Supporting Women and Children Returning from Violent Extremist Contexts: Proposing a 5R Framework to Inform Program and Policy Development.

Women and children returning from areas formerly controlled by the Islamic State typically have experienced high levels of trauma and indoctrination, further complicating politically fraught efforts at reintegration and resettlement. Consequently, countries around the world are grappling with how best to manage the return of these women and children. To help better understand which types of programming can contribute to the successful, non-violent reintegration of these individuals, we incorporated ideas from existing Repatriation and Rehabilitation (R&R) literature, field practitioners, R&R subject matter experts, and literature from adjacent fields (e.g., refugee resettlement, criminal justice, psychological resilience) into a recommended best practice approach to supporting returning women and children. We propose a shift from "R&R" programming to what we call the "5R" framework: Repatriation/ Resettlement, Reintegration, Rehabilitation, and Resilience. This shift provides conceptual clarity related to how different program elements target proximal goals (e.g., wellbeing and personal safety, belonging and opportunity, non-violence, and dignity), and how programming can shift from more centrally- and government-held services to informal and community-based supports.

Rehabilitation and Reintegration of Women and Children Returning from Violent Extremist Contexts: A Rapid Review to Inform Program and Policy Development.

This rapid review used a systematic approach to examine the available literature on rehabilitation and reintegration (R&R) programs for women and children returning from contexts of violent extremism, examining common assumptions, inputs, activities and outcomes across diverse settings. Fifty-one documents including peer reviewed articles and grey literature were included in the analysis. The most common program activities identified included mental health services, community level social programs, promoting school and vocational enrollment, regular health services, and parenting training & education, though there was a lack of consensus around core program components. The analysis points to the need for a robust set of inputs and resources to implement R&R programs including government officials, child welfare, mental health professionals, teachers, law enforcement, healthcare, community leaders, and extended family. The review also uncovered a number of gaps. This includes the need to create clear and analytically distinct definitions of rehabilitation and reintegration that are applicable and relevant to key stakeholders, delineating age-appropriate activities and outcomes for young children, youth, and adults, defining frameworks for service delivery and coordination of stakeholders, and placing R&R programs within existing domains of public safety and restorative justice.

Strengthening Mentorship in Global Health for US Medical Students.

US medical students demonstrate strong interest in receiving global health training. In 2012, the Center for Global Health (CGH) at the University of Illinois College of Medicine (UICOM) developed a Global Medicine (GMED) program to match this interest. From its initiation, mentorship has been a key component of the GMED program. More recently, this has been strengthened by applying additional evidence-informed approaches toward mentoring. These include the "mentor up" approach, a "network of mentors," and an individualized development plan (IDP). Applying these changes were associated with increases in the number of student abstract presentations and peer-reviewed journal publications. Mentorship based upon evidence-informed approaches should be a key component of global health education in academic medical centers.

Developing a global medicine student pre- and post-travel curriculum.

BACKGROUND: The popularity of short-term global health experiences amongst US medical students has been increasing. However, it remains a challenge for medical schools to comprehensively prepare students to work in an international environment and to contribute in ethically responsible and meaningful ways. Students of the Global Medicine program (GMED) of the UIC College of Medicine Center for Global Health set out to develop a pre-and-post travel curriculum that addresses some of these challenges. METHODS: The students surveyed the literature of 66 published global health curricula and identified aspects of pre-and-post travel training that were found to be under-addressed. They then developed a curriculum in conjunction with GMED faculty that incorporated these identified aspects of pre-and-post travel training. RESULTS: Five aspects of pre-and-post travel training were identified as being under-addressed in the literature while traveling. These domains include: [1] examining power relations associated with neo-colonization between and within countries; [2] training for bi-directional learning; [3] examining motivations and goals for participating in global health; [4] addressing personal resiliency and psychosocial wellbeing related to students' travel, and; [5] reflecting on the challenging aspects of the fieldwork experience. CONCLUSIONS: The student-driven curriculum is being integrated into the GMED program through structured didactic sessions, one-on-one mentor meetings and small group discussions. Once students have traveled, the curriculum will be evaluated with the foreign partners they visited.

Rethinking mental healthcare for refugees.

After several years of downturn in new resettlement, the United States is projected to admit 125,000 refugees in the current fiscal year. Refugee communities have known risks of developing mental health problems due to high rates of exposure to war and conflict-related trauma and chronic stressors associated with displacement and resettlement. In this commentary, we examine limitations in the current system of mental health care available to newly arriving refugee communities and make recommendations for expanding and redesigning services to better meet the needs of culturally diverse refugee communities. This includes drawing on public health and prevention frameworks to implement a continuum of services including basic services and security, trauma-informed prevention services to meet the needs of individuals, families and communities and specialized clinical care for those that need it. Across all services, we recommend robust engagement and partnership with refugee community leaders to design and deliver programs.

Understanding birthing preferences of women in Benin City, Nigeria: a qualitative study.

OBJECTIVE: The aim of this study was to explore women's birthing preferences and the motivational and contextual factors that influence their preferences in Benin City, Nigeria, so as to better understand the low rates of healthcare facility usage during childbirth. SETTING: Two primary care centres, a community health centre and a church within Benin City, Nigeria. PARTICIPANTS: We conducted one-on-one in-depth interviews with 23 women, and six focus groups (FGDs) with 37 husbands of women who delivered, skilled birth attendants (SBAs), and traditional birth attendants (TBAs) in a semi-rural region of Benin City, Nigeria. RESULTS: Three themes emerged in the data: (1) women reported frequently experiencing maltreatment from SBAs in clinic settings and hearing stories of maltreatment dissuaded women from giving birth in clinics, (2) women reported that the decision of where to deliver is impacted by how they sort through a range of social, economic, cultural and environmental factors; (3) women and SBAs offered systemic and individual level solutions for increasing usage of healthcare facilities delivery, which included decreasing costs, increasing the ratio of SBAs to patients and SBAs adopting some practices of TBAs, such as providing psychosocial support to women during the perinatal period. CONCLUSION: Women in Benin City, Nigeria indicated that they want a birthing experience that is emotionally supportive, results in a healthy baby and is within their cultural scope. Adopting a woman-centred care approach may encourage more women to transition from prenatal care to childbirth with SBAs. Efforts should be placed on training SBAs as well as investigating how non-harmful cultural practices can be integrated into local healthcare systems.

Prevalence of Perceived Stress, Anxiety, and Depression in HCW in Kosovo during the COVID-19 Pandemic: A Cross-Sectional Survey.

A pandemic may have a negative impact on healthcare workers' (HCW) mental health. In this cross-sectional study, we assess the self-reported prevalence of stress, anxiety, and depression and identify their predictive factors among HCW in Kosovo. The online questionnaire collected data on socio-demographics (sex, age, occupation, education, workplace) and the presence and severity of depression, anxiety, and stress through the 21-item Depression, Anxiety, and Stress Scale (DASS-21) questionnaire. Descriptive statistics, t-test, and linear logistic regression were used to analyze the data. Of the 545 respondents, the majority were male (53.0%), under 60 years of age (94.7%), and married (81.7%). Most of them were physicians (78.2%), while the remaining were nurses, midwives, and other health professionals (22%). Prevalence rates for moderate to extremely high stress, anxiety, and depressive symptoms were 21.9%, 13.0%, and 13.9%, respectively. The nurses reported significantly higher mean scores for depression and anxiety than the physicians (p < 0.05). Being married, having poor health, not exercising, and reporting "burnout" from work significantly predicted higher levels of depressive, anxiety, and stress symptoms among health workers (p < 0.05). Most HCWs (71.6%) reported a mild, moderate, or severe mental health burden, and certain factors predicted higher levels of such burden.

Assessing the interrelationship between stigma, social influence, and cervical cancer prevention in an urban underserved setting: An exploratory study.

In the US, incidence and mortality from cervical cancer disproportionately affects racial/ethnic minorities and low-income women. Despite affordable access to primary and secondary prevention measures at Federally Qualified Health Centers (FQHCs), Human Papillomavirus (HPV) vaccination and screening rates are low, suggesting the presence of non-financial barriers to uptake in this population. This explanatory sequential mixed-methods study sought to explore factors that influence the acceptability of cervical cancer prevention services among parents and legal guardians of vaccine-eligible girls attending an urban FQHC and to assess social influences related to cervical cancer prevention. Participants included eight mothers, one father, and two grandparents/legal guardians. Nine participants self-identified as Black/Afro-Caribbean, or African American, two as Latinx, and one as Native American. The quantitative data suggested discordance between participants' cervical cancer prevention knowledge and their practices. Most indicated that their daughters had received the HPV vaccine but were unsure about HPV transmission modes. Qualitative data revealed that participants were comfortable disclosing information on HPV infection and vaccination status, and most women were likely to share information related to cervical cancer testing and diagnosis. Few comments indicated personal stigma on the part of participants, but there was frequent expression of perceived public stigma (shaming and blaming women), gender differences (men are indifferent to risk), and distrust of the healthcare system. Findings highlight several concepts including the disharmony between knowledge and practice, prevalent perceived public stigma, cumbersome attitudes on the part of men regarding HPV and cervical cancer, and distrust of the healthcare system.

Family-based mental health interventions for refugees across the migration continuum: A systematic review.

This study reviewed the literature on family-based mental health interventions for refugees across migration contexts and settings to identify types of interventions and intervention components, implementation approaches and to assess effectiveness. The review used a systematic approach, and ten intervention studies were retained for analysis. The findings identified three primary types of family-based mental health interventions used with diverse refugee communities in settings in the Global North and South-parenting groups, multiple family groups and home visiting interventions. Findings indicated that non-specialized or peer providers were frequently utilized to deliver the interventions though additional details on the workforce and workforce development strategies are needed to better understand how to sustain and support such providers. The findings suggest that family-based mental health interventions are potentially effective for improving a range of child and caregiver mental health outcomes and improving family processes and functioning among refugee families. However, the empirical evidence is quite limited to date, with a need for additional rigorous studies, especially with refugee families in humanitarian settings, to further build the evidence base.

Conducting research on building psychosocial support for Syrian refugee families in a humanitarian emergency.

BACKGROUND: This case study describes research, which is located in Turkey, where more than 750,000 Syrian refugees reside autonomously in Istanbul. The research developed and pilot tested a novel model for helping urban refugee families with limited to no access to evidence-based mental health services, by delivering a transdiagnostic family intervention for common mental disorders in health and non-health sector settings using a task-sharing approach. This case study addresses the following question: What challenges were encountered in developing and piloting a low intensity trans-diagnostic family support intervention in a humanitarian emergency setting? DISCUSSION: The rapidly growing scale of humanitarian crises requires new response capabilities geared towards addressing populations with prolonged high vulnerability to mental health consequences and limited to no access to mental health, health, and social resources. The research team faced multiple challenges in conducting this research in a humanitarian emergency setting including: 1) Non-existent or weak partnerships geared towards mental health research in a humanitarian emergency; 2) Lack of familiarity with task-sharing; 3). Insufficient language and cultural competency; 3) Fit with families' values and demands; 4) Hardships of urban refugees. Through the research process, the research team learned lessons concerning: 1) building a coalition of academic and humanitarian organization partners; 2) investing in the research capacity building of local researchers and partners; 3) working in a community-collaborative and multi-disciplinary approach. CONCLUSION: Conducting research in humanitarian emergency settings calls for innovative collaborative and multidisciplinary approaches to understanding and addressing many sociocultural, contextual, practical and scientific challenge.

Global Health Education Amidst COVID-19: Disruptions and Opportunities.

This viewpoint examines the impact of COVID-19 travel bans and remote education on the global health education of students from high-income countries (HIC) and low- and middle-income countries (LMIC) and explores potential opportunities for strengthening global health education based upon more dispersed and equitable practices. Global health is unique in the opportunities it can offer to students during the pandemic if programs can manage and learn from the pandemic's many challenges. Global health educators can: shift to sustainable remote engagement and mobilize resources globally to facilitate this; collaborate with partners to support the efforts to deal with the current pandemic and to prepare for its next phases; partner in new ways with health care professional students and faculty from other countries; collaborate in research with partners in studies of pandemic related health disparities in any country; and document and examine the impact of the pandemic on health care workers and students in different global contexts. These strategies can help work around pandemic travel restrictions, overcome the limitations of existing inequitable models of engagement, and better position global health education and face future challenges while providing the needed support to LMIC partners to participate more equally.

Epidemiology of out-of-Hospital Cardiac Arrests, knowledge of cardiovascular disease and risk factors in a regional setting in India: The Warangal Area out-of-hospital Cardiac Arrest Registry (WACAR).

OBJECTIVE: Out-of-Hospital Cardiac Arrest (OHCA) is a global public health problem. There is inadequate data on OHCA in India. The Warangal Area out-of-hospital Cardiac Arrest Registry (WACAR) was planned to understand OHCA in a regional setting in India. METHODS: WACAR is a prospective one-year observational cohort study of OHCA in the Warangal area, Telangana, India. The study included 814 subjects of OHCA of presumed cardiac etiology brought to the Mahatma Gandhi Memorial Hospital during January 1, 2018, and December 31, 2018. The data collected included; standard Utstein variables with additional data on clinical characteristics (modified Utstein template). RESULTS: The majority of OHCA subjects were male with a median age of 60 years, and mostly occurring in residential locations within 1 h of onset of symptoms. Individuals with knowledge of CVD risk factors were more likely to report symptoms before OHCA. Data on resuscitation characteristics were inadequate. CONCLUSIONS: The WACAR study provides baseline data regarding OHCA in a regional setting in India. The study demonstrated barriers involving data collection, patient knowledge of CVD risk factors and disease, and access to healthcare, which; impacted the data registry.

Building Online and Telephone Psychological First Aid Services in a Low Resource Setting During COVID-19: The Case of Kosovo.

The COVID-19 pandemic and the measures brought for prevention of infections are associated with considerable psychosocial and psychological morbidity in the general population. Providing continuous mental health services during the pandemics is a challenge worldwide, especially in low- and middle-income countries (LMICs). This paper reports on the strategies and activities taken to protect public mental health during the COVID-19 pandemic in Kosovo. This included establishing online and phone psychological first aid services and developing psychoeducational videos and webinars. The paper concludes with several lessons learned during the process of establishing and maintaining these interventions, such as: initial political endorsement is crucial to gain and maintain the momentum of services; continuous training of volunteers is crucial for both addressing the needs/problems, which arise during the process of work and maintain the motivation of volunteers; promotion of the services is crucial; academic curricula training mental health professionals should include digital mental health related courses and manualization on how to establish this kind of services in midst of crisis is crucial in order to ensure quick operationalization when needed again especially in LMIC settings. The interventions developed provide opportunity for further research especially by evaluating the impact of the services and exploring how online and provision of mental health and psychoeducation services online could help to cover services gap in times of isolation, limited movement and situations similar to pandemics in settings with limited mental health services and resources. The situation with pandemics with COVID 19 is still far from ending. Future waves of infections and restriction could again spike the mental health and psychosocial and psychological strain of the general population, therefore being prepared in provisions of psychological first aid and other mental health services online is crucial.

Understanding the needs of children returning from formerly ISIS-controlled territories through an emotional security theory lens: Implications for practice.

BACKGROUND: Children who spent time in territories formerly controlled by the Islamic State of Iraq and Syria (ISIS) and who are now being reintegrated into their countries of origin have experienced significant trauma and may present with adjustment or mental health problems. OBJECTIVE: In this paper we describe how Emotional Security Theory (EST; Davies & Cummings, 1994) and its more recent formulation, EST-reformulated (EST-R; Davies & Martin, 2013, 2014), provide a theoretical lens to aid in understanding the ways in which traumatic experiences under ISIS may have an enduring impact on a child's development and well-being. METHODS & RESULTS: The core assumption of EST is that maintaining safety and security is a central goal for a child growing up in the context of conflict. Children living in conflict zones under ISIS rule may have developed emotional insecurity, which in turn is theorized to lead to developmental cascades across multiple domains of functioning and at times result in clinically significant distress. This theoretical understanding can guide intervention, as it suggests that the foci of intervention must (1) minimize social signals indicative of threat while also (2) reducing behavioral response patterns that limit opportunities for exploration and prosocial affiliation. Trauma Systems Therapy is a multidisciplinary child trauma treatment model that addresses both stressors in the social environment and related emotional dysregulation. CONCLUSIONS: Challenges and considerations related to implementing such a comprehensive treatment approach in low- and middle-income countries are discussed.

Global Child Mental Health Research: Time for the Children.

Although 9 of 10 of the world's children live in low- and middle-income countries (LMICs), and children constitute nearly half of the populations of these countries, far too little research has focused on child mental health in LMICs.1 The expansion of research in global health and global mental health over the past several decades has not yet been matched by new research in child and adolescent mental health in LMICs.2 It is time for that to change. New research should include a focus on social drivers and the mechanisms by which they contribute to mental illnesses.

Erratum: Justice for George Floyd and a reckoning for global mental health.

[This corrects the article DOI: 10.1017/gmh.2020.17.].

Factors contributing to healthcare professional burnout during the COVID-19 pandemic: A rapid turnaround global survey.

BACKGROUND: Healthcare professionals (HCPs) on the front lines against COVID-19 may face increased workload and stress. Understanding HCPs' risk for burnout is critical to supporting HCPs and maintaining the quality of healthcare during the pandemic. METHODS: To assess exposure, perceptions, workload, and possible burnout of HCPs during the COVID-19 pandemic we conducted a cross-sectional survey. The main outcomes and measures were HCPs' self-assessment of burnout, indicated by a single item measure of emotional exhaustion, and other experiences and attitudes associated with working during the COVID-19 pandemic. FINDINGS: A total of 2,707 HCPs from 60 countries participated in this study. Fifty-one percent of HCPs reported burnout. Burnout was associated with work impacting household activities (RR = 1·57, 95% CI = 1·39-1·78, P<0·001), feeling pushed beyond training (RR = 1·32, 95% CI = 1·20-1·47, P<0·001), exposure to COVID-19 patients (RR = 1·18, 95% CI = 1·05-1·32, P = 0·005), and making life prioritizing decisions (RR = 1·16, 95% CI = 1·02-1·31, P = 0·03). Adequate personal protective equipment (PPE) was protective against burnout (RR = 0·88, 95% CI = 0·79-0·97, P = 0·01). Burnout was higher in high-income countries (HICs) compared to low- and middle-income countries (LMICs) (RR = 1·18; 95% CI = 1·02-1·36, P = 0·018). INTERPRETATION: Burnout is present at higher than previously reported rates among HCPs working during the COVID-19 pandemic and is related to high workload, job stress, and time pressure, and limited organizational support. Current and future burnout among HCPs could be mitigated by actions from healthcare institutions and other governmental and non-governmental stakeholders aimed at potentially modifiable factors, including providing additional training, organizational support, and support for family, PPE, and mental health resources.

Justice for George Floyd and a reckoning for global mental health.

In the wake of George Floyd's killing by police in Minneapolis and the global response inspired by Black Lives Matter, it is time for the field of global mental health to reexamine how we have acknowledged and addressed racism in our institutions, our research, and our mental health services. In solidarity with street level responses, this is an important opportunity to understand and collaboratively respond to public demand for systemic change. To respond effectively, it is vital to (1) be aware of the colonial history that influences today's practices, and move forward with anti-colonial and anti-racist actions; (2) identify where and why diversity and representation are lacking in the global mental health workforce, then follow steps to combat these disparities; and (3) work with communities and institutions to end both police violence and structural violence.

Factors Contributing to Healthcare Professional Burnout During the COVID-19 Pandemic: A Rapid Turnaround Global Survey.

BACKGROUND: Healthcare professionals (HCPs) on the front lines against COVID-19 may face increased workload, and stress. Understanding HCPs risk for burnout is critical to supporting HCPs and maintaining the quality of healthcare during the pandemic. METHODS: To assess exposure, perceptions, workload, and possible burnout of HCPs during the COVID-19 pandemic we conducted a cross-sectional survey. The main outcomes and measures were HCPs self-assessment of burnout and other experiences and attitudes associated with working during the COVID-19 pandemic. FINDINGS: A total of 2,707 HCPs from 60 countries participated in this study. Fifty-one percent of HCPs reported burnout. Burnout was associated with work impacting household activities (RR=1.57, 95% CI=1.39-1.78, P<0.001), feeling pushed beyond training (RR=1.32, 95% CI=1.20-1.47, P<0.001), exposure to COVID-19 patients (RR=1.18, 95% CI=1.05-1.32, P=0.005), making life prioritizing decisions (RR=1.16, 95% CI=1.02-1.31, P=0.03). Adequate personal protective equipment (PPE) was protective against burnout (RR=0.88, 95% CI=0.79-0.97, P=0.01). Burnout was higher in high-income countries (HICs) compared to low- and middle-income countries (LMICs) (RR=1.18; 95% CI=1.02-1.36, P=0.018). INTERPRETATION: Burnout is prevalent at higher than previously reported rates among HCPs working during the COVID-19 pandemic and is related to high workload, job stress, and time pressure, and limited organizational support. Current and future burnout among HCPs could be mitigated by actions from healthcare institutions and other governmental and non-governmental stakeholders aimed at potentially modifiable factors, including providing additional training, organizational support, support for family, PPE, and mental health resources. FUNDING: N/A.

Rapid Review to Inform the Rehabilitation and Reintegration of Child Returnees from the Islamic State.

Background: An estimated 49,000 women and children who lived in the Islamic State are being held in the Al-Hol refugee camp in Syria. Several countries have repatriated some of these women and children, though most have thus far refused to do so. Many countries are asking whether it is possible to successfully rehabilitate and reintegrate this group and how the evidence base could inform their approach. Objective: The overall objective of this paper is to inform the rehabilitation and reintegration of child returnees from the Islamic State by rapidly reviewing the evidence on children exposed to trauma and adversity. Methods: A rapid review was conducted to identify pertinent evidence regarding outcomes, risk and protective factors, and interventions and to build a framework that could guide policies and practices. Prior work in the areas of refugee children, war-impacted children, child criminal gang members, child victims of maltreatment, and child victims of sex trafficking was reviewed. Evidence was collected and analyzed from 31 prior reviews and studies. Findings: The Rehabilitation and Reintegration Intervention Framework (RRIF) incorporates five levels (individual, family, educational, community, and societal) and identifies five primary goals: 1) promoting individual mental health and well-being; 2) promoting family support; 3) promoting educational success; 4) promoting community support; and 5) improving structural conditions and protecting public safety. Implementing this framework requires public-private partnership with extensive civil society involvement. Conclusions: Rehabilitation and reintegration programs should be based on the evidence of prior work with children exposed to trauma and adversity. RRIF defines a multi-level approach that encompasses promoting individual mental health and well-being, family support, educational success, community support, structural conditions, and public safety. Further multi-disciplinary research is needed to develop evidence in several identified areas concerning child health and developmental problems, family custody, faith and religiosity, and violent extremism assessment and prevention.