The Ethical Triage and Management Guidelines of the Entrapped and Mangled Extremity in Resource Scarce Environments: A Systematic Literature Review.

OBJECTIVE: A systematic literature review (SLR) was performed to elucidate the current triage and treatment of an entrapped or mangled extremity in resource scarce environments (RSEs). METHODS: A lead researcher followed the search strategy following inclusion and exclusion criteria. A first reviewer (FR) was randomly assigned sources. One of the 2 lead researchers was the second reviewer (SR). Each determined the level of evidence (LOE) and quality of evidence (QE) from each source. Any differing opinions between the FR and SR were discussed between them, and if differing opinions remained, then a third reviewer (the other lead researcher) discussed the article until a consensus was reached. The final opinion of each article was entered for analysis. RESULTS: Fifty-eight (58) articles were entered into the final study. There was 1 study determined to be LOE 1, 29 LOE 2, and 28 LOE 3, with 15 determined to achieve QE 1, 37 QE 2, and 6 QE 3. CONCLUSION: This SLR showed that there is a lack of studies producing strong evidence to support the triage and treatment of the mangled extremity in RSE. Therefore, a Delphi process is suggested to adapt and modify current civilian and military triage and treatment guidelines to the RSE.

Health as human security in the occupied Palestinian territory.

We describe the threats to survival, development, and wellbeing in the occupied Palestinian territory using human security as a framework. Palestinian security has deteriorated rapidly since 2000. More than 6000 Palestinians have been killed by the Israeli military, with more than 1300 killed in the Gaza Strip during 22 days of aerial and ground attacks ending in January, 2009. Israeli destruction and control of infrastructure has severely restricted fuel supplies and access to water and sanitation. Palestinians are tortured in prisons and humiliated at Israeli checkpoints. The separation wall and the checkpoints prevent access to work, family, sites of worship, and health-care facilities. Poverty rates have risen sharply, and almost half of Palestinians are dependent on food aid. Social cohesion, which has kept Palestinian society intact, including the health-care system, is now strained. More than US$9 billion in international aid have not promoted development because Palestinians do not have basic security. International efforts focused on prevention of modifiable causes of insecurity, reinvigoration of international norms, support of Palestinian social resilience and institutions that protect them from threats, and a political solution are needed to improve human security in the occupied Palestinian territory.

Adolescent place attachment, social capital, and perceived safety: a comparison of 13 countries.

In adolescence, children become increasingly independent and autonomous, and spend more time in neighborhood settings away from home. During mid-to-late adolescence, youth often become more critical about the place they live. Their attachment to home and even community may decrease as they explore and develop new attachments to other specific places. The aim of this study is to understand how 15-year-old students from 13 countries perceive their local neighborhood area (place attachment, social capital and safety), and how these different community cognitions are interrelated. We hypothesize that their place attachment predicts safety, and that the relationship is mediated in part by social capital. Result show that, despite cross-cultural differences in neighborhood perceptions, the proposed theoretical model fits robustly across all 13 countries.

Country material distribution and adolescents' perceived health: multilevel study of adolescents in 27 countries.

OBJECTIVE: To assess the impact of country material distribution on adolescents' perceptions of health. DESIGN: Cross sectional multilevel study. SETTING: Data were collected from the school based health behaviour in school aged children: WHO cross national study 1997/98, which includes students from 27 European and North American countries. PARTICIPANTS: 12 0381 students in year 6, 8, and 10 who were attending school classes on the day of data collection. MAIN RESULT: Adolescents in countries with a high dispersion of family affluence were more likely to have self rated poor health even after controlling for individual family level of affluence and family social resources. CONCLUSION: There are substantial inequalities in subjective health across European and North American countries related to the distribution of family material resources in these countries.

Do welfare regimes mediate the effect of socioeconomic position on health in adolescence? A Cross-national comparison in Europe, North America, and Israel.

This article examines whether different types of welfare states mediate the effect of socioeconomic position on adolescents' health. The authors' main hypothesis is that countries with stronger redistributive policies will be more effective in weakening the association between socioeconomic position and health, thus reducing health inequalities. Analyses were carried out for Israel and 32 countries of Europe and North America. Data in the 2001-2002 Health Behavior in School-aged Children survey were collected through self-administered questionnaires distributed in schools to boys and girls 11, 13, and 15 years old. Socioeconomic position was measured with the Family Affluence Scale, based on reported consumption in the family. Health indicators were perceived health, general well-being, symptom load, and health behaviors. Social welfare regimes were classified using an expanded Esping-Andersen classification. The analysis supports the authors' hypothesis, at least partially. Social democratic and conservative welfare regimes rank lowest in the strength of association between low socioeconomic position and poor health, followed by liberal and other regime types, but it is more difficult to interpret data from Mediterranean and post-communist countries.

Physical activity of children with and without long-term illness or disability.

BACKGROUND: We know very little about physical activity in children with long-term illness or disability compared with those children without disabilities. Previous studies indicate low physical activity levels among all adolescents. METHODS: The sample consisted of Canadian (n = 2720) and Finnish pupils (n = 3459) approximately 13.5 and 15.5 years of age in general (mainstreamed) education. The study is a part of the Health Behavior in School-aged Children (HBSC) study. Nationally representative data were collected in 2002 using a standardized questionnaire. The moderate-to-vigorous intensity physical activity screening measure was used. RESULTS: Approximately one-fifth of the pupils in both countries had a long-term disability, illness or medical condition. In both countries boys and girls with a long-term illness or disability were equally physically inactive, and adolescents with a long-term illness or disability were as physically active as those without disabilities. CONCLUSIONS: There is no difference between young people with and without long-term illness/disability, and between boys and girls, in relation to their physical activity. However, all of them fall short of recommended guidelines. This indicates that promoting a physically active lifestyle should be of high priority in the lives of young people.

Cross-national comparison of adolescent drinking and cannabis use in the United States, Canada, and the Netherlands.

BACKGROUND: This research examined the prevalence of drinking and cannabis use among adolescents in the United States, Canada, and the Netherlands, countries with substantially different laws and policies relating to these substances. METHODS: Laws regarding drinking and cannabis use were rated for each country. Substance use prevalence data among 10th graders from the Health Behaviour in School-Aged Children Survey conducted in each country in 2005-2006 were examined. RESULTS: Laws regarding alcohol and cannabis were found to be strictest in the United States, somewhat less strict in Canada, and least strict in the Netherlands. On most measures of drinking, rates were lower in the United States than in Canada or the Netherlands. With United States as the referent, relative risks (RR) for monthly drinking were 1.30 (1.11-1.53) for Canadian boys and 1.55 (1.31-1.83) for girls, and 2.0 (1.73-2.31) for Dutch boys and 1.92 (1.62-2.27) for Dutch girls. Drunkenness was also higher among Canadian boys and girls and Dutch boys. However, rates of cannabis use did not differ between the countries, except that Dutch girls were less likely to use cannabis in the past year (RR=.67; .46-.96). CONCLUSIONS: The lower prevalence of adolescent drinking and drunkenness (except among Dutch girls) in the United States is consistent with the contention that strict drinking policies may limit drinking among 10th graders. However, the finding that cannabis use rates did not differ across countries is not consistent with the contention that prohibition-oriented policies deter use or that liberal cannabis policies are associated with elevated adolescent use. Based on these findings, the case for strict laws and policies is considerably weaker for cannabis than for alcohol.

Socio-economic inequality in multiple health complaints among adolescents: international comparative study in 37 countries.

OBJECTIVES: To use comparable data from many countries to examine 1) socio-economic inequality in multiple health complaints among adolescents, 2) whether the countries' absolute wealth and economic inequality was associated with symptom load among adolescents, and 3) whether the countries' absolute wealth and economic inequality explained part of the individual level socio-economic variation in health complaints. METHODS: The Health Behaviour in School-aged Children (HBSC) international study from 2005/06 provided data on 204,534 11-, 13- and 15-year old students from nationally random samples of schools in 37 countries in Europe and North America. The outcome measure was prevalence of at least two daily health complaints, measured by the HBSC Symptom Check List. We included three independent variables at the individual level (sex, age group, family affluence measured by the Family Affluence Scale FAS) and two macro level measures on the country's economic situation: wealth measured by Gross National Product (GNP) and distribution of income measured by the Gini coefficient. RESULTS: There was a significant socio-economic variation in health complaints in 31 of the 37 countries. The overall OR (95 % CI) for 2+ daily health complaints for all countries was 1.31 (1.27-1.36) in the medium versus high FAS group and 2.07 (2.00-2.14) in the low versus high FAS group. This socio-economic gradient in health complaints attenuated somewhat in the multilevel models which included macro level data. There was no association between GNP and health complaints. The OR for high symptom load was 1.35 (1.08-1.69) per 10 % increase in Gini coefficient. The socio-economic gradient in health complaints at the individual level was somewhat attenuated in the multilevel models which included macro level data. CONCLUSIONS: There was a significant association between low FAS and high level of health complaints in 30 of 37 countries. Health complaints increased significantly by increasing income inequality in the country.

Normalising the abnormal: Palestinian youth and the contradictions of resilience in protracted conflict.

This qualitative study explores the construct of resilience by Palestinian youth in the 10th to 12th grades at school living in and around Ramallah in the West Bank. We look at how adolescents themselves interpret and give meaning to the concept of resilience in dehumanising and abnormal conditions. The aim is to 'problematise' the construct to go beyond quantitative research and objective inquiry. Focus groups were conducted with 321 male and female Palestinian students in 15 schools in Ramallah and the surrounding villages. This study presents findings that are consistent with previous research on the value of supportive relationships such as families and friends. Political participation and education are vital to a sense of identity and political resistance. However, a key finding reveals the normalisation of everyday life in fostering resiliency within abnormal living conditions. Palestinian youth, nonetheless, paint a picture of resilience that reveals contradictions and tensions. This study underlines the fluid and dynamic nature of resilience. Despite the desire for order, Palestinian young people complain of emotional distress and boredom. Feelings of desperation are intermingled with optimism. We also argue that the concept of resilience developed in predominantly Western settings ignores a local idiom of communal care and support. International and local organisations providing psychosocial care rely on trauma programmes based on a Western style of counselling. An over-emphasis on individualised intervention overlooks the notion of collective resiliency and fails to build on existing social capital within communities. Policy-makers should do more than 'tweak' preconceived projects to fit the cultural context or to replicate them from one conflict area to another. We should also keep in mind that the search for psychological well-being and justice are not mutually exclusive.

Contraceptive use by 15-year-old students at their last sexual intercourse: results from 24 countries.

OBJECTIVES: To identify and report cross-national patterns in contraceptive use among sexually active adolescents. DESIGN: A cross-national cross-sectional survey. SETTING: Data were collected in 2002 by self-report questionnaire from students in school classrooms. PARTICIPANTS: A cluster sample of 33,943 students aged 15 years from 24 countries. MAIN OUTCOME MEASURES: International standardized questions on ever having had sexual intercourse and contraceptive use at last sexual intercourse. RESULTS: The percentages of students reporting having had sexual intercourse ranged from 14.1% in Croatia to 37.6% in England; 82.3% of those who were sexually active reported that they used condoms and/or birth control pills at last intercourse. Condom use only was most frequent and ranged from 52.7% in Sweden to 89.2% in Greece. Dual use of condoms and contraceptive pills was also relatively frequent, ranging from 2.6% in Croatia to 28.8% in Canada. The use of contraceptive pills was most frequent in northern and western Europe. No contraceptive use at last intercourse was reported by 13.2% of students. CONCLUSIONS: A substantial minority of 15-year-olds have engaged in sexual intercourse. Condom use is the most frequent method of contraception reported by the sexually active respondents, followed by the dual use of condoms and contraceptive pills and contraceptive pills only. The proportions of poorly protected and unprotected youth remain high, and attention to international policy and practice determinants of young sexual behavior and contraceptive use is required.

Individual and collective exposure to political violence: Palestinian adolescents coping with conflict.

BACKGROUND: We conducted a survey of Palestinian adolescents in school. We hypothesized that collective and individual exposures to violence would both negatively affect adolescents' mental health. We also anticipated that the negative effect of collective exposures on mental health would be less than that of individual exposures. Our analysis was designed to test these hypotheses. METHODS: A representative sample of 3415 students of 10th and 11th grades from the Ramallah District of the West Bank participated in the survey. The primary independent variables were scales of individual and collective exposures to trauma/violence (ETV) by the Israeli military and settlers. Factor analysis revealed several sub-scales. Outcome measures were constructed and included: a binary measure of depressive-like states, and emotional, depressive-like state, and somatic scales. Several variables were identified as possible covariates: gender, age, school-type, residence, employment status of father, and identity documents held. RESULTS: Logistic and multiple regression analyses revealed a strong relationship between ETV and adolescents' mental health, with both individual and collective exposures having independent effects. There was a higher prevalence of depressive-like symptoms among girls compared with boys, and in adolescents living in Palestinian refugee camps compared with those living in cities, towns and villages. CONCLUSION: The findings confirmed our hypothesis that both individual and collective ETV independently affect the mental health of adolescents. Contrary to expectations, individual exposures did not consistently have a greater negative effect on health outcomes than collective exposures, although the sub-scale of direct personal exposures to violence consistently showed the strongest effect among sub-scales. The results emphasize the importance of going beyond individual experiences and including the health outcomes of collective violation when analyzing violent and traumatic contexts.