Health equity in Somalia? An evaluation of the progress made from 2006 to 2019 in reducing inequities in maternal and newborn health.

BACKGROUND: Every human being has the right to affordable, high-quality health services. However, mothers and children in wealthier households worldwide have better access to healthcare and lower mortality rates than those in lower-income ones. Despite Somalia's fragile health system and the under-5 mortality rate being among the highest worldwide, it has made progress in increasing reproductive, maternal, and child health care coverage. However, evidence suggests that not all groups have benefited equally. We analysed secondary 2006 and 2018-19 data to monitor disparities in reproductive, maternal, and child health care in Somalia. METHODS: The study's variables of interest are the percentage of contraceptive prevalence through modern methods, adolescent fertility rate, prenatal care, the rate of births attended by midwives, the rate of births in a health care facility, the rate of early initiation of breastfeeding, stunting and wasting prevalence and care-seeking for children under-five. As the outcome variable, we analysed the under-five mortality rate. Using reliable data from secondary sources, we calculated the difference and ratio of the best and worst-performing groups for 2006 and 2018-19 in Somalia and measured the changes between the two. RESULTS: Between 2006 and 2018-19, An increase in the difference between women with high and low incomes was noticed in terms of attended labours. Little change was noted regarding socioeconomic inequities in breastfeeding. The difference in the stunting prevalence between the highest and lowest income children decreased by 20.5 points, and the difference in the wasting prevalence of the highest and the lowest income children decreased by 9% points. Care-seeking increased by 31.1% points. Finally, although under-five mortality rates have decreased in the study period, a marked income slope remains. CONCLUSIONS: The study's findings indicate that Somalia achieved significant progress in reducing malnutrition inequalities in children, a positive development that may have also contributed to the decrease in under-five mortality rate inequities also reported in this study. However, an increase in inequalities related to access to contraception and healthcare for mothers is shown, as well as for care-seeking for sick children under the age of five. To ensure that all mothers and children have equal access to healthcare, it is crucial to enhance efforts in providing essential quality healthcare services and distributing them fairly and equitably across Somalia.

Estimating the Impact of Vaccination Campaigns on Measles Transmission in Somalia.

Somalia is a complex and fragile setting with a demonstrated potential for disruptive, high-burden measles outbreaks. In response, since 2018, Somalian authorities have partnered with UNICEF and the WHO to implement measles vaccination campaigns across the country. In this paper, we create a Somalia-specific model of measles transmission based on a comprehensive epidemiological dataset including case-based surveillance, vaccine registries, and serological surveys. We use this model to assess the impact of these campaign interventions on Somalian's measles susceptibility, showing, for example, that across the roughly 10 million doses delivered, 1 of every 5 immunized a susceptible child. Finally, we use the model to explore a counter-factual epidemiology without the 2019-2020 campaigns, and we estimate that those interventions prevented over 10,000 deaths.

Prioritization of zoonoses for multisectoral, One Health collaboration in Somalia, 2023.

Background: The human population of Somalia is vulnerable to zoonoses due to a high reliance on animal husbandry. This disease risk is exacerbated by relatively low income (poverty) and weak state capacity for health service delivery in the country as well as climate extremes and geopolitical instability in the region. To address this threat to public health efficiently and effectively, it is essential that all sectors have a common understanding of the priority zoonotic diseases of greatest concern to the country. Methods: Representatives from human, animal (domestic and wildlife), agriculture, and environmental health sectors undertook a multisectoral prioritization exercise using the One Health Zoonotic Disease Prioritization (OHZDP) tool developed by the United States CDC. The process involved: reviewing available literature and creating a longlist of zoonotic diseases for potential inclusion; developing and weighting criteria for establishing the importance of each zoonoses; formulating categorical questions (indicators) for each criteria; scoring each disease according to the criteria; and finally ranking the diseases based on the final score. Participants then brainstormed and suggested strategic action plans to prevent, and control prioritized zoonotic diseases. Results: Thirty-three zoonoses were initially considered for prioritization. Final criteria for ranking included: 1) socioeconomic impact (including sensitivity) in Somalia; 2) burden of disease in humans in Somalia); 3) availability of intervention in Somalia; 4) environmental factors/determinants; and 5) burden of disease in animals in Somalia. Following scoring of each zoonotic disease against these criteria, and further discussion of the OHZDP tool outputs, seven priority zoonoses were identified for Somalia: Rift Valley fever, Middle East respiratory syndrome, anthrax, trypanosomiasis, brucellosis, zoonotic enteric parasites (including Giardia and Cryptosporidium), and zoonotic influenza viruses. Conclusions: The final list of seven priority zoonotic diseases will serve as a foundation for strengthening One Health approaches for disease prevention and control in Somalia. It will be used to: shape improved multisectoral linkages for integrated surveillance systems and laboratory networks for improved human, animal, and environmental health; establish multisectoral public health emergency preparedness and response plans using One Health approaches; and enhance workforce capacity to prevent, control and respond to priority zoonotic diseases.

Health research prioritization in Somalia: setting the agenda for context specific knowledge to advance universal health coverage.

Introduction: Despite recognition that health research is an imperative to progress toward universal health coverage, resources for health research are limited. Yet, especially in sub-Saharan Africa, more than 85% of the resources available for health research are spent on answering less relevant research questions. This misalignment is partially due to absence of locally determined health research priorities. In this study, we identified health research priorities which, if implemented, can inform local interventions required to accelerate progress toward universal health coverage in Somalia. Methods: We adapted the child health and nutrition research initiative method for research priority setting and applied it in 4 major phases: (1) establishment of an exercise management team, (2) a web-based survey among 84 respondents to identify health research questions; (3) categorization of identified health research questions; and (4) a workshop with 42 participants to score and rank the identified health research questions. Ethical approval was received from ethics review committee of the London School of Hygiene and Tropical Medicine (Ref:26524) and the Somali Research and Development Institute (Ref: EA0143). Results: Two hundred and thirty-one unique health research questions were identified and categorized under health systems, services and social determinants (77), communicable diseases (54), non-communicable diseases (41) and reproductive, maternal, new-born, child, adolescent health and nutrition (59). A priority score ranging from 1 to 9 was assigned to each of the questions. For each category, a list of 10 questions with the highest priority scores was developed. Across the four categories, an overall list of 10 questions with the highest priority scores was also developed. These related to bottlenecks to accessing essential health services, use of evidence in decision making, antimicrobial resistance, distribution and risk factors for non-communicable diseases, post-traumatic stress disorder and factors associated with low antenatal care attendance among others. Conclusion and recommendations: The developed priority research questions can be used to focus health research and to inform appropriation of health research resources to questions that contribute to generation of local health system knowledge which is required to accelerate progress toward universal health coverage in Somalia. The Somalia national institute of health should set up a consortium for provision of technical and financial support for research addressing the identified priority research questions, establish a mechanism to continuously monitor the extent to which new health interventions in Somalia are informed by knowledge generated through conducting prioritized health research and prioritize interventions aimed at strengthening the broader national health research system for Somalia.

Progress and experiences of implementing an integrated disease surveillance and response system in Somalia; 2016-2023.

Introduction: In 2021, a regional strategy for integrated disease surveillance was adopted by member states of the World Health Organization Eastern Mediterranean Region. But before then, member states including Somalia had made progress in integration of their disease surveillance systems. We report on the progress and experiences of implementing an integrated disease surveillance and response system in Somalia between 2016 and 2023. Methods: We reviewed 20 operational documents and identified key integrated disease surveillance and response system (IDSRS) actions/processes implemented between 2016 and 2023. We verified these through an anonymized online survey. The survey respondents also assessed Somalia's IDSRS implementation progress using a standard IDS monitoring framework Finally, we interviewed 8 key informants to explore factors to which the current IDSRS implementation progress is attributed. Results: Between 2016 and 2023, 7 key IDSRS actions/processes were implemented including: establishment of high-level commitment; development of a 3-year operational plan; development of a coordination mechanism; configuring the District Health Information Software to support implementation among others. IDSRS implementation progress ranged from 15% for financing to 78% for tools. Reasons for the progress were summarized under 6 thematic areas; understanding frustrations with the current surveillance system; the opportunity occasioned by COVID-19; mainstreaming IDSRS in strategic documents; establishment of an oversight mechanism; staggering implementation of key activities over a reasonable length of time and being flexible about pre-determined timelines. Discussion: From 2016 to 2023, Somalia registered significant progress towards implementation of IDSRS. The 15 years of EWARN implementation in Somalia (since 2008) provided a strong foundation for IDSRS implementation. If implemented comprehensively, IDSRS will accelerate country progress toward establishment of IHR core capacities. Sustainable funding is the major challenge towards IDSRS implementation in Somalia. Government and its partners need to exploit feasible options for sustainable investment in integrated disease surveillance and response.

Prevalence of mental disorders and psychological trauma among conflict- affected population in Somalia: a cross-sectional study.

Background: Despite the longstanding psychosocial impact of the interactable conflict in Somalia for the last 30 years, there is lack of epidemiological studies of mental health conditions, especially at the population level. Objectives: The aim of this study is to fill the epidemiological gap and provide population based data on mental health conditions in the South-Central region of Somalia. The specific objectives were: (1) To determine the epidemiological patterns of mental disorders in three sites; Baidoa, Dolow and Kismayo, (2) Understand the socio-demographic characteristics associated with mental health conditions in the study sites, and (3) To assess the correlates between psychological trauma and the mental wellbeing of the population. Methods: This was a cross-sectional study of 713 respondents recruited from the three sites namely Dolow, Baidoa and Kismayo. Data on sociodemographic characteristics and mental disorders were collected using the MINI and sociodemographic questionnaire. Basic descriptive statistics were used to summarize sociodemographic characteristics. Univariable and multivariable logistic regressions were used to examine factors associated with common mental disorders. Statistical significance was considered at a value of p <0.05. Results: Participants' mean age was 32.6 (±10.7) years. More than half (58.5%) of the respondents were male. The overall prevalence of common mental disorders was 557 (78.1%) with panic disorder (39.3%), generalized anxiety disorders (34.9%), major depressive episode current (32.1) and PTSD (29.9%). According to the multivariable logistic regression analysis, being male AOR = 1.74 (95%CI = 1.25, 2.42), having a family size of more than 10 members AOR =1.37 (95% CI = 1.00, 1.89), being unemployed AOR = 1.90 (95%CI = 1.18, 3.06), experienced starvation AOR =3.46 (95%CI = 2.23, 5.37), khat use AOR = 5.87 (955 CI, 1.75-19.65), were identified as predicting factors for the common mental disorders among the study participants. Conclusion: There is a high prevalence of mental disorders with anxiety disorders being the commonest. Findings reflect earlier studies that showed higher rates in conflict and post-conflict settings. It also aligns with past studies in Somalia. As such, there is an urgent need to integrate mental health and psychosocial support within the primary healthcare and other service sectors such as education considering the vast majority of the population are young.

Systemic Administration of Porphyromonas Gingivalis Lipopolysaccharide Induces Glial Activation and Depressive-Like Behavior in Rats.

BACKGROUND: Periodontitis is one of the most common chronic inflammatory disorders in adults. Although clinical studies have suggested a causal relationship between periodontitis and major depression (MD), the biological mechanisms by which periodontitis instigates MD are unknown. We investigated whether a systemic administration of lipopolysaccharide (LPS) from Porphyromonas gingivalis (Pg), a major Gram-negative pathogen of periodontitis, causes depressive-like behavior and glial activation in the hippocampus and the prefrontal cortex (PFC), which are MD-related brain regions. MATERIALS AND METHODS: Eight-week-old male Sprague Dawley rats were randomly divided into a behavioral test group and an immunohistochemistry group. The rats in each group were further assigned to the sham injection (saline) and Porphyromonas gingivalis-lipopolysaccharide (Pg-LPS) injection protocols. The rats received an intraperitoneal injection of saline or Pg-LPS with gradually increasing doses (day 1: 0.5, day 2: 0.5, day 3: 0.75, day 4: 0.75, day 5: 1.0, day 6: 1.0, and day 7: 1.0 mg/kg of body weight) for seven consecutive days. After the systemic administration, the behavior test group underwent the forced swimming test (FST) and Y-maze test. For the immunohistochemistry group, we quantified the immunoreactivity for microglial Iba-1 (ionized calcium-binding adapter molecule 1) and astrocytic glial fibrillary acidic protein (GFAP) in the hippocampus (dentate gyrus [DG], cornu ammonis [CA1 and CA3]) and PFC (prelimbic [PrL] and the infralimbic [IL]) areas. RESULTS: The FST immobility time in the Pg-LPS group was significantly longer than that in the sham group. In the Y-maze test, a significant decline in spontaneous alternation behavior was observed in the Pg-LPS group compared to the sham group. The peripheral administration of Pg-LPS significantly increased the immunoreactivity for Iba-1 in the CA3 and PrL. Pg-LPS injection significantly increased the immunoreactivity for GFAP in the DG, CA1, and CA3. CONCLUSIONS: The major result of this study is that a repeated systemic administration of Pg-LPS caused depressive-like behavior and both microglial and astrocytic activation in rats. This finding may comprise biological evidence of a causal relationship between periodontitis and MD.

The importance of community health workers as frontline responders during the COVID-19 pandemic, Somalia, 2020-2021.

Introduction: We examined the contribution of community health workers as frontline responders for the community-based surveillance in Somalia during the first year of the COVID-19 pandemic for detection of COVID-19 cases and identification of contacts. Methods: We retrieved COVID-19 surveillance data from 16 March 2020 to 31 March 2021 from the health ministry's central database. These data were collected through community health workers, health facilities or at the points of entry. We compared the number of suspected COVID-19 cases detected by the three surveillance systems and the proportion that tested positive using the chi-squared test. We used logistic regression analysis to assess association between COVID-19 infection and selected variables. Results: During the study period, 154,004 suspected cases of COVID-19 were detected and tested, of which 10,182 (6.6%) were positive. Of the notified cases, 32.7% were identified through the community-based surveillance system, 54.0% through the facility-based surveillance system, and 13.2% at points of entry. The positivity rate of cases detected by the community health workers was higher than that among those detected at health facilities (8.6% versus 6.4%; p < 0.001). The community health workers also identified more contacts than those identified through the facility-based surveillance (13,279 versus 1,937; p < 0.001). The odds of COVID-19 detection generally increased by age. Community-based surveillance and health facility-based surveillance had similar odds of detecting COVID-19 cases compared with the points-of-entry surveillance (aOR: 7.0 (95% CI: 6.4, 7.8) and aOR: 7.5 (95% CI: 6.8, 8.3), respectively). Conclusion: The community health workers proved their value as first responders to COVID-19. They can be effective in countries with weak health systems for targeted community surveillance in rural and remote areas which are not covered by the facility-based surveillance system.

COVID-19 Vaccine Acceptance and Hesitancy in Health Care Workers in Somalia: Findings from a Fragile Country with No Previous Experience of Mass Adult Immunization.

Coverage of COVID-19 vaccines in Somalia remains low, including among health workers. This study aimed to identify factors associated with COVID-19 vaccine hesitancy among health workers. In this cross-sectional, questionnaire-based study, 1476 health workers in government and private health facilities in Somalia's federal member states were interviewed face-to-face about their perceptions of and attitudes toward COVID-19 vaccines. Both vaccinated and unvaccinated health workers were included. Factors associated with vaccine hesitancy were evaluated in a multivariable logistic regression analysis. Participants were evenly distributed by sex, and their mean age was 34 (standard deviation 11.8) years. The overall prevalence of vaccine hesitancy was 38.2%. Of the 564 unvaccinated participants, 39.0% remained hesitant. The factors associated with vaccine hesitancy were: being a primary health care worker (adjusted odds ratio (aOR) = 2.37, 95% confidence interval (CI): 1.15-4.90) or a nurse (aOR = 2.12, 95% CI: 1.05-4.25); having a master's degree (aOR = 5.32, 95% CI: 1.28-22.23); living in Hirshabelle State (aOR = 3.23, 95% CI: 1.68-6.20); not having had COVID-19 (aOR = 1.96, 95% CI: 1.15-3.32); and having received no training on COVID-19 (aOR = 1.54, 95% CI: 1.02-2.32). Despite the availability of COVID-19 vaccines in Somalia, a large proportion of unvaccinated health workers remain hesitant about being vaccinated, potentially influencing the public's willingness to take the vaccine. This study provides vital information to inform future vaccination strategies to achieve optimal coverage.

Population-based sero-epidemiological investigation of SARS-CoV-2 infection in Somalia.

OBJECTIVES: To explore the burden of coronavirus disease 2019 (COVID-19) in Somalia by measuring the seroprevalence of antibodies to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the general population. METHODS: We recruited a convenience sample of 2751 participants from among individuals attending outpatient and inpatient departments of public health facilities, or their accompanying family members. Participants were interviewed to collect sociodemographic data and provided a blood sample. We calculated seropositivity rates overall and by sex, age group, state, residence, education and marital status. We used logistic regression analysis - odds ratios and 95% confidence intervals (CI) - to investigate sociodemographic correlates of seropositivity. RESULTS: The overall seropositivity rate was 56.4% (95% CI 54.5-58.3%), while 8.8% of participants reported being previously diagnosed with COVID-19 by July 2021. In the regression analysis, after controlling for covariates, urban residence was significantly asscoiated with seropositivity: OR = 1.74 (95% CI: 1.19-2.55). CONCLUSIONS: Our results show a high seroprevalence rate of SARS-CoV-2 in the Somali population (56.4%), and indicate that many infections have not been captured by the country's surveillance system resulting in considerable under-reporting.

Value of Verbal Autopsy in a Fragile Setting: Reported versus Estimated Community Deaths Associated with COVID-19, Banadir, Somalia.

BACKGROUND: Accurate mortality data associated with infectious diseases such as coronavirus disease 2019 (COVID-19) are often unavailable in countries with fragile health systems such as Somalia. We compared officially reported COVID-19 deaths in Somalia with COVID-19 deaths estimated using verbal autopsy. METHODS: We interviewed relatives of deceased persons to collect information on symptoms, cause, and place of death. We compared these data with officially reported data and estimated the positive and negative predictive values of verbal autopsy. RESULTS: We identified 530 deaths during March-October 2020. We classified 176 (33.2%) as probable COVID-19 deaths. Most deaths (78.5%; 416/530) occurred at home and 144 (34.6%) of these were attributed to COVID-19. The positive predictive value of verbal autopsy was lower for home deaths (22.3%; 95% CI: 15.7-30.1%) than for hospital deaths (32.3%; 95% CI: 16.7-51.4%). The negative predictive value was higher: 97.8% (95% CI: 95.0-99.3%) for home deaths and 98.4% (95% CI: 91.5-100%) for hospital deaths. Conclusions Verbal autopsy has acceptable predictive value to estimate COVID-19 deaths where disease prevalence is high and can provide data on the COVID-19 burden in countries with low testing and weak mortality surveillance where home deaths may be missed.

Population health trends and disease profile in Somalia 1990-2019, and projection to 2030: will the country achieve sustainable development goals 2 and 3?

OBJECTIVES: This study aims to evaluate whether Somalia will reach Sustainable Development Goals 2 and 3 by 2030 and what the country requires to advance closer to these objectives. SETTING: Somalia. PARTICIPANTS: We carried out analyses of secondary data obtained from the following open-access databases: Global Burden of Disease 2019 study; United Nations (UN) Department of Economic and Social Affairs Population Division; World Bank World Development Indicators; United Nations Children's Fund (UNICEF); UNICEF/World Health Organisation (WHO)/World Bank Joint Child Malnutrition Estimates; and UN Interagency Group for Child Mortality Estimation (UN IGME), disaggregated by sex. PRIMARY OUTCOME MEASURES: stillbirth, neonatal, infant, under-five, maternal and child mortality; under-five malnutrition; life expectancy; health-adjusted life expectancy; age-standardised all-cause mortality; age-standardised cause-specific mortality for the leading causes of death; disability-adjusted life years. SECONDARY OUTCOME MEASURES: vitamin A coverage; stunting, overweight in children under 5; top risk factors contributing to cause-specific mortality. RESULTS: life expectancy in Somalia will increase to 65.42 years (95% UI 62.30-68.54) for females and 58.54 years (95% UI 54.89-62.19) for males in 2030. Stunting will continue to decline to 25.2% (90% UI 13.9-39.5%), and the under-five mortality rate will drop to 85.9 per 1000 live births (90% UI 22.0-228.1 per 1000 live births) for females and 96.4 per 1000 live births (90% UI 24.8-255.3 per 1000 live births) for males in 2030. This study's analyses predict that the maternal mortality ratio in Somalia will decline to 696.42 deaths per 100,000 live births in 2030. CONCLUSIONS: there has been progress towards SDG targets in Somalia since 1990. To achieve these, Somalia requires greater health improvements than observed between 1990 and 2019.

Adverse events following introduction of the ChAdOx1 nCoV-19 vaccine in Somalia in 2021: findings from a fragile setting and implications for the future.

Background: Vaccination against coronavirus disease 2019 (COVID-19) began in Somalia on 16 March 2021 with the Covishield (ChAdOx1 nCoV-19) vaccine. However, by the end of 2021, only a small percentage of the population had been fully vaccinated. As side effects play an important role in determining public confidence in vaccines and their uptake, this study aimed to examine reported adverse events following immunization (AEFIs) of vaccine recipients. Methods: This cross-sectional-survey-based study was conducted between March and October 2021 in Somalia. Vaccine recipients who were eligible to receive the first dose of the Covishield vaccine in the first phase of COVID-19 vaccination were eligible for study inclusion. P<0.05 was considered to indicate significance. Results: Of the 149,985 respondents who had received the first dose of the Covishield vaccine, 378 reported side effects. This represented a reported AEFI rate of 2.5 per 1000 population. Amongst those who reported adverse events, males (2.8 per 1000; P<0.001), respondents aged 35-49 years (3.3 per 1000; P=0.001) and teachers (3.5 per 1000; P=0.000) had higher rates of adverse events compared with females, other age groups and other occupations. Amongst population settlement types, a higher rate of AEFIs was observed amongst refugees (23.9 per 1000; P=0.000) and internally displaced populations (19 per 1000; P=0.000). Nearly half of the vaccine recipients who reported side effects (48%) reported one local symptom, and most symptoms were mild in nature. The probability of having acute and severe side effects was found to be 66% lower among males compared with females [odds ratio (OR) 0.44, 95% confidence interval (CI) 0.26-0.73; P=0.002]. Respondents aged >60 years (OR 1.52, 95% CI 0.64-3.62; P=0.34) were more likely to develop acute and severe AEFIs. None of the study population reported any severe life-threatening symptoms or death. Conclusion: Some variables (sex, profession, age) put recipients at higher odds of acute and severe AEFIs, but the Covishield vaccine generally produced mild side effects in a small proportion of the vaccinated population in Somalia. This study confirms that COVID-19 vaccines are safe, and their benefits clearly outweigh any associated risk.

Evaluation of the electronic Early Warning and Response Network (EWARN) system in Somalia, 2017-2020.

BACKGROUND: In 2008, Somalia introduced an electronic based Early Warning Alert and Response Network (EWARN) for real time detection and response to alerts of epidemic prone diseases in a country experiencing a complex humanitarian situation. EWARN was deactivated between 2008 to 2016 due to civil conflict and reactivated in 2017 during severe drought during a cholera outbreak. We present an assessment of the performance of the EWARN in Somalia from January 2017 to December 2020, reflections on the successes and failures, and provide future perspectives for enhancement of the EWARN to effectively support an Integrated Disease Surveillance and Response strategy. METHODS: We described geographical coverage of the EWARN, system attributes, which included; sensitivity, flexibility, timeliness, data quality (measured by completeness), and positive predictive value (PPV). We tested for trends of timeliness of submission of epidemiological reports across the years using the Cochran-Mantel-Haenszel stratified test of association. RESULTS: By December 2020, all 6 states and the Banadir Administrative Region were implementing EWARN. In 2017, only 24.6% of the records were submitted on time, but by 2020, 96.8% of the reports were timely (p < 0.001). Completeness averaged < 60% in all the 4 years, with the worst-performing year being 2017. Overall, PPV was 14.1%. Over time, PPV improved from 7.1% in 2017 to 15.4% in 2019 but declined to 9.7% in 2020. Alert verification improved from 2.0% in 2017 to 52.6% by 2020, (p < 0.001). In 2020, EWARN was enhanced to facilitate COVID-19 reporting demonstrating its flexibility to accommodate the integration of reportable diseases. CONCLUSIONS: During the past 4 years of implementing EWARN in Somalia, the system has improved significantly in timeliness, disease alerts verification, and flexibility in responding to emerging disease outbreaks, and enhanced coverage. However, the system is not yet optimal due to incompleteness and lack of integration with other systems suggesting the need to build additional capacity for improved disease surveillance coverage, buttressed by system improvements to enhance data quality and integration.

Mental health crisis in Somalia: a review and a way forward.

BACKGROUND: Somalia has been without an effective government since the collapse of the military regime in 1991. Years of conflict, disasters, and insecurity have all contributed to very low scores for most health indicators due to poor governance, protracted conflict, underdevelopment, economic decline, poverty, social and gender inequality, and environmental degradation. The three-decade long protracted conflict has led to widespread psychosocial trauma, social deprivation and substance abuse with devastating consequences on mental health. A WHO study showed Somalia has one of the highest rates of mental illness in the world. The main aim of this study is to assist policy makers in setting priorities for the design and delivery of interventions to promote mental health and psychosocial wellbeing in Somalia. METHODS: The study uses a systematic mapping technique (from January 1991 to May 2020) and data collected from public domain, to collect, collate, and present mental health data mainly from WHO's Global Health Observatory. Since there is no primary database for Somalia's public health research, the bibliographic databases used for mental health in this study included Medline, PubMed, CINAHL, PsycINFO, and Google Scholar. Data were extracted using techniques for web data mining for public health. RESULTS: Systematic mapping of mental health-related issues in Somalia showed that policy-related determinants and mental health services dominated (74.4%), followed by the disaster-related determinants and women's health consequences (39.3%). The ratio of the number of beds for mental health in general hospitals (per 100,000 population) in Somalia in 2017 is 0.5 compared to the Eastern Mediterranean region (EMR) at 6.4 and globally at 24. One of the biggest casualties of the civil war was loss of essential human resources in healthcare as most either fled the country or were part of the victims of the war. CONCLUSIONS: The vast scale of the mental health problems in Somalia and the priority setting guidelines for interventions to address the issues outlined in this paper, prompt a dire need that the Somali government and its national/international partners should prioritize and emphasize the need to invest in the prevention and the treatment of mental illness across the country.

Survival analysis of all critically ill patients with COVID-19 admitted to the main hospital in Mogadishu, Somalia, 30 March-12 June 2020: which interventions are proving effective in fragile states?

OBJECTIVES: To determine risk factors for death in patients with coronavirus disease 2019 (COVID-19) admitted to the main hospital in Somalia, and identify interventions contributing to improved clinical outcome in a low-resource and fragile setting. METHODS: A survival analysis was conducted of all patients with COVID-19 admitted to the main hospital in Somalia from 30 March to 12 June 2020. RESULTS: Of the 131 patients admitted to the hospital with COVID-19, 52 (40%) died and 79 (60%) survived. The main factors associated with the risk of in-hospital death were age ≥60 years {survival probability on day 21 was 0.789 [95% confidence interval (CI) 0.658-0.874] in patients aged <60 years vs 0.339 (95% CI 0.205-0.478) in patients aged ≥60 years}, cardiovascular disease [survival probability 0.478 (95% CI 0.332-0.610) in patients with cardiovascular disease vs 0.719 (95% CI 0.601-0.807) in patients without cardiovascular disease] and non-invasive ventilation on admission (patients who were not ventilated but received oxygen were significantly more likely to survive than patients who were ventilated; P<0.001). CONCLUSION: Considering the risk factors (age ≥60 years, presence of cardiovascular disease and use of non-invasive ventilation) is critical when managing patients with severe COVID-19, especially in low-resource settings where availability of skilled healthcare workers for critical care units is limited. These findings also highlight the importance of use of medical oxygen for severely ill patients, and the critical aspect of deciding whether or not to ventilate critical patients with COVID-19 in order to improve clinical outcome.

Investing in mental health in Somalia: harnessing community mental health services through task shifting.

Background: The increase of mental health issues globally has been well documented and now reflected in the United Nations' Sustainable Development Goals as a matter of global health significance. At the same time, studies show the mental health situations in conflict and post-conflict settings much higher than the rest of the world, lack the financial, health services and human resource capacity to address the challenges. Methods: The study used a descriptive literature review and collected data from public domain, mostly mental health data from WHO's Global Health Observatory. Since there is no primary database for Somalia's public health research, the bibliographic databases used for mental health in this study included Medline, PubMed, CINAHL, PsycINFO, and Google Scholar. Results: The review of the mental health literature shows one of the biggest casualties of the civil war was loss of essential human resources in healthcare as most either fled the country or were part of the victims of the war. Conclusion: In an attempt to address the human resource gap, there are calls to task-shift so that available human resource can be utilized efficiently and effectively. This policy paper discusses the case of Somalia, the impact of decade-long civil conflict on mental health and health services, the significant gap in mental health service delivery and how to strategically and evidently task-shift in closing the mental health gap in service delivery.

Predictors of black fungus fear during the COVID-19 pandemic among the Bangladeshi health workers: a cross-sectional study

BackgroundThe emergence of mucormycosis cases amid the COVID-19 pandemic; fear associated with mucormycosis may turn out to be a terrifying public health issue. This study aimed to assess the association between fear and insomnia status and other predictors of mucormycosis among Bangladeshi healthcare workers. MethodsFrom 25 May 2021 to 05 June 2021, a cross-sectional study was carried out among healthcare workers. A total of 422 healthcare workers participated in this study. A semi-structured online questionnaire was used for data collection during the COVID-19 pandemic, followed by convenient and snowball sampling methods. A multivariable linear regression model was fitted to assess the association between fear and insomnia status and other predictors of mucormycosis. ResultsThe results indicated that the respondents with insomnia status had a higher score of mucormycosis fear than not having insomnia ({beta} = 3.91, 95% CI: 2.49, 5.33, p <0.001), significantly. Alongside the increased knowledge score of mucormycosis, the average score of fear increased significantly({beta} = 0.35, 95% CI: 0.20, 0.50, p <0.001). The gender, profession, and death of friends and family members due to COVID-19 significantly affected mucormycosis fear score increment. ConclusionsThis is the first study that focused on assessing the association between mucormycosis fear and insomnia status among the health care workers so far. These study findings recommend emphasizing the mental health aspects and ensuring support to the healthcare workers to better tackle the ongoing public health crisis.