A qualitative assessment of Ukraine's trauma system during the Russian conflict: experiences of volunteer healthcare providers.

BACKGROUND: The Russian Federation's invasion of Ukraine is characterized by indiscriminate attacks on civilian infrastructure, including hospitals and clinics that have devastated the Ukrainian health system putting trauma care at risk. International healthcare providers responded to the need for help with the increasing numbers of trauma patients. We aimed to describe their experiences during the conflict to explore the gaps in systems and care for trauma patients to refine the Global Trauma System Evaluation Tool (G-TSET) tool. METHODS: We conducted qualitative key informant interviews of healthcare providers and business and logistics experts who volunteered since February 2022. Respondents were recruited using purposive snow-ball sampling. Semi-structured, in-depth interviews were conducted virtually from January-March 2023 using a modified version of the G-TSET as an interview guide. Interviews were transcribed verbatim and deductive thematic content analysis was conducted using NVivo. FINDINGS: We interviewed a total of 26 returned volunteers. Ukraine's trauma system is outdated for both administrative and trauma response practices. Communication between levels of the patient evacuation process was a recurrent concern which relied on handwritten notes. Patient care was impacted by limited equipment resources, such as ventilators, and improper infection control procedures. Prehospital care was described as highly variable in terms of quality, while others witnessed limited or no prehospital care. The inability to adequately move patients to higher levels of care affected the quality of care. Infection control was a key issue at the hospital level where handwashing was not common. Structured guidelines for trauma response were lacking and lead to a lack of standardization of care and for trauma. Although training was desired, patient loads from the conflict prohibited the ability to participate. Rehabilitation care was stated to be limited. CONCLUSION: Standardizing the trauma care system to include guidelines, better training, improved prehospital care and transportation, and supply of equipment will address the most critical gaps in the trauma system. Rehabilitation services will be necessary as the conflict continues into its second year.

What is the appropriate antimicrobial use surveillance tool at the health facility level for Uganda and other low- and middle-income countries?

BACKGROUND: An appropriate antimicrobial use (AMU) surveillance system provides critical data and evidence on which antimicrobial stewardship interventions are based. However, Uganda and most other low- and middle-income countries (LMICs) lack efficient systems for monitoring AMU due to unique health system challenges. METHODS: We reviewed the key tools available for AMU surveillance in health facilities. Based on our implementation experience, we present arguments on the need for country authorities to adapt a customized and standardized tool for national uses. RESULTS: Despite ongoing efforts to set up AMU surveillance programs in Uganda, AMU data remain sparse, with most of the available data collected through antimicrobial stewardship related continuous quality improvement efforts implemented by global AMR control programs. There is variability in the interpretation of available AMU surveillance tools and a need to identify the most appropriate AMU surveillance methodologies and tools for Uganda and other LMICs. Data fields for sex and gender are incorrectly categorized and there is no tool that records pregnancy variable. Based on the past four years of practical implementation experience since the launch of the World Health Organization's Point Prevalence Survey methodology in 2018 for inpatient settings, we believe that the tool should be modified in cognizance of existing capacity and priorities in resource-constrained settings. CONCLUSIONS: The World Health Organization, regional experts, ministry of health authorities, and other stakeholders should urgently review available tools with a view to adopting a customized and standardized facility AMU surveillance methodology suitable for national-level rollout in LMICs.

Overlooked sex and gender aspects of emerging infectious disease outbreaks: Lessons learned from COVID-19 to move towards health equity in pandemic response.

Sex and gender issues are especially important in emerging infectious diseases (EIDs) but are routinely overlooked despite data and practice. Each of these have an effect either directly, via the effects on vulnerability to infectious diseases, exposures to infectious pathogens, and responses to illness, and indirectly through effects on disease prevention and control programs. The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the viral agent of coronavirus disease 2019 (COVID-19) has underscored the importance of understanding the sex and gender impacts on pandemics. This review takes a broader looks at how sex and gender impact vulnerability, exposure risk, and treatment and response that affect incidence, duration, severity, morbidity, mortality, and disability of EIDs. And although EID epidemic and pandemic plans need to be "pro-women", they need to be broader and include all sex and gender factors. Incorporation of these factors are a priority at the local, national, and global policy levels to fulfil the gaps in scientific research, public health intervention programs and pharmaceutical service strengthening to reduce emerging disease inequities in the population during pandemics and epidemics. A failure to do so creates acceptance of the inequities and infringes on fairness and human rights norms.

Review of Humanitarian Guidelines to Ensure the Health and Well-being of Afghan Refugees on U.S. Military Bases.

INTRODUCTION: The U.S. military has a 50-year history of managing resettlement or refugee camps on bases. In July and August 2021, more than 124,000 persons were evacuated from Afghanistan, with 55,000 Afghans temporarily housed at U.S. military bases around the world during Operation Allies Welcome (OAW) at its peak. METHODS: PubMed was searched for papers published in English between January 1, 1980, and February 1, 2021, using "Afghanistan" and "health" (including "public health," "maternal health," and "child health"), "maternal, newborn, and child health," and "health situation" as search terms and specific topics of interest. Where scholarly work was unavailable, reports of the United States Agency for International Development, implementing partners, gray literature, donor reports, Afghanistan Ministry of Health documents, national health plans, policies, and strategies, DoD after-action reviews (AARs), and guidance from previous refugee airlifts were also included in the search. RESULTS: Although AARs may provide some helpful guidance for these refugee settings, a review of open-source AARs and had little to no health guidance, focused primarily on administrative issues, and do not follow humanitarian guidelines. DoD guidance for refugee settings is dated and requires updating to be useful. There is a well-developed body of literature of international standards, guidelines, and best practices for refugee settings. Using the standardized Needs Assessment for Refugee Emergencies checklist as a guide, this review provides a standardized refugee health assessment framework for ensuring the health and well-being of Afghan refugees on U.S. military bases is based on humanitarian response guidelines and best practices to ensure their care meets international standards. All groups, especially minority ethnic groups (e.g., Hazaras), sexual and gender minorities, elderly, disabled, or mentally ill persons, need equal access to protection to ensure they are not targeted. Water, sanitation, and hygiene must be gender-sensitive and inclusive which includes well-lit separate facilities for males and females to decrease vulnerability to violence. The displaced population must be involved in the management of the camp through community participation and representation. All providers in OAW should be briefed on the food security and nutrition context of those in their care. Medical providers are most effective if they have significant experience with the refugee population health context. Understanding refugee medicine, the ability to work with illiterate and uneducated populations and translators are important skills. Abiding by international standards of care and being up-to-date with current guidelines for refugee care is important. Reproductive health must be a core component of the overall health response to decrease mortality, morbidity, and disability among reproductive-age women in crisis situations. Immediate and exclusive breastfeeding and international standards for breastfeeding must be adhered to, especially among nutritionally at-risk Afghans who are part of OAW. Education implementors familiar with education in refugee settings are an important contributor to establish formal, informal, non-formal, accelerated, and essence-based education programs. CONCLUSIONS: Partners and providers involved in any refugee setting should become familiar with updated guidelines, standards, and best practices and apply them to any operation to ensure a rights-based approach to protection, care, and the health and well-being of refugees.

Point Prevalence Survey of Antibiotic Use across 13 Hospitals in Uganda.

Standardized monitoring of antibiotic use underpins the effective implementation of antimicrobial stewardship interventions in combatting antimicrobial resistance (AMR). To date, few studies have assessed antibiotic use in hospitals in Uganda to identify gaps that require intervention. This study applied the World Health Organization's standardized point prevalence survey methodology to assess antibiotic use in 13 public and private not-for-profit hospitals across the country. Data for 1077 patients and 1387 prescriptions were collected between December 2020 and April 2021 and analyzed to understand the characteristics of antibiotic use and the prevalence of the types of antibiotics to assess compliance with Uganda Clinical Guidelines; and classify antibiotics according to the WHO Access, Watch, and Reserve classification. This study found that 74% of patients were on one or more antibiotics. Compliance with Uganda Clinical Guidelines was low (30%); Watch-classified antibiotics were used to a high degree (44% of prescriptions), mainly driven by the wide use of ceftriaxone, which was the most frequently used antibiotic (37% of prescriptions). The results of this study identify key areas for the improvement of antimicrobial stewardship in Uganda and are important benchmarks for future evaluations.

Cross-sectional study of mental health and sexual behaviours for Ebola Survivors in Beni, Butembo and Katwa health zones of the Democratic Republic of Congo.

OBJECTIVES: To understand the prevalence of mental health disorders in Ebola-affected communities and their association with condom use. DESIGN: Cross-sectional study. SETTING: Beni, Butembo and Katwa health zones, Democratic Republic of Congo (DRC). PARTICIPANTS: 223 adult Ebola survivors, 102 sexual partners and 74 comparison respondents. PRIMARY AND SECONDARY OUTCOME MEASURES: Post-traumatic stress disorder (PTSD), depression, anxiety, substance use, suicidal ideation and attempts, stigma, condom use and sexual behaviour. RESULTS: Most respondents reported to be married, Christian, from the Nande ethnic group, and farmers/herders. Survivors met symptom criteria for depression at higher rates than partners (23.5% (95% CI 18.0 to 29.1) vs 5.7 (1.2 to 10.1); p<0.001). PTSD symptom criteria for survivors (24.1%, 95% CI 18.5% to 29.7%) and partners (16.7%, 95% CI 9.4% to 23.9%) were four times greater than the comparison participants (6.0%, 95% CI 0.6% to 11.4%). Two times as many survivors as partners reported that sexual activity precautions were discussed at discharge (71.5% (95% CI 65.6 to 77.5) vs 36.2% (95% CI 26.9 to 45.5); p<0.001). The majority of survivors (95.0 (95% CI 85.1% to 98.5%) and partners 98.5% (95% CI 89.6% to 99.8%; p=0.26) participated in risky sexual behaviour after the survivor left the Ebola treatment centre. The ability to refuse sex or insist on condom use before Ebola had a threefold increase in the odds of condom use (adjusted OR 3.3, 95% CI 1.7 to 6.1, p<0.001). Up to 36% of the comparison group held discriminatory views of survivors. CONCLUSIONS: The new outbreaks in both Guinea and DRC show Ebola remains in semen longer than previously known. Understanding and addressing condom non-use and updating condom use guidelines are necessary to protect against future Ebola outbreaks, especially among sexual partners who did not have similar access to health information regarding sexual transmission of Ebola. Mental health treatment and decreasing stigma in Ebola areas is a priority.

Mixed-methods assessment of health and mental health characteristics and barriers to healthcare for Ebola survivors in Beni, Butembo and Katwa health zones of the Democratic Republic of Congo.

OBJECTIVES: Health and mental health characteristics of all respondents, barriers to accessing health and mental health services and the characteristics and those most at risk for mental health disorders. SETTING: Beni, Butembo and Katwa health zones in the Democratic Republic of Congo. PARTICIPANTS: The sample contained 223 Ebola survivors, 102 sexual partners and 74 comparison respondents living in the same areas of the survivors. Survivors were eligible if aged >18 years with confirmed Ebola-free status. The comparison group was neither a survivor nor a partner of a survivor and did not have any household members who contracted Ebola virus disease (EVD). PRIMARY AND SECONDARY OUTCOME MEASURES: Health and mental health characteristics, barriers to care and the association of association of mental health disorders with study population characteristics. RESULTS: Funding was a barrier to accessing needed health services among all groups. Nearly one-third (28.4%, 95% CI 18.0% to 38.7%) of comparison households avoided getting injections for their children. Although most pregnant women were attending antenatal care, less than 40% of respondents stated EVD precautions were discussed at those visits. Trouble sleeping and anger were the strongest predictors of post-traumatic stress disorder, major depressive disorder (MDD), anxiety and suicide attempts with 3-fold to 16-fold increases in the odds of these disorders. There was a 71% decrease in the odds of MDD if current substance abuse (aOR 0.29; 95% CI 0.13 to 0.67; p<0.01) was reported. CONCLUSIONS: Specialised mental health services were limited. Fear of contracting EVD influenced vaccine compliance. Anger and sleep disorders significantly increased the odds of mental health disorders across all groups. Respondents may be using substance abuse as self-medication for MDD. Ebola outbreak areas would benefit from improved screening of mental health disorders and associated conditions like anger and sleep difficulties and improved mental health services that include substance abuse prevention and treatment.

The USU Global Health Distance Learning Program: An International Educational Consortium for Global Health Engagement.

USU's Global Health Distance Learning Program has successfully enrolled over 400 students from all four services spread across six continents. British and Australian military physicians have joined as international partners, and the program now invites additional international, as well as USG interagency and war college partnerships. The program should also be employed as a tool for global health engagement itself.

A mixed methods assessment of barriers to maternal, newborn and child health in gogrial west, south Sudan.

BACKGROUND: Health conditions for mothers, newborns, and children in South Sudan are among the worst worldwide. South Sudan has the highest rate of maternal mortality in the world and despite alarming statistics, few women and children in South Sudan have access to needed healthcare, especially in rural areas. The purpose of this study was to understand the barriers to maternal, newborn and child health in Gogrial West, Warrap State, South Sudan, one of the most underdeveloped states. METHODS: A randomized household quantitative study and supplemental qualitative interviews were employed in 8/9 payams in Gogrial West, Warrap, South Sudan. Interviews were conducted with randomly selected female household members (n = 860) who were pregnant or had children less than 5 years of age, and men (n = 144) with a wife having these characteristics. Non-randomized qualitative interviews (n = 72) were used to nuance and add important socio-cultural context to the quantitative data. Analysis involved the estimation of weighted population means and percentages, using 95% confidence intervals and considering p-values as significant when less than 0.05, when comparisons by age, age of marriage, wife status and wealth were to be established. RESULTS: Most women (90.8%) and men (96.6%) did not want contraception. Only 1.2% of women aged 15-49 had met their need for family planning. On average, pregnant women presented for antenatal care (ANC) 2.3 times and by unskilled providers. Less than half of households had a mosquito net; fewer had insecticide treated nets. Recognition of maternal, newborn and child health danger signs overall was low. Only 4.6% of women had skilled birth attendants. One quarter of children had verifiable DPT3 immunization. Five percent of men and 6% of women reported forced intercourse. Overall men and women accept beatings as a norm. CONCLUSION: Barriers to care for mothers, infants and children are far more than the lack of antenatal care. Maternal, newborn and child health suffers from lack of skilled providers, resources, distance to clinics. A lack of gender equity and accepted negative social norms impedes healthy behaviors among women and children. The paucity of a peer-reviewed evidence base in the world's newest country to address the overwhelming needs of the population suggests these data will help to align health priorities to guide programmatic strategy for key stakeholders.

A national population-based assessment of 2007-2008 election-related violence in Kenya.

BACKGROUND: Following the contested national elections in 2007, violence occurred throughout Kenya. The objective of this study was to assess the prevalence, characteristics, and health consequences of the 2007-2008 election-related violence. METHODS: A cross-sectional, national, population-based cluster survey of 956 Kenyan adults aged ≥ 18 years was conducted in Kenya in September 2011 utilizing a two-stage 90 x 10 cluster sample design and structured interviews and questionnaires. Prevalence of all forms of violence surrounding the 2007 election period, symptoms of major depressive disorder (MDD) and posttraumatic stress disorder (PTSD), and morbidity related to sexual and physical violence were assessed. RESULTS: Of 956 households surveyed, 916 households participated (response rate 95.8%). Compared to pre-election, election-related sexual violence incidents/1000 persons/year increased over 60-fold (39.1-2370.1; p < .001) with a concurrent 37-fold increase in opportunistic sexual violence (5.2-183.1; p < .001). Physical and other human rights violations increased 80-fold (25.0-1987.1; p < .001) compared to pre-election. Overall, 50% of households reported at least one physical or sexual violation. Households reporting violence were more likely to report violence among female household members (66.6% vs. 58.1%; p = .04) or among the Luhya ethnic group (17.0% vs. 13.8%; p = 0.03). The most common perpetrators of election-related sexual violence were reported to be affiliated with government or political groups (1670.5 incidents/1000 persons per year); the Kalenjin ethnic group for physical violations (54.6%). Over thirty percent of respondents met MDD and PTSD symptom criteria; however, symptoms of MDD (females, 63.3%; males, 36.7%; p = .01) and suicidal ideation (females, 68.5%; males, 31.5%; p = .04) were more common among females. Substance abuse was more common among males (males, 71.2%; females, 28.8%; p < .001). CONCLUSION: On a national level in Kenya, politically-motivated and opportunistic sexual and physical violations were commonly reported among sampled adults with associated health and mental health outcomes.

A mixed-methods assessment of sexual and gender-based violence in eastern Democratic Republic of Congo to inform national and international strategy implementation.

CONTEXT: National and international strategies were implemented in eastern Democratic Republic of Congo (DRC) to address sexual and gender-based violence (SGBV). OBJECTIVES: The objective was to assess community attitudes of SGBV and health facility capacity to address SGBV in eastern DRC. DESIGN AND SETTING: The design and setting are as follows: a cross-sectional, population-based cluster survey of 998 adults in eastern DRC territories, a convenience sample of 27 adults using semi-structured directed interviews, qualitative data from 37 focus groups conducted in three health zones, assessment of 64 health facilities and a comparative analysis of SGBV strategies. MAIN OUTCOME MEASURES: The main outcome measures opinions regarding SGBV prevention and justice and health facility capacity to address SGBV. RESULTS: The majority of respondents favored the legal system over community mediation to obtain justice for SGBV. However, 61.1% (95% CI, 51.8-70.5%) of SGBV survivors reported being forced to accept community mediation. Among SGBV survivors, 81.2% (95% CI, 74.5-87.8%) reported no available mental health care. Less than half of all respondents reported access to a hospital, clinic or pharmacy. The analyses and facility assessment reinforce the need to improve SGBV care. CONCLUSIONS: Mixed methodologies point to the complexities of addressing SGBV, assess key elements of SGBV prevention, justice and response, and may ultimately inform national and international strategies.

Former combatants in Liberia: the burden of possible traumatic brain injury among demobilized combatants.

OBJECTIVE: To provide a better understanding of any associations between Disarmament, Demobilization, and Reintegration, previous head injury, and mental health symptoms among former combatants in Liberia. METHODS: A cluster-sampled national survey of the adult household-based Liberian population. FINDINGS: Former combatants with reported head injury were more likely to experience major depressive disorder symptoms, suicidal ideation and attempts, and current substance abuse. Former combatants with head injury are 2.83 times more likely to have major depressive disorder symptoms, and those with suspected traumatic brain injury are five times more likely to have post-traumatic stress disorder. INTERPRETATION: The poor mental health of former combatants in Liberia, both child and adult, might be mitigated if Disarmament, Demobilization, and Reintegration programming assessed participants for head trauma and traumatic brain injury using simple screening methods. The specific health and mental health needs of ex-combatants--a highly vulnerable group--will need to be addressed by Liberia. If left untreated, ex-combatants with high rates of suicidal ideation and post-traumatic stress disorder might be susceptible to re-recruitment into new conflicts in the region.

Association of sexual violence and human rights violations with physical and mental health in territories of the Eastern Democratic Republic of the Congo.

CONTEXT: Studies from the Eastern Region of the Democratic Republic of the Congo (DRC) have provided anecdotal reports of sexual violence. This study offers a population-based assessment of the prevalence of sexual violence and human rights abuses in specific territories within Eastern DRC. OBJECTIVE: To assess the prevalence of and correlations with sexual violence and human rights violations on residents of specific territories of Eastern DRC including information on basic needs, health care access, and physical and mental health. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional, population-based, cluster survey of 998 adults aged 18 years or older using structured interviews and questionnaires, conducted over a 4-week period in March 2010. MAIN OUTCOME MEASURES: Sexual violence prevalence and characteristics, symptoms of major depressive disorder (MDD) and posttraumatic stress disorder (PTSD), human rights abuses, and physical and mental health needs among Congolese adults in specific territories of Eastern DRC. RESULTS: Of the 1005 households surveyed 998 households participated, yielding a response rate of 98.9%. Rates of reported sexual violence were 39.7% (95% confidence interval [CI], 32.2%-47.2%; n = 224/586) among women and 23.6% (95% CI, 17.3%-29.9%; n = 107/399) among men. Women reported to have perpetrated conflict-related sexual violence in 41.1% (95% CI, 25.6%-56.6%; n = 54/148) of female cases and 10.0% (95% CI, 1.5%-18.4%; n = 8/66) of male cases. Sixty-seven percent (95% CI, 59.0%-74.5%; n = 615/998) of households reported incidents of conflict-related human rights abuses. Forty-one percent (95% CI, 35.3%-45.8%; n = 374/991) of the represented adult population met symptom criteria for MDD and 50.1% (95% CI, 43.8%-56.3%; n = 470/989) for PTSD. CONCLUSION: Self-reported sexual violence and other human rights violations were prevalent in specific territories of Eastern DRC and were associated with physical and mental health outcomes.

Involvement of the US Department of Defense in Civilian Assistance, Part I: a quantitative description of the projects funded by the Overseas Humanitarian, Disaster, and Civic Aid Program.

OBJECTIVES: To review the history and goals of the US Department of Defense's largest civilian assistance program, the Overseas Humanitarian, Disaster and Civic Aid Program and to describe the number, geographic regions, years, key words, countries, and types of projects carried out under this program since 2001. METHODS: Using the program's central database, we reviewed all approved projects since 2001 and tabulated them by year, combatant command, country, and key word. We also reviewed the project descriptions of projects funded between January 1, 2006, and February 9, 2008, and examined how their activities varied by combatant command and year. RESULTS: Of the 5395 projects in the database, 2097 were funded. Projects took place in more than 90 countries, with Southern, Pacific, and Africa Command hosting the greatest number. The most common types of projects were school, health, disaster response, and water infrastructure construction, and disaster-response training. The "global war on terror" was the key word most frequently tagged to project descriptions. Project descriptions lacked stated goals as well as implementation and coordination strategies with potential partners, and did not report outcome or impact indicators. CONCLUSION: The geographic reach of the program is vast and projects take place in a wide variety of public sectors. Yet their security and civilian assistance value remains unclear given the lack of stated project goals, implementation strategies, or measures of effectiveness. To facilitate transparency and policy discussion, we recommend project proposals include hypotheses as to how they will enhance US security, their relevance to the public sector they address, and outcome and impact indicators that can assess their value and effectiveness.

Humanitarian assistance and disaster relief: changing the face of defense.

The US Department of Defense (DOD) is evolving to meet new security challenges in the twenty-first century. Today's challenges result from growing political, environmental, and economic instability in important areas of the globe that threaten national and global security. Immediate outreach to foreign nations in times of violent instability or natural disaster fosters security and stability both for the affected country and for the United States. Foreign humanitarian assistance (FHA) is a rapidly evolving military mission that addresses conflict prevention, conflict, postconflict, and natural disasters. With DOD's extensive global medical resources, it is often uniquely qualified to execute a critical role in relief and/or public health efforts. When and how the American military will act in FHA and disaster relief is a still evolving doctrine with three issues deserving particular attention: aligning operations with host government leadership, preserving humanitarian space, and tailoring the US military's unique resources to the specific political and medical situation at hand. The DOD's response to a large-scale earthquake in Peru suggests useful approaches to these three issues, provides a template for future FHA mission, and points to strategic decisions and operational capabilities that need further development to establish the FHA mission firmly within DOD's repertoire of security engagement activities.