Expansion of health facilities in Iraq a decade after the US-led invasion, 2003–2012

Background: In the last few decades, Iraq’s health care capacity has been severely undermined by the effects of different wars, international sanctions, sectarian violence and political instability. In the aftermath of the 2003 US-led invasion, the Ministry of Health has set plans to expand health service delivery, by reorienting the public sector towards primary health care and attributing a larger role to the private sector for hospital care. Quantitative assessments of the post-2003 health policy outcomes have remained scant. This paper addresses this gap focusing on a key outcome indicator that is the expansion of health facilities. Methods: The analysis is based on data on health facilities provided by the World Health Organisation and Iraq’s Ministry of Health. For each governorate, we calculated the change in the absolute number of facilities by type from early 2003 to the end of 2012. To account for population growth, we computed the change in the number of facilities per 100,000 population. We compared trends in the autonomous northern Kurdistan region, which has been relatively stable from 2003 onwards, and in the rest of Iraq (centre/south), where fragile institutions and persistent sectarian strife have posed major challenges to health system recovery. Results: The countrywide number of primary health care centres per 100,000 population rose from 5.5 in 2003 to 7.4 in 2012. The extent of improvement varied significantly within the country, with an average increase of 4.3 primary health care centres per 100,000 population in the Kurdistan region versus an average increase of only 1.4 in central/southern Iraq. The average number of public hospitals per 100,000 population rose from 1.3 to 1.5 in Kurdistan, whereas it remained at 0.6 in centre/south. The average number of private hospitals per 100,000 population rose from 0.2 to 0.6 in Kurdistan, whereas it declined from 0.3 to 0.2 in centre/south. Conclusions: The expansion of both public and private health facilities in the Kurdistan region appears encouraging, but still much should be done to reach the standards of neighbouring countries. The slow pace of improvement in the rest of Iraq is largely attributable to the dire security situation and should be a cause for major concern

Health needs and care seeking behaviours of Yazidis and other minority groups displaced by ISIS into the Kurdistan Region of Iraq

Background During the summer of 2014, ISIS overran Nineveh governorate in Northern Iraq. Yazidis and other religious minorities were subjected to brutal attacks and forced to seek refuge into the neighbouring Kurdistan Region, where they remain living in local communities or in camps. This survey provides a population-based assessment of the health needs and care seeking behaviours of Yazidis and other groups currently residing in camps. Methods The survey covered 13 camps managed by the Kurdish Board of Relief and Humanitarian Affairs. A systematic random sample of 1,300 households with a total of 8,360 members were interviewed between November and December 2015. Participants were asked if any household members had needed care for a health condition in the two weeks preceding the survey, and whether care was obtained from the camp primary health care centre, an outside public hospital or a private clinic. If care was received, the out-of-pocket payment was recorded; otherwise, the reason for not seeking care was queried. Results In 33.9% (CI: 31.0–37.0) of households one or more members had needed care for a health condition in the two weeks preceding the survey. The most likely to have needed care were older persons (18.5%; CI: 13.6–24.6) and infants (18.0%; CI: 11.6–26.8). The reported health conditions revealed a complex picture of communicable and non-communicable diseases as well as mental health problems and physical injuries. Care was primarily sought from private clinics (41.8%; CI: 36.4–47.4) or public hospitals (27.3%; CI: 22.6–32.7) rather than from the camp primary health care clinics (23.6%; CI: 19.5–28.2). The mean out-ofpocket payment for care received was nearly 3 times higher in public hospitals than in the camp primary health care clinics and nearly 11 times higher in private clinics. Cost was the main perceived barrier to obtaining health services. Conclusion Demand for health services was high among Yazidis and other minorities living in camps. Private services were preferred in spite of the tenuous economic circumstances of displaced households. Declines in public sector funding may further restrict access from camp clinics stressing the need for alternative access strategies

Prevalence of non-communicable diseases and access to health care and medications among Yazidis and other minority groups displaced by ISIS into the Kurdistan region of Iraq

The increasing caseload of non-communicable diseases (NCDs) in displaced populations poses new challenges for humanitarian agencies and host country governments in the provision of health care, diagnostics and medications. This study aimed to characterise the prevalence of NCDs and better understand issues related to accessing care among Yazidis and other minority groups displaced by ISIS and currently residing in camps in the Kurdistan Region of Iraq

Mortality and kidnapping estimates for the Yazidi population in the area of Mount Sinjar, Iraq, in August 2014: a retrospective household survey

In August 2014, the so-called Islamic State of Iraq and Syria (ISIS) attacked the Yazidi religious minority living in the area of Mount Sinjar in Nineveh governorate, Iraq. We conducted a retrospective household survey to estimate the number and demographic profile of Yazidis killed and kidnapped

The determinants of handwashing behaviour among internally displaced women in two camps in the Kurdistan Region of Iraq.

BACKGROUND: Diarrhoea is one of the most common causes of mortality and morbidity among populations displaced due to conflict. Handwashing with soap has the potential to halve the burden of diarrhoeal diseases in crisis contexts. This study aimed to identify which determinants drive handwashing behaviour in post-conflict, displacement camps. METHODS: This study was conducted in two camps for internally displaced people in the Kurdistan Region of Iraq. A Barrier Analysis questionnaire was used for assessing the determinants of hand washing behaviour. Participants were screened and classified as either 'doers' (those who wash their hands with soap at critical times) or 'non-doers' (those who do not wash their hands with soap at critical times). Forty-five doers and non-doers were randomly selected from each camp and asked about behavioural determinants. The Barrier Analysis standard tabulation sheet was used for the analysis. RESULTS: No differences were observed between doers and non-doers in relation to self-efficacy, action efficacy, the difficulties and benefits of handwashing, and levels of access to soap and water. In the first of the two camps, non-doers found it harder to remember to wash their hands (P = 0.045), had lower perceived vulnerability to diarrhoea (P = 0.037), lower perceived severity of diarrhoea (P = 0.020) and were aware of 'policies' which supported handwashing with soap (P = 0.037). In the second camp non-doers had lower perceived vulnerability to diarrhoea (P = 0.017). CONCLUSIONS: In these camp settings handwashing behaviour, and the factors that determine it, was relatively homogenous because of the homogeneity of the settings and the socio-demographics of population. Handwashing programmes should seek to improve the convenience and quality of handwashing facilities, create cues to trigger handwashing behaviour and increase perceived risk. We identify several ways to improve the validity of the Barrier Analysis method such as using it in combination with other more holistic qualitative tools and revising the statistical analysis

Women's Health and Status in the Kurdistan Region of Iraq: A Review

Women in the Kurdistan region of Iraq suffer from various health, social and cultural problems. The poor reproductive health of many women is primarily related to inadequate access and utilization of health services. The maternal mortality rate in Iraq has remained high, and its attributes such as early marriage and childbearing, inadequate birth spacing and high cesarean section rates are constant problems in the region. Women also suffer from different aspects of gender discrimination and women's rights abuse such as domestic violence, female genital mutilation, self-mutilation, and honor killing. Many of these problems are deeply rooted in the culture, and the efforts against them face many challenges. Improvement of women's health in the Kurdistan region of Iraq needs an integrated approach that takes into consideration the physical and mental health of women, their families and societies in a holistic way. Interventions should address the cultural and traditional issues sensitively. The strategies to ban harmful behavior, including female genital mutilation and violence against women, need active engagement of the community and educating its members

Risky Driving Behaviours among Medical Students in Erbil, Iraq

Objectives: This study aimed to assess risky driving behaviours among medical students in Erbil, Iraq, and to explore the relationship between risky driving behaviours and perceptions of risky driving. Methods: This self-administered questionnaire-based survey was conducted from January to May 2014 among a random sample of 400 medical students at Hawler Medical University in Erbil. The questionnaire was designed to assess the frequency of engagement in 21 risky driving behaviours, the perceived risk of each behaviour and the preference for each behaviour as ranked on a 5-point scale. Results: A total of 386 students responded to the survey (response rate: 96.5%). Of these, 211 reported that they currently drove a vehicle (54.7%). Drivers most frequently engaged in the following behaviours: playing loud music (35.9%), speeding (30.4%), allowing front seat passengers to not wear seat belts (27.9%) and using mobile phones (27.7%). Least frequent driving behaviours included not stopping at a red light (3.9%), driving while sleepy (4.4%), driving after a mild to moderate intake of alcohol (4.5%) and drunk driving (6.4%). Mean risky driving behaviour scores were significantly higher among males (P <0.001) and those who owned a car (P = 0.002). The mean risk perception score was higher among >20-year-olds (P = 0.028). There was a significant positive relationship between the preference for risky behaviours and risky driving behaviours (beta = 0.44; P <0.001). Conclusion: Medical students in Erbil reported high frequencies of several serious risky driving behaviours. The preference for risky behaviours was found to be an important predictor of risky driving behaviours among medical students in Erbil

Female genital mutilation among Iraqi Kurdish women: a cross-sectional study from Erbil city

BACKGROUND: Iraqi Kurdistan region is one of the areas where female genital mutilation is reportedly widely practiced but inadequately studied. The aim of this study was to determine (i) the prevalence of female genital mutilation among Muslim Kurdish women in Erbil city, (ii) the patterns and types of female genital mutilation, (iii) the factors associated with this practice and (iv) women’s knowledge and attitudes towards this practice. METHODS: A cross-sectional study was conducted in the primary health care centers and the Maternity Teaching Hospital in Erbil city, involving 1987 women aged 15–49 years. Data were obtained about female genital mutilation status and knowledge and perception towards this practice. The participants were clinically examined to verify the self-reported female genital mutilation status. RESULTS: The self-reported prevalence of female genital mutilation was 70.3%, while it was 58.6% according to clinical examination of the women’s genitalia. The most common type of female genital mutilation was type I (99.6%) and the most common age at which mutilation was performed was 4–7 years (60.2%). This practice was mostly performed by traditional birth attendants (72.5%). Only 6.4% of mutilated women reported having complications after mutilation, most commonly bleeding (3.6%). The practice was more reported among housewives (OR = 3.3), those women whose mothers were mutilated (OR = 15.1) or with unknown mutilation status (OR = 7.3) and those women whose fathers were illiterate (OR = 1.4) or could only read and write (OR = 1.6). The common reasons for practicing female genital mutilation were cultural tradition (46.7%) and dictate of religion (38.9%). Only 30% of the participants were aware about the health consequences of female genital mutilation. More than one third (36.6%) of the women support the practice and 34.5% have intention to mutilate their daughters. CONCLUSIONS: Prevalence of female genital mutilation among Muslim Kurdish women in Erbil city is very high; although, most cases are of type I. There is clear lack of knowledge about the health consequences of female genital mutilation and a relatively important segment of women support this practice. Custom or tradition and dictate of religion are the main reasons for this practice that need further in-depth exploration

Objective structured clinical examination: Challenges and opportunities from students’ perspective

Background Objective structured clinical examination (OSCE) has been used in evaluating clinical competence in health professions education around the world. Despite its implementation in Iraq for around a decade, limited studies investigated the challenges and opportunities to improve the standard and quality of this examination from student’s perspective. Methods This qualitative study was based on an online open-ended questionnaire survey that was carried out in the College of Medicine, Hawler Medical University, Iraq at the beginning of the 2018–2019 academic year. A convenience sample of 180 students in the clinical phase (4th, 5th, and 6th) year of study were invited to participate. Results A total of 141 students responded to the online questionnaire. The participants were generally happy with the OSCE, and they recognized many positive aspects, including the role of the OSCE in increasing confidence, engagement and motivating learning, the role of the OSCE in achieving a higher level of learning, the content validity of the OSCE, and the quality of the OSCE. The main weak points of the OSCE identified by the students included unfairness, gender discrimination, duration of the OSCE, and the behavior of the examiners. Suggestions to improve the OSCE examination included improving the examiners’ behavior, with the focus on the training of the examiners, and avoiding discrimination among students.\ud Conclusions Most of the students were generally satisfied with the current OSCE examination. The main concern of the students was related to the organization of the OSCE. Valuable suggestions were raised to improve the OSCE quality including examiners’ and simulated patients’ training

Exploring Iraqi people’s perception about early marriage: a qualitative study

Background and objective Early marriage is prevalent in Iraq, but the factors related to this behavior, especially people's attitudes about it, have not been well studied. It has been proven that early marriage seriously threatens young girls' lives and health. This study aimed to explore the perception of people about early marriage in the Iraqi Kurdistan region. Methods A qualitative method was employed to carry out this study in 2020. Data were collected through 16 focus group discussions in different health centers in Erbil, Iraq. Each focus group included 8–12 participants who had the experience of early marriage. The transcripts of the focus groups were analyzed through the six methodological activities of Van Manen. The trustworthiness of the data was confirmed by using qualitative data evaluation criteria. Results Different themes and subthemes regarding the ideal age of marriage, attitudes toward marriage, reasons for early marriage, advantages and disadvantages of early marriage, and practice of early marriage in the community emerged from focus group discussions. Most participants identified early marriage as inappropriate social behavior that should not be practiced. Reasons for early marriage included poor economic status, protection of girls and boys, low educational level, and respect for old traditions of the community. Divorce and violence against women were the main disadvantages of early marriage. Conclusion There is a generally negative attitude towards early marriage, and the practice's disadvantages and health and psychological consequences are well recognized in Iraqi Kurdistan Region. However, different social, traditional, economic, educational, and religious factors encourage early marriage in the region. Further research is recommended in other governorates in the area to have a more precise and representative idea about the topic