Multi-purpose cash transfers and health among vulnerable Syrian refugees in Lebanon: a prospective cohort study.

BACKGROUND: Multipurpose cash transfers (MPCs) are used on a widespread basis in the Syrian refugee response; however, there is little to no evidence as to how they affect health in humanitarian crises. METHODS: A prospective cohort study was conducted from May 2018 through July 2019 to evaluate the impact of MPCs on health care-seeking and expenditures for child, adult acute, and adult chronic illness by Syrian refugees in Lebanon. Households receiving MPCs from UNHCR were compared to control households not receiving UNHCR MPCs. RESULTS: Care-seeking for childhood illness was consistently high in both MPC and non-MPC households. An increased proportion of households did not receive all recommended care due to cost; this increase was 19.3% greater among MPC recipients than controls (P = 0.002). Increases in child hospitalizations were significantly smaller among MPC recipients than controls (DiD -6.1%; P = 0.037). For adult acute illnesses, care-seeking increased among MPC recipients but decreased in controls (adjusted DiD 11.3%; P = 0.057); differences in change for other utilization outcomes were not significant. The adjusted difference in change in the proportion of MPC households not receiving recommended chronic illness care due to cost compared to controls was - 28.2% (P = 0.073). Access to medication for adult chronic illness also marginally significantly improved for MPC households relative to controls. The proportion of MPC recipients reporting expenses for the most recent child and adult acute illness increased significantly, as did the [log] total visit cost. Both MPC and control households reported significant increases in borrowing to pay for health expenses over the year study period, but differences in change in borrowing or asset sales were not significant, indicating that MPC was not protective against for household financial risks associated with health. CONCLUSIONS: While MPC may have shown some positive effects, findings were mixed and MPC appears insufficient on its own to address health utilization and expenditures. A broader strategy addressing Syrian refugee health in Lebanon is needed of which MPC should be incorporated, with additional support such as additional conditional cash transfers for health.

Scurvy Outbreak Among South Sudanese Adolescents and Young Men - Kakuma Refugee Camp, Kenya, 2017-2018.

Scurvy is a relatively rare micronutrient deficiency disease that can occur among refugees dependent on food aid (1). Inadequate access to fresh fruits and vegetables in refugee camps can result in scurvy (2,3). Kakuma Refugee Camp in Kenya's Turkana District is home to 148,000 refugees, mostly from Somalia and South Sudan, who receive food assistance. In August 2017, a number of South Sudanese adolescent and young adult male refugees were evaluated at a health clinic in the camp for calf pain, chest pain, and gingival swelling. Because the symptoms were nonspecific, no diagnosis was made, and some patients received antibiotics and analgesics. All were managed as outpatients, but symptoms did not improve. During subsequent months, more young men with similar symptoms were reported. On January 20, 2018, the United Nations High Commissioner for Refugees (UNHCR) was informed and conducted clinical examinations. Signs and symptoms included lower limb pain and swelling (in some cases involving joints), lethargy, fatigue, gingival swelling and pain, hyperkeratotic skin changes, and chest pain. Based on these clinical findings, micronutrient deficiency, particularly vitamin C deficiency (scurvy), was considered a possible diagnosis, and an investigation of a possible outbreak was conducted. The suspected scurvy cases all occurred in young men from South Sudan who were living and cooking together in one geographic section of the camp. All patients who received treatment with vitamin C noted improvement of symptoms within <1 week. Patients were provided with food and cash assistance, the latter to allow dietary diversification (i.e., fresh fruits and vegetables). However, both forms of assistance were inadequate to allow access to sufficient amount of calories and the dietary diversification needed for intake of micronutrients, such as vitamin C. It is important to consider these needs when determining the amount of food or cash assistance provided to adolescents and young adult male refugees.

Maternal Health Care Utilization Among Syrian Refugees in Lebanon and Jordan.

Purpose The influx of Syrian refugees into Jordan and Lebanon over the last 5 years presents an immense burden to national health systems. This study was undertaken to assess utilization of maternal health services among Syrian refugees in both countries. Description A cross-sectional survey of Syrian refugees living in urban and rural (non-camp) settings was conducted using a two-stage cluster survey design with probability proportional to size sampling in 2014-2015. Eighty-six percent of surveyed households in Lebanon and 88% of surveyed households in Jordan included women with a live birth in the last year. Information from women in this sub-set of households was analyzed to understand antenatal and intrapartum health service utilization. Assessment A majority of respondents reported seeking antenatal care, 82% and 89% in Jordan and Lebanon, respectively. Women had an average of at least six antenatal care visits. Nearly all births (98% in Jordan and 94% in Lebanon) took place in a health facility. Cesarean rates were similar in both countries; approximately one-third of all births were cesarean deliveries. A substantial proportion of women incurred costs for intrapartum care; 33% of Syrian women in Jordan and 94% of Syrian women in Lebanon reported paying out of pocket for their deliveries. The proportion of women incurring costs for intrapartum care was higher in Jordan both countries for women with cesarean deliveries compared to those with vaginal deliveries; however, this difference was not statistically significant in either country (Jordan p-value = 0.203; Lebanon p-value = 0.099). Conclusion Syrian refugees living in Jordan and Lebanon had similar levels of utilization of maternal health services, despite different health systems and humanitarian assistance provisions. As expected, a substantial proportion of households incurred out-of-pocket costs for essential maternal and newborn health services, making cost a major factor in care-seeking decisions and locations. As health financing policies shift to account for the continued burden of refugee hosting on the health system, sustained attention to the availability and quality of essential maternal and newborn health services is needed to protect both refugee and host populations women's rights to health and health care during pregnancy, childbirth, and the postpartum period.

Health service access and utilization among Syrian refugees in Jordan.

BACKGROUND: The influx of Syrian refugees into Jordan presents an immense burden to the Jordanian health system. Changing lifestyles and aging populations are shifting the global disease burden towards increased non-infectious diseases including chronic conditions, co-morbidities, and injuries which are more complicated and costly to manage. The strain placed on health systems threatens the ability to ensure the health needs of both refugees and host country populations are adequately addressed. In light of the increasing challenges facing host governments and humanitarian actors to meet health needs of Syrian refugees and affected host communities, this study was undertaken to assess utilization of health services among Syrian refugees in non-camp settings. METHODS: A survey of Syrian refugees in Jordan was undertaken in June 2014 to characterize health seeking behaviors and issues related to accessing care. A cluster design with probability proportional to size sampling was used to attain a nationally representative sample of 1550 non-camp Syrian refugee households. Differences in household characteristics by geographic region, facility type, and sector utilized were examined using chi-square and t-test methods. RESULTS: Care-seeking was high with 86.1 % of households reporting an adult sought medical care the last time it was needed. Approximately half (51.5 %) of services were sought from public sector facilities, 38.7 % in private facilities, and 9.8 % in charity/NGO facilities. Among adult care seekers, 87.4 % were prescribed medication during the most recent visit, 89.8 % of which obtained the medication. Overall, 51.8 % of households reported out-of-pocket expenditures for the consultation or medications at the most recent visit (mean US$39.9, median US$4.2). CONCLUSIONS: Despite high levels of care-seeking, cost was an important barrier to health service access for Syrian refugees in Jordan. The cessation of free access to health care since the time of the survey is likely to have worsened health equity for refugees. Dependence of refugees on the public facilities for primary and specialist care has placed a great burden on the Jordanian health system. To improve accessibility and affordability of health services in an equitable manner for both refugees and Jordanian host communities, strategies that should be considered going forward include shifting resources for non-communicable diseases and other traditional hospital services to the primary level and creating strong health promotion programs emphasizing prevention and self-care are strategies.

Health service utilization and access to medicines among Syrian refugee children in Jordan.

BACKGROUND: With over one million Syrian refugee children in the region, we undertook this study to characterize care-seeking behaviors and health service utilization for child refugees with the aim of informing humanitarian programming for non-camp settings in Jordan. METHODS: A survey of Syrian refugees living outside of camps in Jordan was conducted using a 125 × 12 cluster design with probability proportional to size sampling to obtain a representative sample. The questionnaire focused on access to health services, including a module on care seeking for children. RESULTS: Care seeking was high with 90.9% of households with a child less than 18 years seeking medical care the last time it was needed. Households most often sought care for children in the public sector (54.6%), followed by private (36.5%) and charity sectors (8.9%). Among child care seekers, 88.6% were prescribed medication during the most recent visit, 90.6% of which obtained the medication. Overall, 49.4% of households reported out-of-pocket expenditures for either the consultation or prescribed medications at the most recent visit (mean $US21.1 and median $US0). CONCLUSIONS: Syrian refugees had good access to care for their sick children at the time of the survey; however, this has likely deteriorated since the survey because of the withdrawal of free access for refugees. The number of refugees in Jordan and relative accessibility of care has resulted in a large burden on the health system; the Jordanian government will require additional support if current levels of health access are to be maintained for Syrian refugees.

Measles outbreak response among adolescent and adult Somali refugees displaced by famine in Kenya and Ethiopia, 2011.

BACKGROUND: The refugee complexes of Dadaab, Kenya, and Dollo-Ado, Ethiopia, experienced measles outbreaks during June-November 2011, following a large influx of refugees from Somalia. METHODS: Line-lists from health facilities were used to describe the outbreak in terms of age, sex, vaccination status, arrival date, attack rates (ARs), and case fatality ratios (CFRs) for each camp. Vaccination data and coverage surveys were reviewed. RESULTS: In Dadaab, 1370 measles cases and 32 deaths (CFR, 2.3%) were reported. A total of 821 cases (60.1%) were aged ≥15 years, 906 (82.1%) arrived to the camps in 2011, and 1027 (79.6%) were unvaccinated. Camp-specific ARs ranged from 212 to 506 cases per 100 000 people. In Dollo-Ado, 407 cases and 23 deaths (CFR, 5.7%) were reported. Adults aged ≥15 years represented 178 cases (43.7%) and 6 deaths (26.0%). Camp-specific ARs ranged from 21 to 1100 cases per 100 000 people. Immunization activities that were part of the outbreak responses initially targeted children aged 6 months to 14 years and were later expanded to include individuals up to 30 years of age. CONCLUSIONS: The target age group for outbreak response-associated immunization activities at the start of the outbreaks was inconsistent with the numbers of cases among unvaccinated adolescents and adults in the new population. In displacement of populations from areas affected by measles outbreaks, health authorities should consider vaccinating adults in routine and outbreak response activities.

Nutritional status of women and child refugees from Syria-Jordan, April-May 2014.

As a result of civil war, an estimated 2.8 million refugees have fled Syria and reside in neighboring countries, mainly Lebanon, Turkey, Jordan, and Iraq. The largest Syrian refugee camp in the region is Zaatari camp in Jordan, with approximately 79,000 refugees; another estimated 500,000 Syrian refugees live in Jordanian cities, towns, and villages, mostly in the capital (Amman) and in four northern governorates (Irbid, Mafraq, Jarash, and Zarqa). Although all registered refugees in Jordan receive food vouchers from the World Food Programme (WFP) and vulnerable refugees receive cash assistance from the United Nations High Commissioner for Refugees (UNHCR) and nongovernmental organizations, the nutritional status of some refugees might be compromised because of dislocation, lack of income, and limited access to nutritious foods. To assess the nutritional status of Syrian refugees, UNHCR, WFP, the United Nations Children's Fund (UNICEF), Medair International (a nongovernmental organization), and CDC, in collaboration with the United Nations Population Fund and the World Health Organization (WHO), conducted cross-sectional, population-representative cluster surveys in Zaatari camp and among refugees residing in the host community. The surveys were conducted during April-May 2014 with the principal objective of assessing nutritional status of refugee children aged 6-59 months and nonpregnant women of reproductive age (15-49 years). Preliminary findings indicated a high prevalence of anemia in Zaatari camp among both children and women (48.4% and 44.8%, respectively). Nutrition policies aimed at ensuring optimal child and maternal micronutrient status and addressing the underlying risk factors for anemia are likely to result in improved health outcomes and a reduction in anemia.

Risk factors for measles mortality among hospitalized Somali refugees displaced by famine, Kenya, 2011.

BACKGROUND: Measles among displaced, malnourished populations can result in a high case fatality ratio. In 2011, a large measles outbreak occurred in Dadaab, Kenya, among refugees fleeing famine and conflict in Somalia. The aim of this study was to identify predictors of measles deaths among hospitalized patients during the outbreak. METHODS: A retrospective cohort study design was used to investigate measles mortality among hospitalized measles patients with a date of rash onset during 6 June-10 September 2011. Data were abstracted from medical records and a measles case was defined as an illness with fever, maculopapular rash, and either cough, coryza or conjunctivitis. Vaccination status was determined by patient or parental recall. Independent predictors of mortality were identified using logistic regression analysis. RESULTS: Of 388 hospitalized measles patients, 188 (49%) were from hospital X, 70 (18%) from hospital Y, and 130 (34%) from hospital Z; median age was 22 years, 192 (50%) were 15-29 years of age, and 22 (6%) were vaccinated. The mean number of days from rash onset to hospitalization varied by hospital (hospital X = 5, hospital Y = 3, hospital Z = 6; P < .0001). Independent risk factors for measles mortality were neurological complications (odds ratio [OR], 12.8; 95% confidence interval [CI], 3.1-52.4), acute malnutrition (OR, 7.6; 95% CI, 1.3-44.3), and admission to hospital Z (OR, 4.2; 95% CI, 1.3-13.2). CONCLUSIONS: Among Somali refugees, in addition to timely vaccination at border crossing points, early detection and treatment of acute malnutrition and proper management of measles cases may reduce measles mortality.

Review of maternal death audits in refugee camps in UNHCR East and Horn of Africa and Great Lakes Region, 2017-2019.

OBJECTIVES: To review the quality of maternal death audits and identify factors contributing to refugee maternal deaths in the East and Horn of Africa. METHODS: Maternal death audits submitted to The UN Refugee Agency (UNHCR) from 2017 to 2019 in 43 refugee camps in eight countries were analyzed for completeness, obstetric history, cause of death, and contributing factors. RESULTS: A total of 191 refugee maternal death audits were retrieved. The mean age of the deceased was 28 years (range, 15-45 years), and 13% were adolescents and 17% were of advanced maternal age. Most patients (55%) were grand multigravida (≥5 pregnancies). The majority (86%) attended antenatal care visits, with 51% attending four or more visits. Among women who delivered (n = 140), 91% were facility-based deliveries. Most (68%) deaths occurred postpartum. Obstetric hemorrhage (49%) was the leading direct cause of death (with 77 cases of postpartum hemorrhage), followed by hypertensive disorder (19%) and infection (15%). Delays in care were identified in 185 (97%) cases. Delays in receiving care were more prevalent (81%) than in seeking (61%) and reaching (26%) care. CONCLUSION: Factors contributing to delays in receiving care highlight the capacity gaps in provision of emergency obstetric care, including management of postpartum hemorrhage, requiring urgent additional investments. Audit findings also show the need for attention and action towards family planning, contraception, and adolescent sexual and reproductive health services.

Multi-purpose cash transfers and health among vulnerable Syrian refugees in Jordan: A prospective cohort study.

Cash assistance has rapidly expanded in the Syrian refugee response in Jordan and global humanitarian programming, yet little is known about the effect of multipurpose cash transfers (MPC) on health in humanitarian contexts. A prospective cohort study was conducted from May 2018 through July 2019 to evaluate the effectiveness of MPC in improving access to healthcare and health expenditures by Syrian refugees in Jordan. Households receiving MPCs (US$113-219 monthly) were compared to control households not receiving MPCs using difference-in-difference analyses. Overall health care-seeking was consistently high (>85%). Care-seeking for child illness improved among MPCs but declined among controls with a significant adjusted difference in change of 11.1% (P<0.05). In both groups, child outpatient visits significantly increased while emergency room visits decreased. Changes in care-seeking and medication access for adult acute illness were similar between groups; however, hospital admissions decreased among MPCs, yet increased among controls (-8.3% significant difference in change; P<0.05). There were no significant differences in change in chronic illness care utilization. Health expenditures were higher among MPCs at baseline and endline; the only significant difference in health expenditure measures' changes between groups was in borrowing money to pay for health costs, which decreased among MPCs and increased among controls with an adjusted difference in change of -10.3% (P<0.05). The impacts of MPC on health were varied and significant differences were observed for few outcomes. MPC significantly improved care-seeking for child illness, reduced hospitalizations for adult acute illness, and lowered rates of borrowing to pay for health expenditures. No significant improvements in chronic health condition indicators or shifts in sector of care-seeking were associated with MPC. While MPC should not be considered as a stand-alone health intervention, findings may be positive for humanitarian response financing given the potential for investment in MPC to translate to health sector response savings.

Improving diabetes control for Syrian refugees in Jordan: a longitudinal cohort study comparing the effects of cash transfers and health education interventions.

BACKGROUND: Cash transfers are an increasingly common intervention in the Syrian refugee response to meet basic needs, though there is little known of their potential secondary impact on health outcomes in humanitarian settings. METHODS: A quasi-experimental prospective cohort study was implemented from October 2018 through January 2020 to assess the effectiveness of multi-purpose cash (MPC), community health volunteer (CHV)-led education, combined with conditional cash transfers (CCT) with respect to health measures among Syrian refugees with type II diabetes in Jordan. RESULTS: CHV + CCT participants had the highest expenditures at endline and were the only group with statistically significant increases in payments for outpatient diabetes care (25.3%, P < 0.001) and monthly medication costs (13.6%, P < 0.001). Conversely, monthly spending on diabetes medication decreased significantly in the CHV only group (- 18.7%, P = 0.001) yet increased in the MPC and CHV + CCT groups. Expenditures on glucose monitoring increased in all groups but significantly more in the CHV + CCT group (39.2%, P < 0.001). The proportion of participants reporting regular diabetes care visits increased significantly only in the CHV + CCT group (15.1%, P = 0.002). Specialist visits also increased among CHV + CCT participants (16.8%, P = 0.001), but decreased in CHV only participants (- 27.8%, P < 0.001). Decreases in cost-motivated provider selection (- 22.8%, P < 0.001) and not receiving all needed care because of cost (- 26.2%, P < 0.001) were significant only in the CHV + CCT group. A small significant decrease in BMI was observed in the CHV + CCT group (- 1.0, P = 0.005). Decreases in HbA1C were significant in all groups with magnitudes ranging from - 0.2 to - 0.7%. The proportion of CHV + CCT participants with normal blood pressure increased significantly from baseline to endline by 11.3% (P = 0.007). CONCLUSIONS: Combined conditional cash and health education were effective in improving expenditures, health service utilization, medication adherence, blood pressure, and diabetes control. The lower cost health education intervention was similarly effective in improving diabetes control, whereas unconditional cash transfers alone were least effective. Study findings suggest that conditional cash or combined cash and health education are promising strategies to support diabetes control among refugees and that where the purpose of MPC is to improve health outcomes, this alone is insufficient to achieve improvements in the health of refugees with diabetes.

Health Service Utilization among Syrian Refugees with Chronic Health Conditions in Jordan.

INTRODUCTION: The influx of Syrian refugees into Jordan presents an immense burden to the Jordanian health system, particularly in treating chronic health conditions. This study was undertaken to assess utilization of health services for chronic health conditions among Syrian refugees in non-camp settings. METHODS: A survey of Syrian refugees in Jordan was undertaken in June 2014 to characterize health seeking behaviors and issues related to accessing care for hypertension, diabetes, cardiovascular diseases, chronic respiratory diseases, and arthritis. A cluster design with probability proportional to size sampling was used to attain a nationally representative sample of 1550 non-camp Syrian refugee households. RESULTS: Of 1363 cases with a chronic health condition diagnosis, 84.7% had received care in Jordan. Public facilities faced a heavy burden serving over half (53.9%) of care-seekers; the remainder received care in the private (29.6%) and NGO/charity (16.6%) sectors. Individuals with non-communicable diseases (NCDs) in the central region of Jordan and with arthritis had the lowest rates of care-seeking when compared to other regions and conditions. Overall, 31.6% of care-seekers had an out-of-pocket payment for the most recent care-seeking event which averaged 18.8 USD (median = 0 USD), excluding cost of medications. DISCUSSION: Forced displacement presents major challenges to those with NCDs, which have the potential to seriously impact both the quality of life and life expectancy amongst refugees. NCD patterns among Syrian refugees indicate the importance of continuing support to public sector services in Jordan to adequately meet expanding needs and ensure appropriate prevention and control of priority NCDs.

"Impact of and response to increased tuberculosis prevalence among Syrian refugees compared with Jordanian tuberculosis prevalence: case study of a tuberculosis public health strategy".

INTRODUCTION: By the summer of 2014, the Syrian crisis resulted in a regional humanitarian emergency with 2.9 million refugees, including 608,000 in Jordan. These refugees access United Nations High Commissioner for Refugees (UNHCR)-sponsored clinics or Jordan Ministry of Health clinics, including tuberculosis diagnosis and treatment. Tuberculosis care in Syria has deteriorated with destroyed health infrastructure and drug supply chain. Syrian refugees may have undiagnosed tuberculosis; therefore, the UNHCR, the International Organization for Migration (IOM), the National Tuberculosis Program (NTP), and the Centers for Disease Control and Prevention developed the Public Health Strategy for Tuberculosis among Syrian Refugees in Jordan. This case study presents that strategy, its impact, and recommendations for other neighboring countries. CASE DESCRIPTION: UNHCR determined that World Health Organization (WHO) criteria for implementing a tuberculosis program in an emergency were met for the Syrian refugees in Jordan. Jordan NTP assessed their tuberculosis program and found that access to Syrian refugees was the one component of their program missing. Therefore, a strategy for tuberculosis control among Syrian refugees was developed. Since that development through work with IOM, UNHCR, and NTP, tuberculosis case detection among Syrian refugees is almost 40 % greater (74 cases/12 months or 1.01/100,000 monthly through June 2014 vs. 56 cases/16 months or 0.73/100,000 monthly through June 2013) using estimated population figures; more than two fold the 2012 Jordan tuberculosis incidence. Additionally, the WHO objective of curing ≥85 % of newly identified infectious tuberculosis cases was met among Syrian refugees. DISCUSSION AND EVALUATION: Tuberculosis (TB) rates among displaced persons are high, but increased detection is possible. High TB rates were found among Syrian refugees through active screening and will probably persist as the Syrian crisis continues. Active screening can detect tuberculosis early and reduce risk for transmission. However, this strategy needs sustainable funding to continue and all activities have not been realized. CONCLUSIONS: Initial assessment found that tuberculosis among Syrian refugees was at a high incidence rate. Through partnership, a cohesive Jordanian tuberculosis strategy was developed for Syrian refugees and it has potential to inform treatment and control efforts for other regional countries impacted by the Syrian crisis.

Urinary p-nitrophenol as a biomarker of household exposure to methyl parathion.

Methyl parathion (MP) is an organophosphate pesticide illegally applied to the interiors of many hundreds of homes throughout the United States by unlicensed pesticide applicators. Public health authorities developed a protocol for investigating contaminated homes and classifying their need for public health interventions. This protocol included environmental screening for MP contamination and 1-day biomonitoring (a.m. and p.m. spot urine samples) of household members for p-nitrophenol (PNP), a metabolite of MP. The variability of urinary PNP excretion under these exposure conditions was unknown. We collected a.m. and p.m. spot urine samples for 7 consecutive days from 75 individuals, who were members of 20 MP-contaminated households in the greater Chicago, Illinois, area, and analyzed them for PNP. We also assessed the ability of the 1-day sampling protocol to correctly classify exposed individuals and households according to their need for public health interventions, assuming that 1 week of sampling (14 urinary PNPs) represented their true exposure condition. The coefficient of variation of log urinary PNPs for individuals over the course of 7 days of a.m. and p.m. sampling averaged about 15%. Adjusting for urinary excretion of creatinine improved reproducibility of urinary PNPs among children but not among adults. The 1-day protocol correctly classified true risk category in 92% of individuals and 85% of households. The data contained in this study can be used to refine what is already a reasonable and effective approach to identifying MP-exposed households and determining the appropriate public health intervention.

Karenni refugees living in Thai-Burmese border camps: traumatic experiences, mental health outcomes, and social functioning.

In June 2001, we assessed mental health problems among Karenni refugees residing in camps in Mae Hong Son, Thailand, to determine the prevalence of mental illness, identify risk factors, and develop a culturally appropriate intervention program. A systematic random sample was used with stratification for the three camps; 495 people aged 15 years or older from 317 households participated. We constructed a questionnaire that included demographic characteristics, culture-specific symptoms of mental illness, the Hopkins Symptoms Checklist-25, the Harvard Trauma Questionnaire, and selected questions from the SF-36 Health Survey. Mental health outcome scores indicated elevated levels of depression and anxiety symptoms; post-traumatic stress disorder (PTSD) scores were comparable to scores in other communities affected by war and persecution. Psychosocial risk factors for poorer mental health and social functioning outcomes were insufficient food, higher number of trauma events, previous mental illness, and landmine injuries. Modifications in refugee policy may improve social functioning, and innovative mental health and psychosocial programs need to be implemented, monitored, and evaluated for efficacy.

Social organization of free-ranging ruffed lemurs, Varecia variegata variegata: mother-adult daughter relationship.

The relationship between a mother and an adult daughter is examined in a group of free-ranging ruffed lemurs (Varecia variegata) at the Duke University Primate Center (DUPC). Although the two females were affiliative during the birth season, interactions during the mating season were predominantly agonistic. The maturing daughter was dominant to the mother, as has been observed in many caged social groups at the DUPC. Although both mother and daughter produced offspring in the same group, the daughter subsequently aggressively evicted the mother from the enclosure. It was not possible to maintain more than one long-term resident breeding female in the same social group. This pattern contrasts with observations of affiliation among breeding females in the wild. © 1992 Wiley-Liss, Inc.

Six rapid assessments of alcohol and other substance use in populations displaced by conflict.

BACKGROUND: Substance use among populations displaced by conflict is a neglected area of public health. Alcohol, khat, benzodiazepine, opiate, and other substance use have been documented among a range of displaced populations, with wide-reaching health and social impacts. Changing agendas in humanitarian response-including increased prominence of mental health and chronic illness-have so far failed to be translated into meaningful interventions for substance use. METHODS: Studies were conducted from 2006 to 2008 in six different settings of protracted displacement, three in Africa (Kenya, Liberia, northern Uganda) and three in Asia (Iran, Pakistan, and Thailand). We used intervention-oriented qualitative Rapid Assessment and Response methods, adapted from two decades of experience among non-displaced populations. The main sources of data were individual and group interviews conducted with a culturally representative (non-probabilistic) sample of community members and service providers. RESULTS: Widespread use of alcohol, particularly artisanally-produced alcohol, in Kenya, Liberia, Uganda, and Thailand, and opiates in Iran and Pakistan was believed by participants to be linked to a range of health, social and protection problems, including illness, injury (intentional and unintentional), gender-based violence, risky behaviour for HIV and other sexually transmitted infection and blood-borne virus transmission, as well as detrimental effects to household economy. Displacement experiences, including dispossession, livelihood restriction, hopelessness and uncertain future may make communities particularly vulnerable to substance use and its impact, and changing social norms and networks (including the surrounding population) may result in changed - and potentially more harmful-patterns of use. Limited access to services, including health services, and exclusion from relevant host population programmes, may exacerbate the harmful consequences. CONCLUSIONS: The six studies show the feasibility and value of conducting rapid assessments in displaced populations. One outcome of these studies is the development of a UNHCR/WHO field guide on rapid assessment of alcohol and other substance use among conflict-affected populations. More work is required on gathering population-based epidemiological data, and much more experience is required on delivering effective interventions. Presentation of these findings should contribute to increased awareness, improved response, and more vigorous debate around this important but neglected area.