Scaling-up problem management plus for refugees in Switzerland - a qualitative study.

BACKGROUND: Refugees are at an increased risk of developing symptoms of mental disorders but face various structural and socio-cultural barriers to accessing mental health care. The SPIRIT project (Scaling-up Psychological Interventions in Refugees In SwiTzerland) seeks to promote the resilience of refugees and improve their access to mental health care. For this purpose, Problem Management Plus (PM+), an evidence-based low-intensity psychological intervention delivered by trained non-specialist "helpers", is being scaled-up in Switzerland. OBJECTIVE: To identify factors influencing the process of the large-scale implementation of PM + for refugees in Switzerland and to develop recommendations to guide the implementation process. METHODS: 22 semi-structured interviews were conducted with key informants (Syrian refugees who previously participated in PM+, PM + helpers, health professionals working with refugees and decision-makers from the migration, integration, social, and health sectors). The data were analyzed using thematic analysis, combining an inductive and deductive approach. RESULTS: The data revealed three major themes, which might have an impact for the longer-term implementation of PM + in Switzerland. First, preconditions for successful integration in the health system prior to scaling-up such as sustainable funding or the introduction of a stepped care approach. Second, the requirements for the PM + intervention supporting scale-up such as quality control during PM + delivery, PM + modality, time and setting when PM + is offered or the views on task sharing. Third, the perceived benefits of scaling-up PM + in Switzerland. CONCLUSIONS: Our results have shown that PM + must be scaled-up within a stepped care approach, including a functioning triage system and sustainable funding. Rather than selecting one modality or setting, it seemed preferable to offer a variety of formats and settings to achieve maximum reach and benefits. A successful scale-up of PM + in Switzerland might have various benefits. Communicating them to policy-makers and health providers, might enhance their acceptability of the intervention and their willingness to adopt PM + in regulatory structure and promote it.

The effect of different types of migration on symptoms of anxiety or depression and experience of violence among people who use or inject drugs in Kachin State, Myanmar.

BACKGROUND: Evidence on the social determinants of mental health conditions and violence among people who inject or use drugs (PWUD) is limited, particularly in conflict-affected countries. We estimated the prevalence of symptoms of anxiety or depression and experience of emotional or physical violence among PWUD in Kachin State in Myanmar and examined their association with structural determinants, focusing on types of past migration (migration for any reason, economic or forced displacement). MATERIALS: A cross-sectional survey was conducted among PWUD attending a harm reduction centre between July and November 2021 in Kachin State, Myanmar. We used logistic regression models to measure associations between past migration, economic migration and forced displacement on two outcomes (1) symptoms of anxiety or depression (Patient Health Questionnaire-4) and (2) physical or emotional violence (last 12 months), adjusted for key confounders. RESULTS: A total of 406, predominantly male (96.8%), PWUD were recruited. The median age (IQR) was 30 (25, 37) years, most injected drugs (81.5%) and more commonly opioid substances such as heroin or opium (85%). Symptoms of anxiety or depression (PHQ4 ≥ 6) were high (32.8%) as was physical or emotional violence in the last 12 months (61.8%). Almost one-third (28.3%) had not lived in Waingmaw for their whole life (migration for any reason), 77.9% had left home for work at some point (economic migration) and 19.5% had been forced to leave home due to war or armed conflict (forced displacement). A third were in unstable housing in the last 3 months (30.1%) and reported going hungry in the last 12 months (27.7%). Only forced displacement was associated with symptoms of anxiety or depression [adjusted odds ratio, aOR 2.33 (95% confidence interval, CI 1.32-4.11)] and recent experience of violence [aOR 2.18 (95% CI 1.15-4.15)]. CONCLUSION: Findings highlight the importance of mental health services integrated into existing harm reduction services to address high levels of anxiety or depression among PWUD, particularly among those who have been displaced through armed conflict or war. Findings reinforce the need to address broader social determinants, in the form of food poverty, unstable housing and stigma, in order to reduce mental health and violence.

The Ukraine crisis: Mental health resources for clinicians and researchers.

The mental health consequences of the war in Ukraine will be enormous. Mental health professionals who are providing care for people in Ukraine, or those resettled elsewhere, may require access to standardized and validated assessment tools. We have developed a repository of mental health measures that are available in Ukrainian, Russian, and English and can be accessed at http://www.traumameasuresglobal.com/ukraine.

Changes in Mental Health Needs during COVID-19 in the Republic of Georgia: A Longitudinal Follow-up Study.

Background: To examine changes in COVID-19 stressors and symptoms of mental disorders in the Republic of Georgia. Methods: A longitudinal design was used. Following on from our study of May-June 2020, this follow-up study in January-March 2021 was conducted at: (i)an individual level with the same respondents involved in the May-June 2020 study (repeat responders/cohort); and (ii) at a population-wide level, using non-probabilistic sampling. Questionnaire sections covered: (i)demographic, socio-economic characteristics; (ii)level of burden caused by COVID-19-related stressors/concern; and (iii)symptoms of anxiety(GAD-7), depression(PHQ-9), PTSD(ITQ), adjustment disorder(ADNM8). Descriptive and multivariable regression analyses were conducted. Results: Among population-level survey respondents(N=1195), the probability of reporting mental ill health symptoms increased in 2021 compared to 2020 for PTSD(OR1.82), depression(OR1.40), adjustment disorder(OR 1.80), and marginally for anxiety(OR1.17). For the individual repeat respondents(N=455), the probability increased for depression(OR1.88) and adjustment disorder(OR2.56). The perceived burden of pandemic concern worsened in 2021 compared to 2020 for almost all stressors, particularly around access to health care, infecting others, and conflict in the home. PTSD was associated with an increased concern score from 2020 to 2021. Conclusion: Our study highlights the need to strengthen response strategies to address the elevated mental health needs related to COVID-19 in Georgia. It recommends increasing accessibility of early interventions and the need to modernise mental health services to strengthen access to care. It also calls for monitoring patterns of mental health disorders for better understanding and responses to mental health needs in Georgia.

Coping with migration-related stressors - a qualitative study of Nepali male labour migrants.

BACKGROUND: International labour migration has become a crucial livelihood strategy, especially in countries where decently paid employment opportunities are limited. Such opportunities come with many potential benefits but also many stressors that challenge migrants' coping skills, especially when they are in a foreign environment away from their normal support network. This paper explores how labour migrants coped with migration-related stressors using a sample of male Nepali migrants. METHODS: Qualitative life histories were conducted in Kathmandu among returnee male migrants. Coping responses were categorised based Skinner and Zimmer-Gembeck's coping typologies. The interview scripts were transcribed in Nepali and translated into English for analysis. Each interview script was open coded and then categorised according to the 12 core coping families. Data were analysed thematically to explore relationships across and within coping and stressors. RESULTS: Forty-two men were interviewed who mainly worked in low- and semi-skilled jobs in Malaysia, and the Gulf States. The coping strategies most commonly used belonged to the families of problem-solving, support-seeking, negotiation and helplessness. Men used these either individually or collectively with other migrants. Those who sought assistance from authorities or civil society organisations did not always receive the help needed and there were mixed messages as to when and what types of assistance were available. Some stressors involved multiple coping strategies simultaneously, others described changing strategies following unsuccessful earlier attempts. The coping families of helplessness and social isolation reflected migrants' limited power in challenging certain stressors. The choice of coping strategies was also moderated by factors such as outstanding loans, language difficulties, or not wanting to cause their family distress. Some coping strategies used led to  new stressors. CONCLUSIONS: Migrants need greater clarifications on their rights with respect to contract discrepancies, the types of support available, how and from whom to access them once in destination. Improvements to the support mechanisms migrants can access as well as strengthening migrant-led initiatives in destination countries to support labour migrants' in managing stressors are needed. These may contribute to reducing the experiences and impact of such stressors, which may ultimately lead to more successful migration outcomes. As labour migration from Nepal is likely to continue, government and CSOs need to ensure migrants have the support they need to cope with the challenges they may encountered along the way.

Prevalence and predictors of common mental disorders among Syrian refugees in Istanbul, Turkey: a cross-sectional study.

PURPOSE: The war in Syria has created the greatest refugee crisis in the twenty-first century. Turkey hosts the highest number of registered Syrian refugees, who are at increased risk of common mental disorders because of their exposure to war, violence and post-displacement stressors. The aim of this paper is to examine the prevalence and predictors of anxiety, depression, and post-traumatic stress disorder (PTSD) symptoms among Syrian refugees living in Turkey. METHODS: A cross-sectional survey of adult Syrian refugees was conducted between February and May 2018 in Istanbul (Sultanbeyli district). Participants (N = 1678) were randomly selected through the registration system of the district municipality. The Hopkins Symptoms Checklist (HSCL-25) was used to measure anxiety and depression and the Posttraumatic Stress Disorder (PTSD) Checklist (PCL-5) assessed posttraumatic stress. Descriptive and multivariate regression analyses were used. RESULTS: The prevalence of symptoms of anxiety, depression and PTSD were 36.1%, 34.7% and 19.6%, respectively. Comorbidity was high. Regression analyses identified several socio-demographic, health and post-displacement variables that predicted common mental disorders including: being female, facing economic difficulties, previous trauma experience, and unmet need for social support, safety, law and justice. A lifetime history of mental health treatment and problems accessing adequate healthcare were associated with depression and anxiety but not with PTSD. CONCLUSIONS: Mental disorder symptoms are highly prevalent among Syrian refugees in Turkey. The association with post-displacement factors points to the importance of comprehensive health and social services that can address these social, economic and cultural stressors.

MSF experiences of providing multidisciplinary primary level NCD care for Syrian refugees and the host population in Jordan: an implementation study guided by the RE-AIM framework.

BACKGROUND: In response to the rising global NCD burden, humanitarian actors have rapidly scaled-up NCD services in crisis-affected low-and-middle income countries. Using the RE-AIM implementation framework, we evaluated a multidisciplinary, primary level model of NCD care for Syrian refugees and vulnerable Jordanians delivered by MSF in Irbid, Jordan. We examined the programme's Reach, Effectiveness, Adoption and acceptance, Implementation and Maintenance over time. METHODS: This mixed methods retrospective evaluation, undertaken in 2017, comprised secondary analysis of pre-existing cross-sectional household survey data; analysis of routine cohort data from 2014 to 2017; descriptive costing analysis of total annual, per-patient and per-consultation costs for 2015-2017 from the provider-perspective; a clinical audit; a medication adherence survey; and qualitative research involving thematic analysis of individual interviews and focus group discussions. RESULTS: The programme enrolled 23% of Syrian adult refugees with NCDs in Irbid governorate. The cohort mean age was 54.7 years; 71% had multi-morbidity and 9.9% self-reported a disability. The programme was acceptable to patients, staff and stakeholders. Blood pressure and glycaemic control improved as the programme matured and by 6.6 mmHg and 1.12 mmol/l respectively within 6 months of patient enrolment. Per patient per year cost increased 23% from INT$ 1424 (2015) to 1751 (2016), and by 9% to 1904 (2017). Cost per consultation increased from INT$ 209 to 253 (2015-2017). Staff reported that clinical guidelines were usable and patients' self-reported medication adherence was high. Individual, programmatic and organisational challenges to programme implementation and maintenance included the impact of war and the refugee experience on Syrian refugees' ability to engage; inadequate low-cost referral options; and challenges for MSF to rapidly adapt to operating in a highly regulated and complex health system. Essential programme adaptations included refinement of health education, development of mental health and psychosocial services and addition of essential referral pathways, home visit, physiotherapy and social worker services. CONCLUSION: RE-AIM proved a valuable tool in evaluating a complex intervention in a protracted humanitarian crisis setting. This multidisciplinary programme was largely acceptable, achieving good clinical outcomes, but for a limited number of patients and at relatively high cost. We propose that model simplification, adapted procurement practices and use of technology could improve cost effectiveness without reducing acceptability, and may facilitate replication.

The influence of concern about COVID-19 on mental health in the Republic of Georgia: a cross-sectional study.

BACKGROUND: Early evidence indicates increased mental health burden arising from COVID-19 and related control measures. The study aim was to examine concern about COVID-19 and its association with symptoms of mental disorders in the Republic of Georgia. A cross-sectional internet-based survey of adults in Georgia using non-probabilistic sampling was used. Questionnaire topics were: (i) demographic and socio-economic characteristics; (ii) level of burden caused by common causes of COVID-19 related concerns; (iii) strategies used in response to concerns about COVID-19; and (iv) symptoms of mental disorders of anxiety (GAD-7), depression (PHQ-9), PTSD (ITQ) and adjustment disorder (ADNM8). Descriptive and multivariate analyses were conducted. RESULTS: There were 2088 respondents. High levels of symptoms for mental disorders were observed for anxiety (23.9% women, 21.0% men), depression (30.3% women, 25.27% men), PTSD (11.8% women, and 12.5% men), and adjustment disorder (40.7% women, 31.0% men). Factors significantly associated with increased COVID-19 concern included bad/very bad household economic situation, larger household size, current NCD, symptoms of anxiety, adjustment disorder and PTSD. Response strategies significantly associated with reduced mental disorder symptoms included meditation and relaxation exercises, physical exercise, positive thinking, planning for the future, TV/radio, housework/DIY, and working. Drinking alcohol was associated with a greater probability of increased mental disorder symptoms. CONCLUSIONS: High levels of mental disorders were recorded, and they were strongly associated with increased concern about COVID-19. A number of response strategies were identified which may help protect against worse mental health and these could be supported by innovations in mental health care in Georgia.

Planning the scale up of brief psychological interventions using theory of change.

BACKGROUND: A large mental health treatment gap exists among conflict-affected populations, and Syrian refugees specifically. Promising brief psychological interventions for conflict-affected populations exist such as the World Health Organization's Problem Management Plus (PM+) and the Early Adolescent Skills for Emotions (EASE) intervention, however, there is limited practical guidance for countries of how these interventions can be taken to scale. The aim of this study was to unpack pathways for scaling up PM+ and EASE for Syrian refugees. METHODS: We conducted three separate Theory of Change (ToC) workshops in Turkey, the Netherlands, and Lebanon in which PM+ and EASE are implemented for Syrian refugees. ToC is a participatory planning process involving key stakeholders, and aims to understand a process of change by mapping out intermediate and long-term outcomes on a causal pathway. 15-24 stakeholders were invited per country, and they participated in a one-day interactive ToC workshop on scaling up. RESULTS: A cross-country ToC map for scale up brief psychological interventions was developed which was based on three country-specific ToC maps. Two distinct causal pathways for scale up were identified (a policy and financing pathway, and a health services pathway) which are interdependent on each other. A list of key assumptions and interventions which may hamper or facilitate the scaling up process were established. CONCLUSION: ToC is a useful tool to help unpack the complexity of scaling up. Our approach highlights that scaling up brief psychological interventions for refugees builds on structural changes and reforms in policy and in health systems. Both horizontal and vertical scale up approaches are required to achieve sustainability. This paper provides the first theory-driven map of causal pathways to help support the scaling-up of evidence-based brief psychological interventions for refugees and populations in global mental health more broadly.

A narrative review of health research capacity strengthening in low and middle-income countries: lessons for conflict-affected areas.

Conducting health research in conflict-affected areas and other complex environments is difficult, yet vital. However, the capacity to undertake such research is often limited and with little translation into practice, particularly in poorer countries. There is therefore a need to strengthen health research capacity in conflict-affected countries and regions.In this narrative review, we draw together evidence from low and middle-income countries to highlight challenges to research capacity strengthening in conflict, as well as examples of good practice. We find that authorship trends in health research indicate global imbalances in research capacity, with implications for the type and priorities of research produced, equity within epistemic communities and the development of sustainable research capacity in low and middle-income countries. Yet, there is little evidence on what constitutes effective health research capacity strengthening in conflict-affected areas. There is more evidence on health research capacity strengthening in general, from which several key enablers emerge: adequate and sustained financing; effective stewardship and equitable research partnerships; mentorship of researchers of all levels; and effective linkages of research to policy and practice.Strengthening health research capacity in conflict-affected areas needs to occur at multiple levels to ensure sustainability and equity. Capacity strengthening interventions need to take into consideration the dynamics of conflict, power dynamics within research collaborations, the potential impact of technology, and the wider political environment in which they take place.

Alcohol use among conflict-affected persons in Ukraine: risk factors, coping and access to mental health services.

BACKGROUND: There are approximately 1.5 million internally displaced persons (IDPs) in Ukraine as a result of the conflict in eastern Ukraine. Exposure to violence, forced displacement and increased mental disorders are potential risk-factors for alcohol use disorder (AUD). The aim of this study was to estimate the prevalence of and risk factors for AUD among Ukrainian IDPs and investigate the relationship between AUD, mental health service utilization and coping behaviours. METHODS: A nation-wide cross-sectional survey of 2203 IDPs was conducted. Data were collected on AUD [using alcohol use disorder identification test (AUDIT)], mental health disorders, utilization of health services and coping behaviours. Multivariable logistic regression was used to identify risk factors for AUD, and to estimate the odds ratios for the association between alcohol use and utilization of health services and coping behaviours. RESULTS: Of 2203 IDPs surveyed, 8.4% of men and 0.7% of women screened positive for AUD (AUDIT >7). Among current drinkers, AUD was present in 14.9% of men and 1.8% of women. Age, cumulative trauma exposure and anxiety were significantly associated with AUD in multivariable analysis. Alcohol users were 43% less likely to access health services for mental health compared with non-users. AUD was associated with more negative coping behaviours. CONCLUSIONS: AUD is present within the male Ukrainian IDP population. Alcohol use was significantly associated with lower utilization of mental health services and more negative coping behaviours. AUD screening and low-intensity treatment services should be expanded for IDPs in Ukraine, particularly if integrated into mental health and psychosocial support programmes.

Patterns of somatic distress among internally displaced persons in Ukraine: analysis of a cross-sectional survey.

PURPOSE: There are often high rates of mental disorders in low- and middle-income countries during humanitarian crises, but the prevalence of somatic distress (SD) is underreported in the existing health service research. We aim to examine the patterns of SD among internally displaced persons (IDPs) in Ukraine, who were forcibly displaced due to the ongoing conflict in the country's eastern region. METHODS: The study design was a cross-sectional survey of 2203 adult IDPs throughout Ukraine. The survey collected data on sociodemographic characteristics, traumatic life events (Life Events Checklist), utilisation of mental health care services, and self-reported outcomes of SD (Patient Health Questionnaire 15), anxiety (Generalised Anxiety Disorder 7), depression (Patient Health Questionnaire 9), and post-traumatic stress (PTSD Checklist). Descriptive and multivariate regression analyses were used. RESULTS: Over half of respondents (n = 1142, 55%) were identified as being at risk of SD (PHQ-15 score ≥ 6), and the prevalence of moderate (n = 377, 18%) and high severity SD risk (n = 275, 13%) was substantial. There were significant associations (p < 0.05) between SD and age, female gender, economic status, self-reported depression and post-traumatic stress, and multiple trauma exposures. Being at risk of SD was also significantly associated with increased functional disability. Use of mental health care services was low across this population and only high SD risk seemed to be a reliable predictor of care-seeking behaviour. CONCLUSIONS: There is a significant risk of SD among IDPs in Ukraine. Our results illustrate the need for targeted health service research and regional programs to ensure that mental health needs are appropriately met.

Evidence on public health interventions in humanitarian crises.

Recognition of the need for evidence-based interventions to help to improve the effectiveness and efficiency of humanitarian responses has been increasing. However, little is known about the breadth and quality of evidence on health interventions in humanitarian crises. We describe the findings of a systematic review with the aim of examining the quantity and quality of evidence on public health interventions in humanitarian crises to identify key research gaps. We identified 345 studies published between 1980 and 2014 that met our inclusion criteria. The quantity of evidence varied substantially by health topic, from communicable diseases (n=131), nutrition (n=77), to non-communicable diseases (n=8), and water, sanitation, and hygiene (n=6). We observed common study design and weaknesses in the methods, which substantially reduced the ability to determine causation and attribution of the interventions. Considering the major increase in health-related humanitarian activities in the past three decades and calls for a stronger evidence base, this paper highlights the limited quantity and quality of health intervention research in humanitarian contexts and supports calls to scale up this research.

Bibliometric analysis of global migration health research in peer-reviewed literature (2000-2016).

BACKGROUND: The health of migrants has become an important issue in global health and foreign policy. Assessing the current status of research activity and identifying gaps in global migration health (GMH) is an important step in mapping the evidence-base and on advocating health needs of migrants and mobile populations. The aim of this study was to analyze globally published peer-reviewed literature in GMH. METHODS: A bibliometric analysis methodology was used. The Scopus database was used to retrieve documents in peer-reviewed journals in GMH for the study period from 2000 to 2016. A group of experts in GMH developed the needed keywords and validated the final search strategy. RESULTS: The number of retrieved documents was 21,457. Approximately one third (6878; 32.1%) of the retrieved documents were published in the last three years of the study period. In total, 5451 (25.4%) documents were about refugees and asylum seekers, while 1328 (6.2%) were about migrant workers, 440 (2.1%) were about international students, 679 (3.2%) were about victims of human trafficking/smuggling, 26 (0.1%) were about patients' mobility across international borders, and the remaining documents were about unspecified categories of migrants. The majority of the retrieved documents (10,086; 47.0%) were in psychosocial and mental health domain, while 2945 (13.7%) documents were in infectious diseases, 6819 (31.8%) documents were in health policy and systems, 2759 (12.8%) documents were in maternal and reproductive health, and 1918 (8.9%) were in non-communicable diseases. The contribution of authors and institutions in Asian countries, Latin America, Africa, Middle East, and Eastern European countries was low. Literature in GMH represents the perspectives of high-income migrant destination countries. CONCLUSION: Our heat map of research output shows that despite the ever-growing prominence of human mobility across the globe, and Sustainable Development Goals of leaving no one behind, research output on migrants' health is not consistent with the global migration pattern. A stronger evidence base is needed to enable authorities to make evidence-informed decisions on migration health policy and practice. Research collaboration and networks should be encouraged to prioritize research in GMH.

Barriers to mental health care utilization among internally displaced persons in the republic of Georgia: a rapid appraisal study.

BACKGROUND: There is a paucity of evidence on access to services for mental health and psychosocial support for conflict-affected populations in low- and middle-income countries. In the Republic of Georgia, rates of utilization of mental health services among internally displaced people with mental disorders are low. We set out to identify the health system barriers leading to this treatment gap. METHODS: We used rapid appraisal methods (collection and triangulation of multiple data sources) to investigate barriers to accessing mental health care services among adult IDPs in Georgia. Data collection included review of existing policy documents and other published data, as well as semi-structured interviews with 29 key informants including policy makers, NGO staff, health professionals and patients. RESULTS: The following factors emerged as important barriers affecting access to mental health care services among IDPs in Georgia: inadequate insurance coverage of mental disorders and poor identification and referral systems, underfunding, shortage of human resources, poor information systems, patient out-of-pocket payments and stigmatization. CONCLUSION: While rapid appraisal methods cannot control for potential biases or achieve representativeness, triangulation supports internal validity and reliability of the data collected, allowing data to be used to inform health care interventions. The appropriateness and potential effectiveness of policy interventions such as insurance coverage of a wider range of mental disorders, integration of services for these at the primary health care level, and community-based approaches in this context should be explored.

Diabetes care in a complex humanitarian emergency setting: a qualitative evaluation.

BACKGROUND: Evidence is urgently needed from complex emergency settings to support efforts to respond to the increasing burden of diabetes mellitus (DM). We conducted a qualitative study of a new model of DM health care (Integrated Diabetic Clinic within an Outpatient Department [IDC-OPD]) implemented by Médecins Sans Frontières (MSF) in Mweso Hospital in eastern Democratic Republic of Congo (DRC). We aimed to explore patient and provider perspectives on the model in order to identify factors that may support or impede it. METHODS: We used focus group discussions (FGDs; two discussions, each with eight participants) and individual semi-structured qualitative interviews (seven patients and 10 staff) to explore experience of and perspectives on the IDC-OPD. Participants were recruited purposively to represent a range of DM disease severity and staff functions respectively, and to ensure the age and gender distribution was representative of the population of DM patients registered in the clinic. Data were coded in NVivo10© and analysed using an inductive thematic approach. RESULTS: There appears to be little awareness surrounding DM in patient communities, resulting in delays presenting to hospital. Patients describe their first reactions to symptoms as fear and confusion, often assuming symptoms are of another disease (e.g. HIV/AIDS). They often express disbelief that they could have DM (e.g. stating DM is a 'rich man's disease') and lack acceptance that there is no cure. Patients experienced difficulty travelling to appointments, exacerbated by flare-ups in the conflict. Providing psycho-social and sensitisation activities in a group setting appears to offer an opportunity for patients to support each other in their effort to adhere to drug treatment and follow-up appointments. All patients reported great difficulty in adhering to the recommended diet, which was viewed as unaffordable and unavailable, and fear that this would be the biggest obstacle to maintaining their drug treatment (as treatment must be taken with food). CONCLUSION: Our findings emphasize the importance of community awareness of DM and the value of treatment support, including psychosocial and educational support to DM patients and their families, and culturally sensitive, low-cost dietary advice, to ensuring the adoption and maintenance of DM treatment.

A Systematic Review on Harmful Alcohol Use Among Civilian Populations Affected by Armed Conflict in Low- and Middle-Income Countries.

BACKGROUND: There are currently over 55 million refugees and internally displaced persons due to armed conflict. In addition, there are around 150 million more conflict-affected residents who remain in their home communities. Armed conflict poses a number of potential risks for harmful alcohol use. OBJECTIVE: The objective of the study was to systematically examine evidence on harmful alcohol use among conflict-affected populations in low- and middle-income countries. METHODS: A systematic review methodology was used following PRISMA guidelines. Quantitative studies were selected with outcomes relating to harmful alcohol use among conflict-affected populations in low- and middle-income countries. Seven bibliographic databases and a range of gray literature sources were searched. Descriptive analysis was applied and a quality assessment conducted using the Newcastle-Ottawa Quality Assessment Scale. RESULTS: The search yielded 10,037 references of which 22 studies met inclusion criteria. Twenty-one of the studies used a cross-sectional design, and 1 used a case series design. Evidence on risk factors for harmful alcohol use was weak overall. Factors associated with harmful alcohol use were male gender, older age, cumulative trauma event exposure, and depression. There were no studies on the effectiveness of interventions for harmful alcohol use. The strength of evidence was also limited by the generally moderate quality of the studies. CONCLUSIONS: Substantially more evidence is required to understand the scale of conflict-associated harmful alcohol use, key risk factors, association of alcohol use with physical and mental disorders, and effectiveness of interventions to address harmful alcohol use in conflict-affected populations.

Three Steps to Improve Management of Noncommunicable Diseases in Humanitarian Crises.

Kiran Jobanputra and colleagues argue that better evidence, guidance, and tools are needed to improve the effectiveness and feasibility of noncommunicable disease care in humanitarian settings.

Psychological Distress and Problem Drinking.

We examine the influence of harmful alcohol use on mental health using a flexible two-step instrumental variables approach and household survey data from nine countries of the former Soviet Union. Using alcohol advertisements to instrument for alcohol, we show that problem drinking has a large detrimental effect on psychological distress, with problem drinkers exhibiting a 42% increase in the number of mental health problems reported and a 15% higher chance of reporting very poor mental health. Ignoring endogeneity leads to an underestimation of the damaging effect of excessive drinking. Findings suggest that more effective alcohol policies and treatment services in the former Soviet Union may have added benefits in terms of reducing poor mental health.

A systematic review on tobacco use among civilian populations affected by armed conflict.

OBJECTIVE: To systematically examine evidence on tobacco use among conflict-affected civilian populations. DATA SOURCES: Primary quantitative and qualitative studies published in English up to April 2014. Bibliographic databases searched were EMBASE, Global Health, MEDLINE, PsycEXTRA, PsycINFO, Web of Science, Cochrane; with the main terms of: (Smoke*, tobacco*, cigarette*, nicotine, beedi, bidi, papirosi, dip, chew, snuff, snus, smokeless tobacco) AND (armed-conflict, conflict-affected, conflict, war, refugee, internally displaced, forcibly displaced, asylum, humanitarian). Grey literature was searched using humanitarian databases, websites and search engines. STUDY SELECTION: Studies were independently selected by two reviewers, with a study outcome of tobacco use and a population of conflict-affected civilian populations such as internally displaced persons, refugees, residents in conflict-affected areas, residents and returning forcibly displaced populations returning in stabilised and postconflict periods. 2863 studies were initially identified. DATA EXTRACTION: Data were independently extracted. The Quality Assessment Tool for Quantitative Studies and the Critical Appraisal Skills Programme for qualitative studies were used to assess study quality. DATA SYNTHESIS: 39 studies met inclusion criteria and descriptive analysis was used. Findings were equivocal on the effect of conflict on tobacco use. Evidence was clearer on associations between post-traumatic stress and other mental disorders with nicotine dependence. However, there were too few studies for definitive conclusions. No study examined the effectiveness of tobacco-related interventions. The quantitative studies were moderate (N=13) or weak (N=22) quality, and qualitative studies were moderate (N=3) or strong (N=2). CONCLUSIONS: Some evidence indicates links between conflict and tobacco use but substantially more research is required.