Barriers to Health among IDPs in Kabul, Afghanistan: a qualitative study

Background: Forced displacement is a significant problem for regions experiencing prolonged humanitarian crises due to armed conflict. Afghanistan, having experienced over four decades of conflict, has an estimated 1.2 million internally displaced persons (IDPs), a majority of which are concentrated in urban centers. IDPs have limited resources and face challenges accessing health services through traditional channels, leading to a disproportionate burden of morbidity and mortality. Health care facilities created for and existing within IDP camps also face numerous challenges. We aim to understand the structural factors that negatively impact health and the specific barriers to healthcare access for IDPs using qualitative methods. Methods: A brief qualitative study was done to assess the barriers to health faced by IDPs and to understand the experience of providers caring for IDPs. We conducted open-ended interviews using a semi-structured interview guide across three IDP camps in Kabul, Afghanistan between May and June 2017. Participants were interviewed in focus groups, interviewing a total of 37 IDP ag 18 and older. In addition, two former health care providers were interviewed. We used grounded theory to code interviews using a priori and emergent coding, from which several themes and sub-themes emerged. Two independent readers coded the data and discrepancies were resolved by consensus. Results: Human security, water access, limited livelihood and employment, poor housing infrastructure and environmental factors significantly impacted IDP health. Closure of clinics within the camps caused substantial limitations to healthcare service access. Accessing existing health care infrastructure was limited by cost, distance, discrimination, and limited access to medication and vaccinations, particularly for children. Key informant interviews identified healthcare funding and vaccination delivery to be priority problems. Across all focus groups and key informant interviews, there appeared to be a solid and trusted patient-provider relationship. Conclusion Structural factors that negatively impact health coupled with new barriers to healthcare access for IDPs in Kabul are a source of serious concern. Our study identified structural factors that exacerbate poor health and new challenges to healthcare access resulting from the discontinuation of in-camp health services. Further research should be done on the barriers and facilitators of transition from emergency humanitarian response to long-term care for IDPs, as well as on the ability of local health systems to absorb vulnerable populations after humanitarian crises

An NGO-Implemented Community-Clinic Health Worker Approach to Providing Long-Term Care for Hypertension in a Remote Region of Southern India.

Poor blood pressure control results in tremendous morbidity and mortality in India where the leading cause of death among adults is from coronary heart disease. Despite having little formal education, community health workers (CHWs) are integral to successful public health interventions in India and other low- and middle-income countries that have a shortage of trained health professionals. Training CHWs to screen for and manage chronic hypertension, with support from trained clinicians, offers an excellent opportunity for effecting systemwide change in hypertension-related burden of disease. In this article, we describe the development of a program that trained CHWs between 2014 and 2015 in the tribal region of the Sittilingi Valley in southern India, to identify hypertensive patients in the community, refer them for diagnosis and initial management in a physician-staffed clinic, and provide them with sustained lifestyle interventions and medications over multiple visits. We found that after 2 years, the CHWs had screened 7,176 people over age 18 for hypertension, 1,184 (16.5%) of whom were screened as hypertensive. Of the 1,184 patients screened as hypertensive, 898 (75.8%) had achieved blood pressure control, defined as a systolic blood pressure less than 140 and a diastolic blood pressure less than 90 sustained over 3 consecutive visits. While all of the 24 trained CHWs reported confidence in checking blood pressure with a manual blood pressure cuff, 4 of the 24 CHWs reported occasional difficulty documenting blood pressure values because they were unable to write numbers properly. They compensated by asking other CHWs or members of their community to help with documentation. Our experience and findings suggest that a CHW blood pressure screening system linked to a central clinic can be a promising avenue for improving hypertension control rates in low- and middle-income countries

Depression and HIV in Botswana: A Population-Based Study on Gender-Specific Socioeconomic and Behavioral Correlates

Depression is a leading contributor to the burden of disease worldwide, a critical barrier to HIV prevention and a common serious HIV co-morbidity. However, depression screening and treatment are limited in sub-Saharan Africa, and there are few population-level studies examining the prevalence and gender-specific factors associated with depression.We conducted a cross-sectional population-based study of 18–49 year-old adults from five districts in Botswana with the highest prevalence of HIV-infection. We examined the prevalence of depressive symptoms, using a Hopkins Symptom Checklist for Depression (HSCL-D) score of ≥1.75 to define depression, and correlates of depression using multivariate logistic regression stratified by sex.Of 1,268 participants surveyed, 25.3% of women and 31.4% of men had depression. Among women, lower education (adjusted odds ratio [AOR] 2.07, 95% confidence interval [1.30–3.32]), higher income (1.77 [1.09–2.86]), and lack of control in sexual decision-making (2.35 [1.46–3.81]) were positively associated with depression. Among men, being single (1.95 [1.02–3.74]), living in a rural area (1.63 [1.02–2.65]), having frequent visits to a health provider (3.29 [1.88–5.74]), anticipated HIV stigma (fearing discrimination if HIV status was revealed) (2.04 [1.27–3.29]), and intergenerational sex (2.28 [1.17–4.41]) were independently associated with depression.Depression is highly prevalent in Botswana, and its correlates are gender-specific. Our findings suggest multiple targets for screening and prevention of depression and highlight the need to integrate mental health counseling and treatment into primary health care to decrease morbidity and improve HIV management efforts

HIV/AIDS and Human Rights in Botswana and Swaziland: A Matter of Dignity and Health

A health and human rights framework provides a comprehensive perspective for understanding complex interactions between HIV/AIDS, human rights, and the health of individuals and communities. By helping to identify a broad range of social factors that affect health, such a framework also facilitates the development of interventions and policies that maximize both health and human rights benefits. In this Article, we discuss the various linkages between health and human rights and review the literature on HIV/AIDS and human rights, with a focus on under-resourced settings. In particular, we examine how the framework is relevant to the specific epidemics in Botswana and Swaziland, based on the findings of populations-based studies in the two countries conducted by Physicians for Human Rights in 2004 and 2005. In Botswana and Swaziland, which have the world\u27s highest rates of HIV/AIDS, HIV transmission occurs primarily through sexual practices rooted in women\u27s disempowerment and lack of human rights, and is further facilitated by poverty and food insufficiency. The legal system in both of these countries discriminates against women and limits their autonomy through restrictions on property ownership, inheritance and other rights. Social, economic and cultural practices create and enforce these legalized gender inequalities in all aspects of women\u27s lives. Neither country has met its obligations as signatories to treaties and covenants under international human rights law. As a result, women continue to be disproportionately vulnerable to HIV/AIDS. Once infected, women experience a host of further violations of human rights, including those enumerated in international treaties, covenants and laws to which both Botswana and Swaziland are signatories. To address the epidemic effectively and eliminate such violations, states must incorporate a comprehensive health and human rights framework. Respect for human rights is not optional in the struggle to prevent and alleviate the suffering caused by HIV/AIDS; it is a moral and legal imperative

Death, injury and disability from kinetic impact projectiles in crowd-control settings: a systematic review

Objective We conducted a systematic review of the available literature on deaths, injuries and permanent disability from rubber and plastic bullets, as well as from bean bag rounds, shot pellets and other projectiles used in arrests, protests and other contexts from 1 January 1990 until 1 June 2017.Data sources PubMed, Scopus, JSTOR and grey literature.Data synthesis We report on descriptive statistics as well as data on injury severity, permanent disability and death. We analysed potential risk factors for injury severity, including the site of impact, firing distance and access to medical care.Results Of 3228 identified articles, 26 articles met inclusion criteria. These articles included injury data on 1984 people, 53 of whom died as a result of their injuries. 300 people suffered permanent disability. Deaths and permanent disability often resulted from strikes to the head and neck (49.1% of deaths and 82.6% of permanent disabilities). Of the 2135 injuries in those who survived their injuries, 71% were severe, injuries to the skin and to the extremities were most frequent. Anatomical site of impact, firing distance and timely access to medical care were correlated with injury severity and risk of disability.Conclusions Kinetic impact projectiles (KIPs), often called rubber or plastic bullets, are used commonly in crowd-control settings. We find that these projectiles have caused significant morbidity and mortality during the past 27 years, much of it from penetrative injuries and head, neck and torso trauma. Given their inherent inaccuracy, potential for misuse and associated health consequences of severe injury, disability and death, KIPs do not appear to be appropriate weapons for use in crowd-control settings. There is an urgent need to establish international guidelines on the use of crowd-control weapons to prevent unnecessary injuries and deaths

Death, injury and disability from kinetic impact projectiles in crowd-control settings: a systematic review

Objective We conducted a systematic review of the available literature on deaths, injuries and permanent disability from rubber and plastic bullets, as well as from bean bag rounds, shot pellets and other projectiles used in arrests, protests and other contexts from 1 January 1990 until 1 June 2017.Data sources PubMed, Scopus, JSTOR and grey literature.Data synthesis We report on descriptive statistics as well as data on injury severity, permanent disability and death. We analysed potential risk factors for injury severity, including the site of impact, firing distance and access to medical care.Results Of 3228 identified articles, 26 articles met inclusion criteria. These articles included injury data on 1984 people, 53 of whom died as a result of their injuries. 300 people suffered permanent disability. Deaths and permanent disability often resulted from strikes to the head and neck (49.1% of deaths and 82.6% of permanent disabilities). Of the 2135 injuries in those who survived their injuries, 71% were severe, injuries to the skin and to the extremities were most frequent. Anatomical site of impact, firing distance and timely access to medical care were correlated with injury severity and risk of disability.Conclusions Kinetic impact projectiles (KIPs), often called rubber or plastic bullets, are used commonly in crowd-control settings. We find that these projectiles have caused significant morbidity and mortality during the past 27 years, much of it from penetrative injuries and head, neck and torso trauma. Given their inherent inaccuracy, potential for misuse and associated health consequences of severe injury, disability and death, KIPs do not appear to be appropriate weapons for use in crowd-control settings. There is an urgent need to establish international guidelines on the use of crowd-control weapons to prevent unnecessary injuries and deaths

Health impacts of chemical irritants used for crowd control: a systematic review of the injuries and deaths caused by tear gas and pepper spray

Chemical irritants used in crowd control, such as tear gases and pepper sprays, are generally considered to be safe and to cause only transient pain and lacrimation. However, there are numerous reports that use and misuse of these chemicals may cause serious injuries. We aimed to review documented injuries from chemical irritants to better understand the morbidity and mortality associated with these weapons

A systematic review and meta-analysis assessing the impact of droughts, flooding, and climate variability on malnutrition

Background Both the World Health Organization and the Intergovernmental Panel on Climate Change project that malnutrition will be the greatest contributor to climate change-associated morbidity and mortality. Although there have been several studies that have examined the potential effects of climate change on human health broadly, the effects on malnutrition are still not well understood. We conducted a systematic review investigating the role of three climate change proxies (droughts, floods, and climate variability) on malnutrition in children and adults. Methods and findings We identified 22 studies examining the effects of droughts, floods, and climate variability on at least one malnutrition metric. We found that 17 out of 22 studies reported a significant relationship between climate change proxies and at least one malnutrition metric. In meta-analysis, drought conditions were significantly associated with both wasting (Odds Ratio [OR] 1.46, 95% Confidence Interval [CI] 1.05-2.04) and underweight prevalence (OR 1.46, 95% CI 1.01-2.11). Conclusions Given the long-term consequences of malnutrition on individuals and society, adoption of climate change adaptation strategies such as sustainable agriculture and water irrigation practices, as well as improving nutritional interventions aimed at children aged 1–2 years and older adults, should be prioritised on global policy agendas in the coming years

Health impacts of chemical irritants used for crowd control: a systematic review of the injuries and deaths caused by tear gas and pepper spray

Abstract Background Chemical irritants used in crowd control, such as tear gases and pepper sprays, are generally considered to be safe and to cause only transient pain and lacrimation. However, there are numerous reports that use and misuse of these chemicals may cause serious injuries. We aimed to review documented injuries from chemical irritants to better understand the morbidity and mortality associated with these weapons. Methods We conducted a systematic review using PRISMA guidelines to identify injuries, permanent disabilities, and deaths from chemical irritants worldwide between January 1, 1990 and March 15, 2015. We reviewed injuries to different body systems, injury severity, and potential risk factors for injury severity. We also assessed region, context and quality of each included article. Results We identified 31 studies from 11 countries. These reported on 5131 people who suffered injuries, two of whom died and 58 of whom suffered permanent disabilities. Out of 9261 total injuries, 8.7% were severe and required professional medical management, while 17% were moderate and 74.3% were minor. Severe injuries occurred to all body systems, with the majority of injuries impacting the skin and eyes. Projectile munition trauma caused 231 projectile injuries, with 63 (27%) severe injuries, including major head injury and vision loss. Potentiating factors for more severe injury included environmental conditions, prolonged exposure time, and higher quantities of chemical agent in enclosed spaces. Conclusions Although chemical weapons may have a limited role in crowd control, our findings demonstrate that they have significant potential for misuse, leading to unnecessary morbidity and mortality. A nuanced understanding of the health impacts of chemical weapons and mitigating factors is imperative to avoiding indiscriminate use of chemical weapons and associated health consequences

Ethics Simulation in Global Health Training (ESIGHT).

IntroductionMany health care trainees and providers have reported feeling unprepared for the ethical dilemmas they faced while practicing in global health. Simulation is an effective teaching modality in the training of health care professionals. This resource describes the development, implementation, and assessment of an innovative simulation training program for global health ethics.MethodsWe conducted simulation training with trainees and professionals from various health care disciplines. After a didactic component in which general ethical principles were introduced, participants acted as either lead or observer in four simulations representing different ethical challenges. Participants interacted with simulated patients within a set designed to resemble a resource-constrained environment. Data on the participants' experiences and evaluations of the program's effectiveness were collected through pre-/postsession surveys and focus groups.ResultsAll 53 participants (100%) agreed that the simulations "effectively highlighted ethical dilemmas I could face abroad," and 98% agreed that the content "was useful in my preparation for an international elective." Responses from surveys and focus groups stressed the importance of the realistic and emotional nature of the simulation in increasing confidence and preparedness, as well as a preference for simulation as the modality for teaching global health ethics.DiscussionSimulation for global health ethics training can help to raise awareness of the complex ethical challenges one may face abroad. Incorporating simulation training within broader global health curricula can improve trainee preparedness and confidence in appropriately and effectively identifying, strategizing, and navigating through ethical dilemmas in the field