set of 63 opinion-oriented items on the current hospital coding practice. Descriptive statistics and exploratory factor analysis (EFA) were used for data analysis. RESULTS: SCAD and Non-SCAD hospitals were different in many aspects, especially the number of medical statisticians, experience of medical statisticians and physicians, as well as number of certified coders. Factor analysis revealed a simplified 3-factor, 20-item model to assess hospital coding practice and classify hospital intention. CONCLUSION: Hospital providers should not be assumed capable of producing high quality DRG codes, especially in resource-limited settings.

Quantifying the Ripple Effects of Civil War: How Armed Conflict Is Associated with More Severe Violence in the Home.

Both the fields of public health and that of human rights seek to improve human well-being, including through reducing and preventing all forms of violence, to help individuals attain the highest quality of life. In both fields, mathematical methods can help "visibilize" the hidden architecture of violence, bringing new methods to bear to understand the scope and nuance of how violence affects populations. An increasing number of studies have examined how residing in a conflict-affected place may impact one of the most pervasive forms of violence-intimate partner violence (IPV)-during and after conflict. This paper contributes to this effort by examining whether severe forms of IPV are associated with previous experience of political violence in one conflict-affected country: Liberia. Our findings indicate that living in a district with conflict fatalities increased the risk of IPV among women by roughly 60%. Additionally, living in a district with conflict fatalities increased the risk of a past-year injury from IPV by 50%. This analysis brings to light links between two of the most pervasive forms of violence-political violence and violence against women. The findings suggest that women residing in a district that is more highly affected by conflict, not only people experiencing direct trauma during conflict, may be at risk of increased violence long after peace is declared. These findings point to the need for targeted programs that address IPV postconflict.

Health and healthcare in North Korea: a retrospective study among defectors.

BACKGROUND: To gain insights into the socio-economic and political determinants of ill health and access to healthcare in North Korea. METHODS: A retrospective survey using respondent-driven sampling conducted in 2014-15 among 383 North Korean refugees newly resettling in South Korea, asking about experiences of illness and utilization of healthcare while in North Korea, analyzed according to measures of political, economic and human rights indicators. RESULTS: Although the Public Health Act claims that North Korea provides the comprehensive free care system, respondents reported high levels of unmet need and, among those obtaining care, widespread informal expenditure. Of the respondents, 55.1% (95%CI, 47.7-63.7%) had received healthcare for the most recent illness episode. High informal costs (53.8%, 95%CI, 45.1-60.8%) and a lack of medicines (39.5%, 95%CI, 33.3-47.1%) were reported as major healthcare barriers resulting in extensive self-medication with narcotic analgesics (53.7%, 95%CI, 45.7-61.2%). In multivariate logistic regressions, party membership was associated with better access to healthcare (Adjusted OR (AOR) = 2.34, 95%CI, 1.31-4.18), but household income (AOR = 0.40, 95%CI 0.21-0.78) and informal market activity (AOR = 0.29, 95%CIs 0.15-0.50) with reduced access. Respondents who could not enjoy political and economic rights were substantially more likely to report illness and extremely reduced access to care, even with life-threatening conditions. CONCLUSIONS: There are large disparities in health and access to healthcare in North Korea, associated with political and economic inequalities. The scope to use these findings to bring about change is limited but they can inform international agencies and humanitarian organizations working in this unique setting.

Improving mental health and psychosocial wellbeing in humanitarian settings: reflections on research funded through R2HC.

Major knowledge gaps remain concerning the most effective ways to address mental health and psychosocial needs of populations affected by humanitarian crises. The Research for Health in Humanitarian Crisis (R2HC) program aims to strengthen humanitarian health practice and policy through research. As a significant portion of R2HC's research has focused on mental health and psychosocial support interventions, the program has been interested in strengthening a community of practice in this field. Following a meeting between grantees, we set out to provide an overview of the R2HC portfolio, and draw lessons learned. In this paper, we discuss the mental health and psychosocial support-focused research projects funded by R2HC; review the implications of initial findings from this research portfolio; and highlight four remaining knowledge gaps in this field. Between 2014 and 2019, R2HC funded 18 academic-practitioner partnerships focused on mental health and psychosocial support, comprising 38% of the overall portfolio (18 of 48 projects) at a value of approximately 7.2 million GBP. All projects have focused on evaluating the impact of interventions. In line with consensus-based recommendations to consider a wide range of mental health and psychosocial needs in humanitarian settings, research projects have evaluated diverse interventions. Findings so far have both challenged and confirmed widely-held assumptions about the effectiveness of mental health and psychosocial interventions in humanitarian settings. They point to the importance of building effective, sustained, and diverse partnerships between scholars, humanitarian practitioners, and funders, to ensure long-term program improvements and appropriate evidence-informed decision making. Further research needs to fill knowledge gaps regarding how to: scale-up interventions that have been found to be effective (e.g., questions related to integration across sectors, adaptation of interventions across different contexts, and optimal care systems); address neglected mental health conditions and populations (e.g., elderly, people with disabilities, sexual minorities, people with severe, pre-existing mental disorders); build on available local resources and supports (e.g., how to build on traditional, religious healing and community-wide social support practices); and ensure equity, quality, fidelity, and sustainability for interventions in real-world contexts (e.g., answering questions about how interventions from controlled studies can be transferred to more representative humanitarian contexts).

From political to personal violence: Links between conflict and non-partner physical violence in post-conflict Liberia.

War and interpersonal violence together account for a large burden on global health. Yet very few studies look at the relationship between these types of aggression. Non-partner physical violence (NPPV) is an often-understudied form of gender-based violence (GBV). This analysis draws on two datasets from one conflict-affected country, Liberia, to evaluate the impact of conflict on NPPV post-conflict. The Armed Conflict Location and Event Dataset (ACLED) measures the intensity of the conflict in Liberia from 1999-2003, while the Demographic and Heath Survey (DHS) data measure women's experiences with violence four years post-conflict. Almost half of women surveyed (45%) indicated that they experienced any kind of NPPV, highlighting the widespread nature of this issue. A multilevel modelling approach was used to account for the nesting of individuals within districts. Women living in districts that experienced conflict events in four or five years were almost three times as likely (aOR 2.93, p < .001) to experience past-year NPPV compared to individuals living in no conflict districts. Findings from this study suggest women residing in a conflict event-affected district may be at heightened risk of increased violence even years after peace is declared.

From the battlefield to the bedroom: a multilevel analysis of the links between political conflict and intimate partner violence in Liberia.

OBJECTIVES: Assess the link between levels of armed conflict and postconflict intimate partner violence (IPV) experienced by women in Liberia. METHODS: Armed Conflict Location and Event Data Project data were used to measure conflict-related fatalities in districts in Liberia during the country's civil war from 1999 to 2003. These data were linked to individual-level data from the 2007 Demographic and Health Survey, including past-year IPV. Multilevel logistic models accounting for the clustering of women within districts evaluated the relationship of conflict fatalities with postconflict past-year IPV. Additional conflict measures, including conflict events and cumulative years of conflict, were assessed. RESULTS: After adjusting for individual-level characteristics correlated with IPV, residence in a conflict fatality-affected district was associated with a 50% increase in risk of IPV (adjusted OR (aOR): 1.55, 95% CI 1.26 to 1.92). Women living in a district that experienced 4-5 cumulative years of conflict were also more likely to experience IPV (aOR 1.88, 95% CI 1.29 to 2.75). CONCLUSION: Residing in a conflict-affected district even 5 years after conflict was associated with postconflict IPV. POLICY IMPLICATIONS: Recognising and preventing postconflict IPV violence is important to support long-term recovery in postconflict settings.

Human Rights as Political Determinants of Health: A Retrospective Study of North Korean Refugees.

INTRODUCTION: The gravity, scale, and nature of human rights violations are severe in North Korea. Little is known about the mental health consequences of the lifelong exposures to these violations. METHODS: In 2014-2015, a retrospective study was conducted among 383 North Korean refugees in South Korea using respondent-driven sampling to access this hidden population. This study collected information on the full range of political and economic rights violations and measured post-traumatic stress disorder, anxiety and depression symptoms, and social functioning by standard instruments. Multivariate regression analysis was performed with the adjustment of political, economic, and demographic variables in 2016-2017. RESULTS: The results indicate elevated symptoms of anxiety (60.1%, 95% CI=54.3%, 65.7%), depression (56.3%, 95% CI=50.8%, 61.9%), and post-traumatic stress disorder (22.8%, 95% CI=18.6%, 27.4%), which are significantly associated with exposures to political rights violations (ten to 19 items versus non-exposure: anxiety AOR=16.78, p<0.001, depression AOR=12.52, p<0.001, post-traumatic stress disorder AOR=16.71, p<0.05), and economic rights violations (seven to 13 items versus non-exposure: anxiety AOR=5.68, p<0.001, depression AOR=4.23, p<0.01, post-traumatic stress disorder AOR=5.85, p<0.05). The mean score of social functioning was also lower in those who were exposed to political (adjusted difference= -13.29, p<0.001) and economic rights violations (adjusted difference= -11.20, p<0.001). CONCLUSIONS: This study highlights mental health consequences of lifelong human rights violations in North Korea. Beyond the conventional approach, it suggests the need for a collaborative preventive response from global health and human rights activists to address human rights in regard to mental health determinants of the 20 million people in North Korea.

Tsunami mortality estimates and vulnerability mapping in Aceh, Indonesia.

OBJECTIVES: We aimed to quantify tsunami mortality and compare approaches to mortality assessment in the emergency context in Aceh, Indonesia, where the impact of the 2004 tsunami was greatest. METHODS: Mortality was estimated using geographic information systems-based vulnerability models and demographic methods from surveys of tsunami-displaced populations. RESULTS: Tsunami mortality in Aceh as estimated by demographic models was 131066 and was similar to official figures of 128063; however, it was a conservative estimate of actual mortality and is substantially less than official estimates of 168561 presumed dead, which included those classified as missing. Tsunami impact was greatest in the district of Aceh Jaya, where an estimated 27.0% (n=23862) of the population perished; Aceh Besar and Banda Aceh were also severely affected, with mortality at 21.0% (n = 61 650) and 11.5% (n = 25 903), respectively. Mortality was estimated at 23.7% for the population at risk and 5.6% overall. CONCLUSIONS: Mortality estimates were derived using methodologies that can be applied in future disasters when predisaster demographic data are not available. Models could be useful in the early stages of disaster response by facilitating geographic targeting and management of humanitarian assistance.

Estimating demographic indicators in a conflict-affected population in eastern Sudan.

INTRODUCTION: Although the international community currently is focused on Darfur, it is important that the status of other conflict-affected populations throughout Sudan are not overlooked. For the past decade, the Beja population, located along the Sudan-Eritrea border, has been affected by a conflict that has drawn little attention from the international community. METHODS: This study assessed crude mortality rates and other demographic characteristics using a mortality study nested within a nutrition assessment using cluster sampling methods. RESULTS: The crude mortality rate among the Beja population in the National Democratic Alliance (NDA)-controlled territories between October 2003 and October 2004 was estimated at 1.4/10,000/day (95% confidence interval (CI): 1.2-1.6); the under five years of age mortality rate was estimated at 2.7/10,000/day (95% CI: 2.2-3.3). Both of these are elevated rates that exceed the accepted threshold to declare a humanitarian emergency. CONCLUSIONS: When considered with recent reports of elevated malnutrition rates, the status of Beja is critical by international standards. Study findings suggest that: (1) nesting demographic objectives into other planned assessments (such as nutrition) are a feasible and cost-effective means for non-governmental organizations to characterize beneficiary populations; and (2) the Beja residing in the NDA-controlled territories are facing elevated mortality and are in urgent need of humanitarian assistance.