Characteristics of injuries during the 2006 Lebanon conflict: a three-center retrospective study of survivors, 16 years after the conflict.

Background: Armed conflict injury is a growing public health concern, particularly in regions like the Middle East and North Africa (MENA). The protracted conflicts and political unrest in this region have led to a substantial number of injuries. Despite this, there is still limited understanding of the specific injury patterns stemming from conflicts, such as the 2006 Lebanon conflict. This study aimed to assess the characteristics and burdens of injuries resulting from this conflict, which occurred 16 years prior to this research. Methods: This retrospective study analyzed data of individuals affected by the 2006 Lebanon conflict, across three tertiary care centers. Demographics, injuries, complications, injury management, and hospitalization expenses were extracted from medical records and analyzed using SPSS version 29.0. Categorical variables were presented as counts and proportions, and continuous variables as mean ± standard deviation (SD). Hospital comparisons utilized chi-square or Fisher's exact tests for categorical variables, and one-way ANOVAs for continuous variables. Analysis was conducted from September to November 2023. Results: Across three hospitals, 341 patients were studied, comprising 73.6% males and 26.4% females. Among them, a notable proportion (57.3% males and 34.1% females) fell within the 18-39 age range. Children and adolescents under 18 years accounted for 15.9% of males and 25.9% of females. Blast-related injuries predominated, with 24.5% resulting from direct damage caused by explosive parts and 33.3% from blast wave forces. Extremity trauma occurred in 49.0% of patients, and head/neck trauma in 24.9%. Common injuries, including penetrating, musculoskeletal, and traumatic brain injuries affected 34.9%, 31.1, and 10.0% of patients, respectively. Wound repair, fracture treatment, and debridement were the most performed procedures on 15.5, 13.5 and 9.7% of the patients, respectively. The total cost of care was USD 692,711, largely covered by the Ministry of Public Health (95.9%). Conclusion: Conflict-related injuries significantly contribute to the global burden of disease. Therefore, there is a pressing need to improve national guidelines to prioritize life-threatening cases and potential long-term disabilities. Furthermore, enhancing electronic registry systems to collect clinical data on injured patients is essential for conducting research and better understanding the needs of conflict casualties.

Healthy ageing in a multi-ethnic population: A descriptive cross-sectional analysis from the HELIUS study.

OBJECTIVE: We investigated ethnic health disparities in the Healthy Life in an Urban Setting multi-ethnic cohort using the multidimensional Healthy Ageing Score. STUDY DESIGN: We conducted a cross-sectional analysis of the study baseline data (2011-2015) collected through questionnaires/physical examinations for 17,091 participants (54.8 % women, mean (SD) age = 44.5 (12.8) years) from South-Asian Surinamese (14.8 %), African Surinamese (20.5 %), Dutch (24.3 %), Moroccan (15.5 %), Turkish (14.9 %), and Ghanaian (10.1 %) origins, living in Amsterdam, the Netherlands. MAIN OUTCOME MEASURES: We computed the Healthy Ageing Score developed in the Rotterdam Study, which has seven biopsychosocial domains: chronic diseases, mental health, cognitive function, physical function, pain, social support, and quality of life. That score was used to discern between healthy, moderate, and poor ageing. We explored differences in healthy ageing by ethnicity, sex, and age group using multinomial logistic regression. RESULTS: The Healthy Ageing Score [overall: poor (69.0 %), moderate (24.8 %), and healthy (6.2 %)] differed between ethnicities and was poorer in women and after midlife (cut-off 45 years) across ethnicities (all p < 0.001). In the fully adjusted models in men and women, poor ageing (vs. healthy ageing) was highest in the South-Asian Surinamese [adjusted odds ratios (95 % confidence intervals)] [2.96 (2.24-3.90) and 6.88 (3.29-14.40), respectively] and Turkish [2.80 (2.11-3.73) and 7.10 (3.31-15.24), respectively] vs. Dutch, in the oldest [5.89 (3.62-9.60) and 13.17 (1.77-98.01), respectively] vs. youngest, and in the divorced [1.48 (1.10-2.01) and 2.83 (1.39-5.77), respectively] vs. married. Poor ageing was inversely associated with educational and occupational levels, mainly in men. CONCLUSIONS: Compared with those of Dutch ethnic origin, ethnic minorities displayed less healthy ageing, which was more pronounced in women, before and after midlife, and was associated with sociodemographic factors.

Long-term burden of war injuries among civilians in LMICs: case of the July 2006 war in Lebanon.

Introduction: Lebanon, a country located on the eastern shore of the Mediterranean Sea, is one of the world's smaller sovereign states. In the past few decades, Lebanon endured a perpetual political turmoil and several armed conflicts. July 12, 2006, marked the start of a one-month war in Lebanon, which resulted in thousands of casualties. Little is known about the long-term consequences of war injuries inflicted on civilians during the July 2006 war. Methods: The objectives of this paper were to identify and evaluate: 1- civilians' access to healthcare and medicine under conditions of war; 2- the long-term socioeconomic burden on injured civilians; and 3- their quality of life more than a decade post-war. We adopted a mixed-method research design with an emphasis on the qualitative component. We conducted interviews with patients, collected clinical and financial data from hospital medical records, and administered a self-rated health questionnaire, the EQ-5D-5L. Simple descriptive statistics were calculated using Excel. NVivo 12® was used for data management and thematic analysis. Results: We conducted 25 interviews. Injured civilians were mostly males, average age of 27. The most common mechanism of injury was blast injury. Most patients underwent multiple surgeries as well as revision surgeries. The thematic analysis revealed three themes: 1- recall of the time of the incident, the thousand miles journey, and patients' access to services; 2- post-trauma sequelae and services; and 3- long-term impact. Patients described the long-term burden including chronic pain, poor mobility, anxiety or depression, and limited activities of daily living. Discussion: Civilians injured during the July 2006 war described the traumatising events they endured during the war and the limited access to medical care during and post-war. Up until this study was conducted, affected civilians were still experiencing physical, psychological, and financial sequelae. Acknowledging the limitations of this study, which include a small sample size and recall bias, the findings underscore the necessity for the expansion of services catering to civilians injured during wartime.

Urban Governance, Multisectoral Action, and Civic Engagement for Population Health, Wellbeing, and Equity in Urban Settings: A Systematic Review.

Objectives: To identify the validated and reliable indicators and tools to assess good governance for population health, wellbeing, and equity in urban settings, and assess processes of multisectoral action and civic engagement as reported by peer-reviewed articles. Methods: We conducted a systematic review searching six databases for observational studies reporting strategies of either urban health, multisectoral action or civic engagement for wellbeing, health, or equity. Results: Out of 8,154 studies initially identified we included 17. From the included studies, 14 presented information about high-income countries. The general population was the main target in most studies. Multisectoral action was the most frequently reported strategy (14 studies). Three studies used Urban Health Equity Assessment and Response Tool (Urban HEART). Health indicators were the most frequently represented (6 studies). Barriers and facilitators for the implementation of participatory health governance strategies were reported in 12 studies. Conclusion: Data on the implementation of participatory health governance strategies has been mainly reported in high-income countries. Updated and reliable data, measured repeatedly, is needed to closely monitor these processes and further develop indicators to assess their impact on population health, wellbeing, and equity.

Concepts and definitions of healthy ageing: a systematic review and synthesis of theoretical models.

Background: Healthy ageing (HA) has been defined using multiple approaches. We aim to produce a comprehensive overview and analysis of the theoretical models underpinning this concept and its associated normative terms and definitions. Methods: We conducted a systematic review of peer-reviewed HA models in Embase.com, Medline (Ovid), Cochrane CENTRAL, CINAHL, PsycINFO, and Web of Science until August 2022. Original theoretical papers, concept analyses, and reviews that proposed new models were included. Operational models/definitions, development psychology theories and mechanisms of ageing were excluded. We followed an iterative approach to extract the models' characteristics and thematically analyze them based on the approach of Walker and Avant. The protocol was registered in PROSPERO (CRD42021238796). Findings: Out of 10,741 records, we included 59 papers comprising 65 models/definitions, published in English (1960-2022) from 16 countries in Europe, Asia, and America. Human ageing was described using 12 normative terms, mainly (models (%)): successful (34 (52%)), healthy (eight (12%)), well (five (8%)), and active (four (6%)). We identified intrinsic/extrinsic factors interacting throughout the life course, adaptive processes as attributes, and outcomes describing ageing patterns across objective and subjective dimensions (number of models/definitions): cognitive (62), psychological (53), physical (49), social (49), environmental (19), spiritual (16), economic (13), cultural (eight), political (six), and demographic (four) dimensions. Three types of models emerged: health-state outcomes (three), adaptations across the life course (31), or a combination of both (31). Two additional sub-classifications emphasized person-environment congruence and health promotion. Interpretation: HA conceptualizations highlight its multidimensionality and complexity that renders a monistic model/definition challenging. It has become evident that life long person-environment interactions, adaptations, environments, and health promotion/empowerment are essential for HA. Our model classification provides a basis for harmonizing terms and dimensions that can guide research and comparisons of empirical findings, and inform social and health policies enabling HA for various populations and contexts. Funding: MM, ZMRD, and OI are supported by the European Union's Horizon 2020 Marie Sklodowska-Curie grant No 801076, and MM is also supported by the Swiss National Foundation grant No 189235.

How COVID-19 highlighted the need for infection prevention and control measures to become central to the global conversation: experience from the conflict settings of the Middle East.

Within just a few months, the coronavirus disease 2019 (COVID-19) pandemic managed to bring to the foreground the conversation that infection prevention and control (IPC) experts have been pushing for decades regarding the control of the spread of infections. Implementing the basics of IPC has been a challenge for all affected countries battling with an exponential COVID-19 curve of infection. Preventing nosocomial transmission of the disease has been difficult in highly resourced and stable contexts, but even more so in the conflict context of the Middle East. COVID-19 has added further challenges to the long list of existing ones, hindering the implementation of the optimal IPC measures that are necessary to break the chain of infection of both respiratory and non-respiratory infections in those settings. This paper outlines and gives examples of the challenges faced across the Middle East conflict setting and serves as a call for action for IPC to be prioritized, given the resources needed, and fed with contextualized evidence.

The socioeconomic burden of antibiotic resistance in conflict-affected settings and refugee hosting countries: a systematic scoping review.

BACKGROUND: Antibiotic resistance (ABR) is a major global threat. Armed and protracted conflicts act as multipliers of infection and ABR, thus leading to increased healthcare and societal costs. We aimed to understand and describe the socioeconomic burden of ABR in conflict-affected settings and refugee hosting countries by conducting a systematic scoping review. METHODS: A systematic search of PubMed, Medline (Ovid), Embase, Web of Science, SCOPUS and Open Grey databases was conducted to identify all relevant human studies published between January 1990 and August 2019. An updated search was also conducted in April 2020 using Medline/Ovid. Independent screenings of titles/abstracts followed by full texts were performed using pre-defined criteria. The Newcastle-Ottawa Scale was used to assess study quality. Data extraction and analysis were based on the PICOS framework and following the PRISMA-ScR guideline. RESULTS: The search yielded 8 studies (7 publications), most of which were single-country, mono-center and retrospective studies. The studies were conducted in Lebanon (n = 3), Iraq (n = 2), Jordan (n = 1), Palestine (n = 1) and Yemen (n = 1). Most of the studies did not have a primary aim to assess the socioeconomic impact of ABR and were small studies with limited statistical power that could not demonstrate significant associations. The included studies lacked sufficient information for the accurate evaluation of the cost incurred by antibiotic resistant infections in conflict-affected countries. CONCLUSION: This review highlights the scarcity of research on the socioeconomic burden of ABR on general populations in conflict-affected settings and on refugees and migrants in host countries, and lists recommendations for consideration in future studies. Further studies are needed to understand the cost of ABR in these settings to develop and implement adaptable policies.

Research Capacity and Training Needs for Cancer in Conflict-Affected MENA Countries.

Background: The global cancer burden is disproportionately greater in low- and middle-income countries, including those affected by conflict in the Middle East and North Africa (MENA) region. Contributing factors include inadequate control of risk factors plus limited surveillance and treatment options. Weak healthcare infrastructure may be further compounded by the conflict prevalent in multiple MENA countries. Improved cancer surveillance, research, and capacity strengthening are essential for implementing cancer control plans in the MENA region, requisite for reducing the disproportionate cancer burden. Aims: This article aims to understand the barriers to cancer research and training in conflict-affected MENA countries, and to identify opportunities for developing capacities for reliable cancer research strategies. Methods: This study employs a mixed-method approach utilizing an online questionnaire with open and close ended questions targeting oncologists and cancer researchers in conflict-affected MENA countries. For open-ended questions, we performed a qualitative content analysis to identify thematic barriers. Results: Forty-eight respondents, mostly Medical and Radiation Oncologists, completed the questionnaire. The most significant training needs were conducting clinical, basic, and qualitative cancer research. The most prominent barriers identified were insufficient training in data analysis and research design (77% and 75% of respondents, respectively) and insufficient institutional and government funding (94% and 85%, respectively). For the qualitative data, we organized the barriers into six themes, the most common was the lack of research infrastructure (28%). Conclusions: Despite an escalating cancer burden, conflict-affected MENA countries are lagging in knowledge production and implementation of evidence-based cancer research. Novel modes of knowledge transmission and collaboration across geographical and political boundaries are sorely needed. Based on our study, we recommend developing innovative and accessible training opportunities focusing on developing basic, clinical, and qualitative research skills. Research capacity-strengthening initiatives should encourage the investigation of context-specific research questions with the potential to make a meaningful impact on cancer control in the region.

Mapping breast cancer journal publications in conflict settings in the MENA region: a scoping review.

BACKGROUND: Breast cancer is a major cause of cancer-related morbidity and mortality among women in the the Middle East and North Africa (MENA) region. Conflict and political instability in the region may affect medical research output, including that on breast cancer. This scoping review aims to systematically identify and map breast cancer publications across different stages of the cancer care pathway and across conflict-affected countries within the MENA region. The findings of this work will highlight the impact of conflict on cancer research that could be mitigated with the proper contextualised capacity strengthening intervention. METHODS: We followed the PRISMA-Scr methodology. We searched for peer-reviewed publications on topics related to breast cancer in 11 databases: Medline, PubMed, EMBASE, Web of Science, PROQUEST, CINAHL, Global Index Medicus, Arab World Searches Complete, Popline, Scopus and Google Scholar using both controlled vocabulary and keywords. Publication abstracts and full-text versions were screened for duplicates and included in our study based on pre-specified eligibility criteria: focused on breast cancer, related to the specific country of analysis and human or health system studies. We used a structured data extraction form to extract information related to the article, its methodology and the cancer care pathway being studied. RESULTS: A total of 19,215 citations were retrieved from our search. After removing duplicates, a total of 8,622 articles remained. Title and abstract screening retained 1,613 articles. Publications with first author affiliations to Turkey were consistently the highest across all categories of the cancer care pathway. Trends show an increase in articles from Lebanon, Jordan and Palestine after 2015. Early exploratory and epidemiological studies represented the majority of breast cancer research, followed by policy and implementation research and lastly experimental research. Most research conducted followed an observational study design. Important gaps were identified in the research output related to advanced breast cancer and palliative care (Libya, Syria and Yemen), mental health (Libya), and knowledge and education of breast cancer (Libya and Syria). CONCLUSION: This scoping review has identified key areas in breast cancer research that lack significant research activity in conflict MENA settings. These areas, including but are not limited to palliative care, mental health, and education, can be prioritised and developed through regional collaboration and contextualised capacity strengthening initiatives.

Ecology of War, Health Research and Knowledge Subjugation: Insights from the Middle East and North Africa Region.

In an ecology of war, as experienced in the Middle East and North Africa region, health research faces several interrelated challenges: de-prioritization, paucity in the generation of reliable data, and its securitization. This directly contributes to local knowledge subjugation and research waste as local narratives are disqualified in favor of institutionalized and privileged global unitary knowledge. Huge efforts that require political will and commitment, coupled with multidisciplinary approaches and sustainable collaborations between researchers and humanitarian workers at the local, regional and global levels, are indispensable to give more space for the abandoned local knowledge in order to have contextualized and more impactful interventions where more lives are saved.

Strengthening capacity for cancer research in conflict settings: key informant insights from the Middle East.

BACKGROUND: Management of cancer in the Middle East and North Africa (MENA) region is accompanied by multiple challenges including heterogeneous access to early detection and treatment options and limited implementation of national cancer control plans. Furthermore, protracted armed conflicts across the region have had dramatic effects, including disruption of healthcare systems and the migration of healthcare professionals. Strengthening capacity for cancer research has been identified as a key intervention to correct data poverty, inform policy, manage limited resources and improve health outcomes. OBJECTIVE: The main objective of this study is to gain insights into the landscape, barriers and enablers of cancer training, research and care in the MENA region. METHOD: We utilised purposive sampling to interview 16 key informants from a diverse academic, medical and research background originating from countries affected by conflicts, such as Lebanon, and from active conflict zones including Iraq and Syria. RESULTS: The themes that emerged from the interviews focused on the barriers to cancer care, barriers to cancer research and training, strengths and importance of cancer research and training recommendations. The detrimental effect of conflict on cancer provision and research was a cross-cutting sub-theme disrupting cancer care provision and research due to unsafe environments, fragmented facilities, absence of drugs and migration of personnel. When asked about perceived optimal training format for cancer research, most informants recommended a post-graduate, face-to-face training focusing on cancer research methods and concepts. CONCLUSION: This study offers a unique insight into the barriers affecting cancer research and capacity-strengthening priorities from oncologists and researchers working in conflict-affected areas of the MENA region. These data will form the base for future capacity-strengthening initiatives addressing specific regional challenges.

A conceptual framework for capacity strengthening of health research in conflict: the case of the Middle East and North Africa region.

BACKGROUND: In conflict settings, research capacities have often been de-prioritized as resources are diverted to emergency needs, such as addressing elevated morbidity, mortality and health system challenges directly and/or indirectly associated to war. This has had an adverse long-term impact in such protracted conflicts such as those found in the Middle East and North Africa region (MENA), where research knowledge and skills have often been compromised. In this paper, we propose a conceptual framework for health research capacity strengthening that adapts existing models and frameworks in low- and middle-income countries and uses our knowledge of the MENA context to contextualise them for conflict settings. METHODS: The framework was synthesized using "best fit" framework synthesis methodology. Relevant literature, available in English and Arabic, was collected through PubMed, Google Scholar and Google using the keywords: capacity building; capacity strengthening; health research; framework and conflict. Grey literature was also assessed. RESULTS: The framework is composed of eight principal themes: "structural levels", "the influence of the external environment", "funding, community needs and policy environment", "assessing existing capacity and needs", "infrastructure and communication", "training, leadership and partnership", "adaptability and sustainability", and "monitoring and evaluation"; with each theme being supported by examples from the MENA region. Our proposed framework takes into consideration safety, infrastructure, communication and adaptability as key factors that affect research capacity strengthening in conflict. As it is the case more generally, funding, permissible political environments and sustainability are major determinants of success for capacity strengthening for health research programmes, though these are significantly more challenging in conflict settings. Nonetheless, health research capacity strengthening should remain a priority. CONCLUSION: The model presented is the first framework that focuses on strengthening health research capacity in conflict with a focus on the MENA region. It should be viewed as a non-prescriptive reference tool for health researchers and practitioners, from various disciplines, involved in research capacity strengthening to evaluate, use, adapt and improve. It can be further extended to include representative indicators and can be later evaluated by assessing its efficacy for interventions in conflict settings.

Correction to: Informal healthcare provision in Lebanon: an adaptive mechanism among displaced Syrian health professionals in a protracted crisis.

[This corrects the article DOI: 10.1186/s13031-019-0224-y.].

Informal healthcare provision in Lebanon: an adaptive mechanism among displaced Syrian health professionals in a protracted crisis.

BACKGROUND: Syrian healthcare workers (HCWs) are among those who fled the Syrian conflict only to face further social and economic challenges in host countries. In Lebanon, this population group cannot formally practice, yet many are believed to be operating informally. These activities remain poorly documented and misunderstood by the academic, policy and humanitarian communities. This study aims to understand mechanisms of informal provision of services, the facilitators and barriers for such practices and to present policy recommendations for building on this adaptive mechanism. METHOD: A qualitative descriptive study based on an in-depth interview approach with a sample of Syrian informal healthcare workers (IHCWs) residing in Lebanon was adopted. Known sponsor networks followed by snowball sampling approaches were used to recruit participants. Data collection occurred between September and December 2017. All interviews were audio-recorded, transcribed and translated into English. An inductive thematic analysis was used. RESULTS: Twenty-two participants were recruited. Motivational factors that led HCWs to practice informally were personal (e.g. source of income/livelihood), societal (cultural competency), and need to fulfill a gap in the formal health service sector. Being connected to a network of IHCWs facilitated initiation of the informal practice until eventually becoming part of a community of informal practice. The central challenge was the informal nature of their practice and its negative consequences. Most IHCWs were afraid of arrest by the government upon identification. Most interviewees indicated being discriminated against by host communities in the form of differential wages and tense interpersonal relationships. Almost all recommended a change in policy allowing them to practice formally under a temporary registration until their return to Syria. CONCLUSION: Our study confirmed the presence of IHCWs operating in Lebanon. Despite its informal nature, participants perceived that this practice was filling a gap in the formal health system and was helping to alleviate the burden of IHCWs and refugee health needs. In line with interviewees' views, we recommend that policy decision makers within humanitarian agencies and the Government of Lebanon explore the possibilities for allowing temporary registration of displaced Syrian IHCW to benefit local host communities and refugee populations.