BACKGROUND
Sexual violence is widespread in the eastern parts of the Democratic Republic of the Congo, including in the North Kivu province. Moreover, in this region survivors of sexual violence often have limited access to care and encounter a variety of barriers when seeking care and support. The aim of this study was to explore community perceptions about access to care, barriers, enablers and possible actions to improve access to care for survivors of sexual violence in North Kivu. A deeper understanding of community perceptions about access to care can guide ongoing efforts to overcome barriers and increase access to care for survivors of sexual violence.
METHODS
The study utilised a qualitative design, based on focus group discussions with male and female adult community members in the study area. Previous experience of sexual violence was not a requirement. The transcripts from the discussions were analysed using manifest and latent qualitative content analysis.
RESULTS
A total of 18 focus group discussions were carried out. The analysis resulted in three main themes; Knowledge and misconceptions around medical consequences crucial for care seeking, Community and family attitudes playing a dual role in care seeking behaviours and Care seeking dependent on optimised healthcare facilities and sensitive staff.
CONCLUSIONS
Lack of correct knowledge, harmful attitudes from community and healthcare staff, and poorly adapted healthcare services constitute barriers to accessing care. Improved awareness raising around sexual violence is needed to address both lack of knowledge and misconceptions. Efforts should be made to build upon the community support models and actively work to improve community attitudes towards survivors of sexual violence. In addition, there is a need for better adapted healthcare services with improved proximity, access for different groups of survivors and respectful and well-trained healthcare staff.
BACKGROUND
Access to safe abortion care (SAC) should be improved in fragile and humanitarian settings, and the implementation of interventions in that regard are currently limited. This is especially true for self-managed abortion (SMA), although it holds the potential of revolutionizing the prevention of maternal death and suffering.
CASE PRESENTATION
The medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) piloted a self-managed abortion model of care in the Middle East. 22 women were remotely supported in managing their safe abortions with a counsellor over the phone, using misoprostol doses that they took at home after having taken mifepristone in our health facility. We share our experience by describing the model of care and discussing the lessons learned through its implementation.
CONCLUSIONS
The program delivered abortion services successfully and required few resources. This paper also reflects on the importance of facilitating SMA in humanitarian contexts. It increases access to care by providing increased confidentiality, close support, ample information, autonomy, and flexibility. It is simple to implement, effective, often preferred by women, and can be linked to information about contraception. The implementation of self-managed models should be expanded, notably in projects that do not have a sexual and reproductive health focus and in restrictive and challenging contexts. It represents a true revolution for access to safe abortion care.
BACKGROUND
Humanitarian crises bring unique, and potentially growing challenges to people with type 1 diabetes (T1D). We aimed to determine, in youth with T1D (mean age (± 1SD) 0–17.9 years) within and coming from humanitarian crises settings (HCS), the reported prevalence that meet international consensus targets for glycaemic, blood pressure and lipid management, and incidence of severe hypoglycaemia or diabetic ketoacidosis.
METHODS
A narrative review of quantitative data was conducted, using a systematic process. MEDLINE (Ovid), Global Health, Web of Science, Scopus, Embase, CINAHL, APA PsycINFO, Cochrane trials, and the reference lists of eligible records were searched (January 2014-February 2024); ten records covering ten separate studies were retrieved.
RESULTS
Glycaemic management was consistently suboptimal in HCS. However, among individuals coming from HCS, glycaemia varied. Across both groups, data relating to blood pressure, lipids, severe hypoglycaemia or diabetic ketoacidosis were either unavailable or limited.
CONCLUSION
Findings expose the dearth of data relating to defined youth with T1D within and coming from HCS, leaving the status of this population largely uncharacterised. With limited data indicating suboptimal T1D management, there is a pressing need for the development of a consensus guideline on, and core indicators relating to such youth within and coming from HCS, plus monitoring systems and outcome data.
BACKGROUND
Conflict-related sexual violence (CRSV) is a significant health and human rights issue in humanitarian contexts, but there is a need of further research on differences between sexes in terms of severity of symptoms and improvement. Consequently, we explored the differences in severity and outcomes among male and female survivors of CRSV who received mental health and psychosocial support (MHPSS) in an armed conflict setting.
METHODS
We retrospectively analysed medical records from 3442 CRSV survivors in a MHPSS programme in Borno State, Nigeria, between 2018 and 2019. Patient characteristics, severity (measured with Clinical Global Impression of Severity Scale [CGI-S scale]), and improvement (measured with Clinical Global Impression of improvement [CGI-I] scale) were assessed by an attending counsellor. We assessed predictors for severity and improvement using a multivariable logistic regression analysis and time to improvement by sex using Kaplan Meier (K-M) curves and Cox regression.
RESULTS
We included 3442 patients who had at least one CRSV event in this study (2955 [85.9%] female, 486 [14.1%] male, one unknown). The most prevalent categories of symptoms were depression (49.9%; n = 1716), post-traumatic (25.6%; n = 879), and anxiety (20.3%; n = 697) symptoms. Most patients had mild (59.0%; n = 1869/3170) or moderate (36.4%; n = 1153/3170) symptoms at baseline, with 4.7% having severe symptoms (n = 148/3170). The logistic regression analysis (n = 1106), showed male patients had a 59% higher odds of severe symptoms at baseline than female patients (aOR 1.59; 95% CI 1.04-2.45). Among males, those older than 55 years had three times higher odds of presenting severe symptoms than younger patients (aOR 3.65; 95% CI 1.43-9.34). Women aged 36-55 years were more likely to present improvement than younger female patients (aOR 1.32; 95% CI 1.11-1.58). For both sexes, prompt attention after a CRSV event (≤ 3 days) positively predicted improvement (aOR 13.9; 95% CI 1.48-130 males, aOR 2.11; 95% CI 1.22-3.64 females) compared to late attention. Time to improvement did not differ between sexes, with an average of at least three consultations needed to achieve improvement.
CONCLUSIONS
Our study suggests that psychological attention of survivors within the first 72 h should be a priority. MHPSS programmes addressing CRSV should be inclusive to all patients, and gender-neutral approaches to ensure access, safety, confidentiality, and non-discrimination for all survivors should be developed.
Limb salvage by ortho-plastic teams is the standard protocol for treating open tibial fractures in high-income countries, but there’s limited research on this in conflict settings like the Gaza Strip. This study assessed the clinical impact of gunshot-related open tibial fractures, compared patient management by orthopedic and ortho-plastic teams, and identified the risk factors for bone non-union in this context.
METHODS
A retrospective review of medical records was conducted on Gaza Strip patients with gunshot-induced-open tibial fractures from March 2018 to October 2020. Data included patient demographics, treatments, and outcomes, with at least one year of follow-up. Primary outcomes were union, non-union, infection, and amputation.
RESULTS
The study included 244 injured individuals, predominantly young adult males (99.2%) with nearly half (48.9%) having Gustilo-Anderson type IIIB fractures and more than half (66.8%) with over 1 cm of bone loss. Most patients required surgery, including rotational flaps and bone grafts with a median of 3 admissions and 9 surgeries. Ortho-plastic teams managed more severe muscle and skin injuries, cases with bone loss > 1 cm, and performed less debridement compared to other groups, though these differences were not statistically significant. Non-union occurred in 53% of the cases, with the ortho-plastic team having the highest rate at 63.6%. Infection rates were high (92.5%), but no significant differences in bone or infection outcomes were observed among the different groups. Logistic regression analysis identified bone loss > 1 cm, vascular injury, and the use of a definitive fixator at the first application as predictors of non-union.
CONCLUSIONS
This study highlights the severity and complexity of such injuries, emphasizing their significant impact on patients and the healthcare system. Ortho-plastic teams appeared to play a crucial role in managing severe cases. However, further research is still needed to enhance our understanding of how to effectively manage these injuries.
This study evaluated an early warning, alert and response system for a crisis-affected population in Doolo zone, Somali Region, Ethiopia, in 2019–2021, with a history of epidemics of outbreak-prone diseases. To adequately cover an area populated by a semi-nomadic pastoralist, or livestock herding, population with sparse access to healthcare facilities, the surveillance system included four components: health facility indicator-based surveillance, community indicator- and event-based surveillance, and alerts from other actors in the area. This evaluation described the usefulness, acceptability, completeness, timeliness, positive predictive value, and representativeness of these components.
METHODS
We carried out a mixed-methods study retrospectively analysing data from the surveillance system February 2019–January 2021 along with key informant interviews with system implementers, and focus group discussions with local communities. Transcripts were analyzed using a mixed deductive and inductive approach. Surveillance quality indicators assessed included completeness, timeliness, and positive predictive value, among others.
RESULTS
1010 signals were analysed; these resulted in 168 verified events, 58 alerts, and 29 responses. Most of the alerts (46/58) and responses (22/29) were initiated through the community event-based branch of the surveillance system. In comparison, one alert and one response was initiated via the community indicator-based branch. Positive predictive value of signals received was about 6%. About 80% of signals were verified within 24 h of reports, and 40% were risk assessed within 48 h. System responses included new mobile clinic sites, measles vaccination catch-ups, and water and sanitation-related interventions. Focus group discussions emphasized that responses generated were an expected return by participant communities for their role in data collection and reporting. Participant communities found the system acceptable when it led to the responses they expected. Some event types, such as those around animal health, led to the community’s response expectations not being met.
CONCLUSIONS
Event-based surveillance can produce useful data for localized public health action for pastoralist populations. Improvements could include greater community involvement in the system design and potentially incorporating One Health approaches.
There has been little documentation of the large networks of community health workers that contributed to Ebola Virus Disease (EVD) surveillance during the 2018–2020 Democratic Republic of Congo (DRC) epidemic in the form of community-based surveillance (CBS). These networks, comprised entirely of local community members, were a critical and mostly unrecognized factor in ending the epidemic. Challenges with collection, compilation, and analysis of CBS data have made their contribution difficult to quantify. From November 2019 to March 2020, the DRC Ministry of Health (MoH), the World Health Organization (WHO), and Médecins Sans Frontières (MSF) worked with communities to strengthen existing EVD CBS in two key health areas in Ituri Province, DRC. We describe CBS strengthening activities, detail collaboration with communities and present results of these efforts. We also provide lessons learned to inform future outbreak responses.
METHODS
As the foundation of CBS, community health workers (CHW) completed training to identify and report patients who met the EVD alert definitions. Alerts were investigated and if validated, the patient was sent for isolation and EVD testing. Community members provided early and ongoing input to the CBS system. We established a predefined ratio of community- elected CHW, allocated by population, to assure equal and adequate coverage across areas. Strong performing CHW or local leaders managed the CHWs, providing a robust supervision structure. We made additional efforts to integrate rural villages, revised tools to lighten the reporting burden and focused analysis on key indicators. Phased roll-out of activities ensured time for community discussion and approval. An integrated treatment center (ITC) combined EVD testing and isolation with free primary health care (PHC), referral services, and an ambulance network.
RESULTS
A total of 247 CHW and supervisors completed training. CBS had a retention rate of 94.3% (n?=?233) with an average daily reporting rate of 97.4% (range 75.0-100.0%). Local chiefs and community leaders participated in activities from the early stages. Community feedback, including recommendations to add additional CHW, run separate meetings in rural villages, and strengthen PHC services, improved system coverage and performance. Of 6,711 community referrals made, 98.1% (n?=?6,583) were classified as alerts. Of the alerts, 97.4% (n?=?6,410) were investigated and 3.0% (n?=?190) were validated. Of the community referrals, 73.1% (n?=?4,905) arrived for care at the ITC. The contribution of CBS to total alerts in the surveillance system increased from an average of 47.3% in the four weeks prior to system strengthening to 69.0% after. In one of the two health areas, insufficient reporting in rural villages suggested inadequate coverage, with 8.3% of the total population contributing 6.1% of alerts.
DISCUSSION
CBS demonstrated the capacity of community networks to improve early disease detection and expand access to healthcare. Early and consistent community involvement proved vital to CBS, as measured by system performance, local acceptance of EVD activities, and health service provision. The CBS system had high reporting rates, number of alerts signaled, proportion of alerts investigated, and proportion of community referrals that arrived for care. The change in contribution of CBS to total alerts may have been due in part to system strengthening, but also to the expansion in the EVD suspect case definition. Provision of PHC, referral services, and an ambulance network linked EVD response activities to the existing health system and facilitated CBS performance. More importantly, these activities provided a continuum of care that addressed community prioritized health needs. The involvement of local health promotion teams was vital to the CBS and other EVD and PHC activities. Lessons learned include the importance of early and consistent community involvement in surveillance activities and the recommendation to assure local representation in leadership positions.
In the Central African Republic (CAR), HIV/AIDS is the main cause of death in women aged 15–49 years. Increased testing coverage is essential in prevention of HIV/AIDS, especially in areas where conflict hinders access to health care. Socio-economic status (SES) has been shown to be associated with HIV testing uptake. We investigated whether “Provider-initiated HIV testing and counselling” (PITC) could be implemented in a family planning clinic in an active conflict zone in the Central African Republic to reach women of reproductive age and assessed whether socioeconomic status was associated with testing uptake.
METHODS
Women aged 15–49 years were recruited from a free family planning clinic run by Médecins Sans Frontières in the capital Bangui. An asset-based measurement tool was created based on analysis of qualitative in-depth interviews. Measures of socioeconomic status were constructed from the tool, also by using factor analysis. Logistic regression was used to quantify the association between SES and HIV testing uptake (yes/no), while controlling for potential confounders: age, marital status, number of children, education level and head of household.
RESULTS
A total of 1419 women were recruited during the study period, where 87.7% consented to HIV testing, and 95.5% consented to contraception use. A total of 11.9% had never been tested for HIV previously. Factors negatively associated with HIV testing uptake were: being married (OR = 0.4, 95% CI 0.3–0.5); living in a household headed by the husband as opposed to by another person (OR = 0.4, 95% CI 0.3–0.6), and lower age (OR = 0.96, 95% CI 0.93–0.99). Higher level of education (OR = 1.0, 95% CI 0.97–1.1) and having more children aged under 15 (OR = 0.92, 95% CI 0.81–1.1) was not associated with testing uptake. In multivariable regression, testing uptake was lower in the higher SES groups, but the differences were not significant (OR = 0.80, 95% CI 0.55–1.18).
CONCLUSIONS
The findings show that PITC can be successfully implemented in the patient flow in a family planning clinic, without compromising contraception uptake. Within the PITC framework in a conflict setting, socioeconomic status was not found to be associated with testing uptake in women of reproductive age.