Child health in Syria: recognising the lasting effects of warfare on health

The war in Syria, now in its fourth year, is one of the bloodiest in recent times. The legacy of war includes damage to the health of children that can last for decades and affect future generations. In this article we discuss the effects of the war on Syria's children, highlighting the less documented longer-term effects. In addition to their present suffering, these children, and their own children, are likely to face further challenges as a result of the current conflict. This is essential to understand both for effective interventions and for ethical reasons

The intergenerational effects of war on the health of children.

Background: The short- and medium-term effects of conflict on population health are reasonably well documented. Less considered are its consequences across generations and potential harms to the health of children yet to be born. Discussion: Looking first at the nature and effects of exposures during conflict, and then at the potential routes through which harm may propagate within families, we consider the intergenerational effects of four features of conflict: violence, challenges to mental health, infection and malnutrition. Conflict-driven harms are transmitted through a complex permissive environment that includes biological, cultural and economic factors, and feedback loops between sources of harm and weaknesses in individual and societal resilience to them. We discuss the multiplicative effects of ongoing conflict when hostilities are prolonged. Summary: We summarize many instances in which the effects of war can propagate across generations. We hope that the evidence laid out in the article will stimulate research and – more importantly – contribute to the discussion of the costs of war; particularly in the longer-term in post-conflict situations in which interventions need to be sustained and adapted over many years

Scalability of digital psychological innovations for refugees: A comparative analysis in Egypt, Germany, and Sweden

E-mental health interventions may offer innovative means to increase access to psychological support and improve the mental health of refugees. However, there is limited knowledge about how these innovations can be scaled up and integrated sustainably into routine services. This study examined the scalability of a digital psychological intervention called Step-by-Step (SbS) for refugees in Egypt, Germany, and Sweden. We conducted semi-structured interviews (n = 88) with Syrian refugees, and experts in SbS or refugee' mental health systems in the three countries. Data collection and analysis were guided by a system innovation perspective. Interviewees identified three contextual factors that influenced scalability of SbS in each country: increasing use of e-health, the COVID-19 pandemic, and political instability. Nine factors lay at the interface between the innovation and potential delivery systems, and these were categorised by culture (ways of thinking), structure (ways of organising), and practice (ways of doing). Factors related to culture included: perceived need and acceptability of the innovation. Acceptability was influenced by mental health stigma and awareness, digital trust, perceived novelty of self-help interventions, and attitudes towards non-specialist (e-helper) support. Factors related to structure included financing, regulations, accessibility, competencies of e-helpers, and quality control. Factors related to practice were barriers in the initial and continued engagement of end-users. Many actors with a potential stake in the integration of SbS across the three countries were identified, with nineteen stakeholders deemed most powerful. Several context-specific integration scenarios were developed, which need to be tested. We conclude that integrating novel e-mental health interventions for refugees into routine services will be a complex task due to the many interrelated factors and actors involved. Multi-stakeholder collaboration, including the involvement of end-users, will be essential. Previous article in issu

Treatment gap and mental health service use among Syrian refugees in Turkey

Abstract Introduction Turkey hosts the highest number of Syrian refugees in Europe. Refugees are often vulnerable to situational forms of psychosocial distress as a consequence of exposure to war and violence which may result in more profound mental health problems if no treatment is sought. The aim of this study is to report evidence on mental health and psychosocial support (MHPSS) needs, access and barriers to MHPSS care among Syrians refugees living in Istanbul, Turkey. Methods A cross-sectional survey was conducted among Syrian refugees aged 18 years or over in Istanbul (Sultanbeyli) between February and May 2018. Data among 1’678 Syrian refugees were collected on mental health outcomes using the Posttraumatic Stress Disorder (PTSD) Checklist (PCL-5) and the Hopkins Symptoms Checklist (HSCL-25) for depression and anxiety. We also collected data on health care utilization, barriers to seeking and continuing care as well as knowledge and attitudes towards mental health. Descriptive analyses were used. Results The prevalence of PTSD, depression and anxiety was 19.6%, 34.7% and 36.1% respectively. The treatment gap was 89% for PTSD, 90% for anxiety and 88% for depression. 249 respondents (15%) screened positive for either PTSD, depression or anxiety in our survey and self-reported emotional/behavioural problems since arriving in Sultanbeyli. Several structural and attitudinal barriers for not seeking care were reported. Conclusions To overcome the treatment gap, mental health care programmes need to be more responsive to the needs of Syrian refugees. Barriers to seeking and continuing care can be overcome by providing MHPSS services in the community which facilitate access to care. Community-based programmes of care should be supported by activities which increase awareness about mental health issues and tackle negative attitudes towards mental illness. Key messages This study provides the first nationally representative data on the mental health of Syrian refugees in Turkey, and shows that refugees have high mental health needs. Syrian refugees do not seek mental health care despite availability of mental health services in the community. </jats:sec

Reproductive health and quality of life of young Burmese refugees in Thailand

BACKGROUND: Of the 140,000 Burmese* refugees living in camps in Thailand, 30% are youths aged 15-24. Health services in these camps do not specifically target young people and their problems and needs are poorly understood. This study aimed to assess their reproductive health issues and quality of life, and identifies appropriate service needs. METHODS: We used a stratified two-stage random sample questionnaire survey of 397 young people 15-24 years from 5,183 households, and 19 semi-structured qualitative interviews to assess and explore health and quality of life issues. RESULTS: The young people in the camps had very limited knowledge of reproductive health issues; only about one in five correctly answered at least one question on reproductive health. They were clear that they wanted more reproductive health education and services, to be provided by health workers rather than parents or teachers who were not able to give them the information they needed. Marital status was associated with sexual health knowledge; having relevant knowledge of reproductive health was up to six times higher in married compared to unmarried youth, after adjusting for socio-economic and demographic factors. Although condom use was considered important, in practice a large proportion of respondents felt too embarrassed to use them. There was a contradiction between moral views and actual behaviour; more than half believed they should remain virgins until marriage, while over half of the youth experienced sex before marriage. Two thirds of women were married before the age of 18, but two third felt they did not marry at the right age. Forced sex was considered acceptable by one in three youth. The youth considered their quality of life to be poor and limited due to confinement in the camps, the limited work opportunities, the aid dependency, the unclear future and the boredom and unhappiness they face. CONCLUSIONS: The long conflict in Myanmar and the resultant long stay in refugee camps over decades affect the wellbeing of these young people. Lack of sexual health education and relevant services, and their concerns for their future are particular problems, which need to be addressed. Issues of education, vocational training and job possibilities also need to be considered.*Burmese is used for all ethnic groups

Somatic distress among Syrian refugees in Istanbul, Turkey: A cross-sectional study.

•Over 40% of respondents experienced moderate to severe somatic symptom severity. •Pain in arms, legs, joints, back, and headaches most frequently reported symptoms. •Somatic distress associated with female gender and depression, anxiety and PTSD. •Evidenced-based mental health interventions should be integrated into primary care

Treatment gap and mental health service use among Syrian refugees in Sultanbeyli, Istanbul: a cross-sectional survey.

AIMS: Syrian refugees may have increased mental health needs due to the frequent exposure to potentially traumatic events and violence experienced during the flight from their home country, breakdown of supportive social networks and daily life stressors related to refugee life. The aim of this study is to report evidence on mental health needs and access to mental health and psychosocial support (MHPSS) among Syrians refugees living in Sultanbeyli-Istanbul, Turkey. METHODS: A cross-sectional survey was conducted among Syrian refugees aged 18 years or over in Sultanbeyli between February and May 2018. We used random sampling to select respondents by using the registration system of the municipality. Data among 1678 Syrian refugees were collected on mental health outcomes using the Posttraumatic Stress Disorder (PTSD) Checklist (PCL-5) and the Hopkins Symptoms Checklist (HSCL-25) for depression and anxiety. We also collected data on health care utilisation, barriers to seeking and continuing care as well as knowledge and attitudes towards mental health. Descriptive analyses were used. RESULTS: The estimated prevalence of symptoms of PTSD, depression and anxiety was 19.6, 34.7 and 36.1%, respectively. In total, 249 respondents (15%) screened positive for either PTSD, depression or anxiety in our survey and self-reported emotional/behavioural problems since arriving in Sultanbeyli. The treatment gap (the proportion of these 249 people who did not seek care) was 89% for PTSD, 90% for anxiety and 88% for depression. Several structural and attitudinal barriers for not seeking care were reported, including the cost of mental health care, the belief that time would improve symptoms, fear of being stigmatised and lack of knowledge on where and how to get help. Some negative attitudes towards people with mental health problems were reported by respondents. CONCLUSIONS: Syrian refugees hardly access MHPSS services despite high mental health needs, and despite formally having access to the public mental health system in Turkey. To overcome the treatment gap, MHPSS programmes need to be implemented in the community and need to overcome the barriers to seeking care which were identified in this study. Mental health awareness raising activities should be provided in the community alongside the delivery of psychological interventions. This is to increase help-seeking and to tackle negative attitudes towards mental health and people with mental health problems

Malaria control under the Taliban regime: insecticide-treated net purchasing, coverage, and usage among men and women in eastern Afghanistan

BACKGROUND: Scaling up insecticide-treated mosquito net (ITN) coverage is a key malaria control strategy even in conflict-affected countries 12. Socio-economic factors influence access to ITNs whether subsidized or provided free to users. This study examines reported ITN purchasing, coverage, and usage in eastern Afghanistan and explores women's access to health information during the Taliban regime (1996-2001). This strengthens the knowledge base on household-level health choices in complex-emergency settings. METHODS: Fifteen focus group discussions (FGDs) and thirty in-depth interviews were conducted with men and women from ITN-owning and non-owning households. FGDs included rank ordering, pile sorting and focused discussion of malaria knowledge and ITN purchasing. Interviews explored general health issues, prevention and treatment practices, and women's malaria knowledge and concerns. Seven key informant interviews with health-related workers and a concurrent survey of 200 ITN-owning and 214 non-owning households were used to clarify or quantify findings. RESULTS: Malaria knowledge was similar among men and women and ITN owners and non-owners. Women reported obtaining health information through a variety of sources including clinic staff, their husbands who had easier access to information, and particularly female peers. Most participants considered ITNs very desirable, though not usually household necessities. ITN owners reported more household assets than non-owners. Male ITN owners and non-owners ranked rugs and ITNs as most desired, while women ranked personal assets such as jewellery highest. While men were primarily responsible for household decision-making and purchasing, older women exerted considerable influence. Widow-led and landless households reported most difficulties purchasing ITNs. Most participants wanted to buy ITNs only if they could cover all household members. When not possible, preferential usage was given to women and children. CONCLUSIONS: Despite restricted access to health facilities and formal education, Afghan women were surprisingly knowledgeable about the causes of malaria and the value of ITNs in prevention. Inequities in ITN usage were noted between rather than within households, with some unable to afford even one ITN and others not wanting ITNs unless all household members could be protected. Malaria knowledge thus appears a lesser barrier to ITN purchasing and coverage in eastern Afghanistan than are pricing and distribution strategies

Health Impacts of Catastrophic Climate Change: Expert Workshop. Avoid Dangerous Climate Change (AVOID)

Climate change is likely to have serious and significant impacts on human population health. The mechanisms by which climate change may affect health are becoming better understood. Current quantitative methods of estimating future health impacts rely on disease-specific models that primarily describe relationships between mean values of weather variables and health outcomes and do not address the impacts of extreme events or weather disasters. Extreme events have the potential to disrupt community function, which is of concern for decision-makers. Estimating the magnitude and extent of impacts from low probability high impact events is challenging because there is often no analogue that can provide relevant evidence and that take into account the complexity of factors determining future vulnerability and health impacts (the social determinants of health)