Refugees and internally displaced persons are highly vulnerable to sexual violence during conflic... more Refugees and internally displaced persons are highly vulnerable to sexual violence during conflict and subsequent displacement. However, accurate estimates of the prevalence of sexual violence among in these populations remain uncertain. Our objective was to estimate the prevalence of sexual violence among refugees and displaced persons in complex humanitarian emergencies. We conducted systematic review of relevant literature in multiple databases (EMBASE, CINAHL, and MEDLINE) through February 2013 to identify studies. We also reviewed reference lists of included articles to identify any missing sources. Inclusion criteria required identification of sexual violence among refugees and internally displaced persons or those displaced by conflict in complex humanitarian settings. Studies were excluded if they did not provide female sexual violence prevalence, or that included only single case reports, anecdotes, and those that focused on displacement associated with natural disasters. A...
Background.Gender-based violence (GBV) is both a global public health problem and violation of hu... more Background.Gender-based violence (GBV) is both a global public health problem and violation of human rights. Refugees and internally displaced persons experience an increased risk of GBV and health outcomes associated with GBV are often exacerbated in conflict settings.Methods.A mixed methods study to examine the feasibility and acceptability of universal screening for GBV in a refugee population in the Dadaab refugee camp of Kenya, using the ASIST-GBV from January to July 2015.Results.Of 9366 women offered screening at International Rescue Committee health clinics, about 89% (n = 8369) female refugees consented to participate. Only 15% of the potentially eligible population could participate in GBV screening because of the ongoing struggle to identify private space in the clinics. Over 85% of women reported being ‘willing’ or ‘very willing’ to participate in GBV screening; 96% felt they had a good or very good experience with the screening protocol. Qualitative findings stressed th...
Problem In 2017, there were 25.4 million refugees worldwide, of whom 33,400 were resettled in the... more Problem In 2017, there were 25.4 million refugees worldwide, of whom 33,400 were resettled in the United States. In fiscal year 2016, 20,455 individuals were granted permanent asylum status in the United Sates. Both in the United States and overseas, refugees/asylees face significant disparities in accessing needed medical, mental health, and social support. Approach The Refugee Health Partnership (RHP) was developed by Johns Hopkins University School of Medicine students and colleagues at a local refugee resettlement agency in 2011. The program pairs teams of preclinical medical students with recently resettled refugees/asylees who have special health care needs. After receiving training, students conducted monthly home visits and accompanied patients to appointments to assist them in navigating the health care system over one year. Students participated in monthly reflection exercises to process experiences and attended monthly seminars facilitated by expert faculty and guests. Ou...
Objective Experts have proposed core curriculum components for international emergency medicine (... more Objective Experts have proposed core curriculum components for international emergency medicine (IEM) fellowships. This study examined perceptions of program directors (PDs) and fellows on whether IEM fellowships cover these components, whether their perspectives differ and the barriers preventing fellowships from covering them. Methods From 1 November 2011 to 30 November 2011, a survey was administered to PDs, current fellows and recent graduates of the 34 US IEM fellowships. Respondents quantified their fellowship experience in six proposed core curriculum areas: emergency medicine (EM) systems development, EM education, humanitarian assistance, public health, emergency medical services and disaster medicine. Analysis was performed regarding what per cent of programmes fulfil the six curriculum areas. A paired t test determined the difference between PDs’ and fellows’ responses. Agreement between PDs and fellows within the same programme was determined using a κ statistic. Results...
Over the past few decades there has been a steady growth in funding for global health, yet genera... more Over the past few decades there has been a steady growth in funding for global health, yet generally little is known about funding for global health research. As part of the 2013 Academic Emergency Medicine consensus conference, a session was convened to discuss emergency care research funding in the global health context. Overall, the authors found a lack of evidence available to determine funding priorities or quantify current funding for acute care research in global health. This article summarizes the initial preparatory research and reports on the results of the consensus conference focused on identifying challenges and strategies to improve funding for global emergency care research. The consensus conference meeting led to the creation of near- and long-term goals to strengthen global emergency care research funding and the development of important research questions. The research questions represent a consensus view of important outstanding questions that will assist emergency care researchers to better understand the current funding landscape and bring evidence to the debate on funding priorities of global health and emergency care. The four key areas of focus for researchers are: 1) quantifying funding for global health and emergency care research, 2) understanding current research funding priorities, 3) identifying barriers to emergency care research funding, and 4) using existing data to quantify the need for emergency services and acute care research. This research agenda will enable emergency health care scientists to use evidence when advocating for more funding for emergency care research.
(1) definition of indicators of the effectiveness of information sharing enabled by a technologic... more (1) definition of indicators of the effectiveness of information sharing enabled by a technological solution; (2) classification of the types of information to be shared during disaster response; (3) classification of mechanisms for information sharing (including traditional mechanisms); and (4) assessments of which methods are best suited to which types of information. Basic level, ICT-based information-sharing ensures that individual data items are delivered to everyone involved, but does not process the data into information. More advanced systems can collate information (e.g., produce reports indicating how many persons are suffering from a particular condition). With derived level information-sharing, the ICT system can perform possibly complex computations to calculate higher-level measures and indicators based on combinations of basic data items. This presentation will discuss how derived level information-sharing can be linked to the concept of indicators of function and basic societal functions (BSF), as defined in the Utstein Style. Conclusions: Information and communications technology-based systems have a key role in supporting effective coordination and control in disaster response. The framework presented here can act as a common reference for the design and assessment of such systems.
Introduction:In the aftermath of Hurricane Katrina, a significant number of faith-based organizat... more Introduction:In the aftermath of Hurricane Katrina, a significant number of faith-based organizations (FBOs) that were not a part of the formal National Response Plan (NRP) initiated and sustained sheltering operations.Objective:The objective of this study was to examine the sheltering opera-tions of FBOs, understand the decision-making process of FBO shelters, and identify the advantages and disadvantages of FBO shelters.Methods:Verbal interviews were conducted with FBO shelter leaders. Inclusion criteria were: (1) opening in response to the Katrina disaster; (2) oper-ating for more than three weeks; and (3) being a FBO. Enrolled shelters were examined using descriptive data methods.Results:The majority of shelters operating in Mississippi up to three weeks post-Katrina were FBO-managed. All of the operating FBO shelters in Mississippi that met the inclusion criteria were contacted with a response rate of 94%. Decisions were made by individuals or small groups in most shelters rega...
Background: Organizations working in conflict-affected areas have a need to monitor and evaluate ... more Background: Organizations working in conflict-affected areas have a need to monitor and evaluate their programs, however this is often difficult due to the logistical challenges of conflict areas. Lot quality assurance sampling may be a suitable method of assessing programs in these situations. Methods: We conducted a secondary data analysis of information collected during Medair's routine program management functions. Medair's service area in West Darfur, Sudan was divided into seven supervisory areas. Using the available population information, a sampling frame was developed and interviews were conducted from randomly selected caretakers of children in each supervisory area every six months over 19 months. A survey instrument with questions related to key indicators for immunizations and maternal, newborn, and child health was used for the interviews. Based on Medair's goals for each indicator, decision rules were calculated for the indicators; these decision rules determined which supervisory areas and indicators performed adequately in each assessment period. Pearson's chi-squared tests, adjusted for the survey design using STATA "svy: tab" commands, were used to detect overall differences in coverage in this analysis. Results: The coverage of tetanus toxoid vaccination among pregnant women increased from 47.2 to 69.7 % (p value = 0.046), and births attended by a skilled health professional increased from 35.7 to 52.7 % (p value = 0.025) from the first to last assessment periods. Measles vaccinations declined from 72.0 to 54.1 % (p value = 0.046). The estimated coverage for the proportion of women receiving a postpartum dose of vitamin A (54.7 to 61.3 %, p value = 0.44); pregnant women receiving a clean delivery kit (54.6 to 47.1 %, p value = 0.49); and pentavalent vaccinations (49.7 to 42.1 %, p value = 0.28) did not significantly change. Conclusions: Lot quality assurance sampling was a feasible method for Medair staff to evaluate and optimize primary health programs in a conflict-affected area. Medair managers were able to collect, analyze, and disseminate data to staff alongside the routine work of the organization. These results suggest LQAS may be used in other complex humanitarian emergencies in which there are logistical challenges and limited resources.
Refugees and internally displaced persons who are affected by armed-conflict are at increased vul... more Refugees and internally displaced persons who are affected by armed-conflict are at increased vulnerability to some forms of sexual violence or other types of gender-based violence. A validated, brief and easy-to-administer screening tool will help service providers identify GBV survivors and refer them to appropriate GBV services. To date, no such GBV screening tool exists. We developed the 7-item ASIST-GBV screening tool from qualitative research that included individual interviews and focus groups with GBV refugee and IDP survivors. This study presents the psychometric properties of the ASIST-GBV with female refugees living in Ethiopia and IDPs in Colombia. Several strategies were used to validate ASIST-GBV, including a 3 month implementation to validate the brief screening tool with women/girls seeking health services, aged ≥15 years in Ethiopia (N = 487) and female IDPs aged ≥ 18 years in Colombia (N = 511). High proportions of women screened positive for past-year GBV accordin...
Background: Kabul has over 12,000 people who inject drugs (PWID), most of them heroin users, and ... more Background: Kabul has over 12,000 people who inject drugs (PWID), most of them heroin users, and opioid substitution therapy has recently been introduced as an effective method to reduce opioid use. We aimed to evaluate a pilot Opioid Substitution Therapy Pilot Program (OSTPP) in Kabul, Afghanistan, particularly to (1) describe characteristics of the participants enrolled in the program and (2) identify factors associated with client retention in the OSTPP. Findings: Two cross-sectional surveys evaluated participants attending the OSTPP at baseline (n = 83) and 18 months after (n = 57). Questionnaires assessed socio-demographic, drug use behavior, and general and mental health factors. After 18 months, 57 participants remained in the OSTPP. Participants lost to follow-up were younger (p < 0.01) and married (p < 0.01) and had no family contact (p < 0.01). Participants at 18 months reported no criminal activity in the last month and only two (3.5 %) reported heroin use in the last month, constituting significant decreases from baseline. Conclusions: While preliminary results are promising, further evaluation is needed to determine the feasibility of implementing OSTPP in this setting and effectiveness in reducing injection risk behaviors in Afghanistan.
Gender-based violence (GBV) is prevalent among, though not specific to, conflict affected populat... more Gender-based violence (GBV) is prevalent among, though not specific to, conflict affected populations and related to multifarious levels of vulnerability of conflict and displacement. Colombia has been marked with decades of conflict, with an estimated 5.2 million internally displaced persons (IDPs) and ongoing violence. We conducted qualitative research to understand the contexts of conflict, displacement and dynamics with GBV. This as part of a multi-phase, mixed method study, in collaboration with UNHCR, to develop a screening tool to confidentially identify cases of GBV for referral among IDP women who were survivors of GBV. Qualitative research was used to identify the range of GBV, perpetrators, contexts in conflict and displacement, barriers to reporting and service uptake, as well as to understand experiences of service providers. Thirty-five female IDPs, aged 18 years and older, who self-identified as survivors of GBV were enrolled for in-depth interviews in San Jose de Gua...
Injecting drug use is the primary mode of HIV transmission and acquisition in Afghanistan. People... more Injecting drug use is the primary mode of HIV transmission and acquisition in Afghanistan. People who inject drugs (PWID) in the country have been characterized by high risk injecting behavior and a high burden of HCV infection. We aimed to estimate the burden of HIV, HCV, and other infectious diseases and to identify the correlates of HIV and HCV infection among PWID living in three major Afghan cities in 2009. Epidemiologic data was collected among PWID for the integrated biological and behavioral surveillance (IBBS) survey between May and August, 2009 in three Afghan cities. Data were collected using a structured questionnaire and biologic specimens to screen for HIV, HBV, HCV, syphilis, and HSV-2 using rapid testing kits. Multiple logistic regression models were constructed to identify correlates of infection. Among 548 participants, pooled HIV prevalence was 7.1% (Mazar-i-Sharif: 1.0%, Kabul: 3.1%, Herat: 18.4%) and HCV prevalence was 40.3%. Almost all participants with HIV inf...
Objective: It is in order to examine associations between social desirability (SD) and self-repor... more Objective: It is in order to examine associations between social desirability (SD) and self-reports of abstinence among youths in rural Ethiopia. Methods: Youths of ages 15-24 (114 participants) were administered questionnaire to assess HIV knowledge and primary abstinence and a modified Marlowe-Crowne Social Desirability Scale to assess SD bias. The relationships between SD groups (dichotomized into high and low) and abstinence by various characteristics were assessed by using Fisher's exact p-values. Results: The odds of individuals reporting abstinence were 13.2 times greater in the high SD group compared to the low SD group (p-value 0.002) when adjusted for education, gender, age group, and HIV knowledge. The differences in abstinence between the high and low SD score groups were also examined for selected variables. Conclusions: Individuals who exhibited more SD bias were more likely to report primary abstinence. SD bias should be considered when conducting self-reported surveys to measure the effectiveness of HIV prevention programs.
Background: Comparisons between refugees receiving health care in settlement-based facilities and... more Background: Comparisons between refugees receiving health care in settlement-based facilities and persons living in host communities have found that refugees have better health outcomes. However, data that compares utilization of health services between refugees and the host population, and across refugee settlements, countries and regions is limited. The paper will address this information gap. The analysis in this paper uses data from the United Nations High Commissioner of Refugees (UNHCR) Health Information System (HIS). Methods: Data about settlement populations and the use of outpatient health services were exported from the UNHCR health information system database. Tableau Desktop was used to explore the data. STATA was used for data cleaning and statistical analysis. Differences in various indicators of the use of health services by region, gender, age groups, and status (host national vs. refugee population) were analyzed for statistical significance using generalized estimating equation models that adjusted for correlated data within refugee settlements over time. Results: Eighty-one refugee settlements were included in this study and an average population of 1.53 million refugees was receiving outpatient health services between 2008 and 2009. The crude utilization rate among refugees is 2.2 visits per person per year across all settlements. The refugee utilization rate in Asia (3.5) was higher than in Africa on average (1.8). Among refugees, females have a statistically significant higher utilization rate than males (2.4 visits per person per year vs. 2.1). The proportion of new outpatient attributable to refugees is higher than that attributable to host nationals. In the Asian settlements, only 2% outpatient visits, on average, were attributable to host community members. By contrast, in Africa, the proportion of new outpatient (OPD) visits by host nationals was 21% on average; in many Ugandan settlements, the proportion of outpatient visits attributable to host community members was higher than that for refugees. There was no statistically significant difference between the size of the male and female populations across refugee settlements. Across all settlements reporting to the UNHCR database, the percent of the refugee population that was less than five years of age is 16% on average. Conclusions: The availability of a centralized database of health information across UNHCR-supported refugee settlements is a rich resource. The SPHERE standard for emergencies of 1-4 visits per person per year appears to be relevant for Asia in the post-emergency phase, but not for Africa. In Africa, a post-emergency standard of 1-2 visits per person per year should be considered. Although it is often assumed that the size of the female population in refugee settlements is higher than males, we found no statistically significant difference between the size of the male and female populations in refugee settlements overall. Another assumption-that the under-fives make up 20% of the settlement population during the emergency phase-does not appear to hold for the post-emergency phase; under-fives made up about 16% of refugee settlement populations.
Background High levels of gender-based violence (GBV) persist among conflict-affected populations... more Background High levels of gender-based violence (GBV) persist among conflict-affected populations and within humanitarian settings and are paralleled by under-reporting and low service utilization. Novel and evidence-based approaches are necessary to change the current state of GBV amongst these populations. We present the findings of qualitative research, which were used to inform the development of a screening tool as one potential strategy to identify and respond to GBV for females in humanitarian settings. Methods Qualitative research methods were conducted from January-February 2011 to explore the range of experiences of GBV and barriers to reporting GBV among female refugees. Individual interview participants (n=37) included female refugees (≥15 years), who were survivors of GBV, living in urban or one of three camps settings in Ethiopia, and originating from six conflict countries. Focus group discussion participants (11 groups; 77 participants) included health, protection an...
Background: Studies of HIV often use self-reported surveys to measure sexual knowledge, attitudes... more Background: Studies of HIV often use self-reported surveys to measure sexual knowledge, attitudes, and practices. However, the self-reported data are vulnerable to social desirability (SD), a propensity of individuals to report favorable responses. The Marlowe-Crowne Social Desirability Scale (MC-SDS) was developed as a measure of the effect of social desirability, but it has not been adapted for or used in Africa. This study aimed to apply the MC-SDS nested in an HIV behavioral intervention program and to measure its reliability in four African countries. Methods: The MC-SDS was adapted based on consultations with local stakeholders and pilot tested in Ethiopia, Kenya, Mozambique, and Uganda. Trained interviewers administered the modified 28-item MC-SDS survey to 455 men and women (ages 15-24 years). The scores for the social desirability scales were calculated for all participants. An analysis of the internal consistency of responses was conducted using the Cronbach's α coefficient. Acceptable internal consistency was defined as an α coefficient of ≥ 0.70. Results: Mean social desirability scores ranged from a low of 15.7 in Kenya to a high of 20.6 in Mozambique. The mean score was 17.5 for Uganda and 20.6 for Mozambique. The Cronbach's α coefficients were 0.63 in Kenya, 0.66 in Mozambique, 0.70 in Uganda, and 0.80 in Ethiopia. Conclusions: The MC-SDS can be effectively adapted and implemented in sub-Saharan Africa. The reliability of responses in these settings suggest that the MC-SDS could be a useful tool for capturing potential SD in surveys of HIV related risk behaviors.
Study objective: Anecdotal evidence suggests that the population displaced to shelters from Hurri... more Study objective: Anecdotal evidence suggests that the population displaced to shelters from Hurricane Katrina had a significant burden of disease, socioeconomic vulnerability, and marginalized health care access. For agencies charged with providing health care to at-risk displaced populations, knowing the prevalence of acute and chronic disease is critical to direct resources and prevent morbidity and mortality. Methods: We performed a 2-stage 18-cluster sample survey of 499 evacuees residing in American Red Cross shelters in Louisiana 2 weeks after landfall of Hurricane Katrina. In stage 1, shelters with a population of more than 100 individuals were randomly selected, with probability proportional to size sampling. In stage 2, 30 adult heads of household were randomly chosen within shelters by using a shelter log or a map of the shelter where no log existed. Survey questions focused on demographics, socioeconomic indicators, acute and chronic burden of disease, and health care access. Results: Two thirds of the sampled population was single, widowed, or divorced; the majority was female (57.6%) and black (76.4%). Socioeconomic indicators of under-and unemployment (52.9%), dependency on benefits or assistance (38.5%), lack of home ownership (66.2%), and lack of health insurance (47.0%) suggested vulnerability. One third lacked a health provider. Among those who arrived at shelters with a chronic disease (55.6%), 48.4% lacked medication. Hypertension, hypercholesterolemia, diabetes, pulmonary disease, and psychiatric illness were the most common chronic conditions. Risk factors for lacking medications included male sex (odds ratio [OR] 1.58; 95% confidence interval [CI] 0.96 to 2.59) and lacking health insurance (OR 2.25; 95% CI 1.21 to 4.20). More than one third (34.5%) arrived at the shelter with symptoms warranting immediate medical intervention, including dehydration (12.0%), dyspnea (11.5%), injury (9.4%), and chest pain (9.7%). Risk factors associated with presenting to shelters with acute symptoms included concurrent chronic disease with medication (OR 2.60; 95% CI 1.98 to 3.43), concurrent disease and lacking medication (OR 2.22; 95% CI 1.36 to 3.63), and lacking health insurance (OR 1.83; 95% CI 1.10 to 3.02). Conclusion: A population-based understanding of vulnerability, health access, and chronic and acute disease among the displaced will guide disaster health providers in preparation and response. [Ann Emerg Med.
Refugees and internally displaced persons are highly vulnerable to sexual violence during conflic... more Refugees and internally displaced persons are highly vulnerable to sexual violence during conflict and subsequent displacement. However, accurate estimates of the prevalence of sexual violence among in these populations remain uncertain. Our objective was to estimate the prevalence of sexual violence among refugees and displaced persons in complex humanitarian emergencies. We conducted systematic review of relevant literature in multiple databases (EMBASE, CINAHL, and MEDLINE) through February 2013 to identify studies. We also reviewed reference lists of included articles to identify any missing sources. Inclusion criteria required identification of sexual violence among refugees and internally displaced persons or those displaced by conflict in complex humanitarian settings. Studies were excluded if they did not provide female sexual violence prevalence, or that included only single case reports, anecdotes, and those that focused on displacement associated with natural disasters. A...
Background.Gender-based violence (GBV) is both a global public health problem and violation of hu... more Background.Gender-based violence (GBV) is both a global public health problem and violation of human rights. Refugees and internally displaced persons experience an increased risk of GBV and health outcomes associated with GBV are often exacerbated in conflict settings.Methods.A mixed methods study to examine the feasibility and acceptability of universal screening for GBV in a refugee population in the Dadaab refugee camp of Kenya, using the ASIST-GBV from January to July 2015.Results.Of 9366 women offered screening at International Rescue Committee health clinics, about 89% (n = 8369) female refugees consented to participate. Only 15% of the potentially eligible population could participate in GBV screening because of the ongoing struggle to identify private space in the clinics. Over 85% of women reported being ‘willing’ or ‘very willing’ to participate in GBV screening; 96% felt they had a good or very good experience with the screening protocol. Qualitative findings stressed th...
Problem In 2017, there were 25.4 million refugees worldwide, of whom 33,400 were resettled in the... more Problem In 2017, there were 25.4 million refugees worldwide, of whom 33,400 were resettled in the United States. In fiscal year 2016, 20,455 individuals were granted permanent asylum status in the United Sates. Both in the United States and overseas, refugees/asylees face significant disparities in accessing needed medical, mental health, and social support. Approach The Refugee Health Partnership (RHP) was developed by Johns Hopkins University School of Medicine students and colleagues at a local refugee resettlement agency in 2011. The program pairs teams of preclinical medical students with recently resettled refugees/asylees who have special health care needs. After receiving training, students conducted monthly home visits and accompanied patients to appointments to assist them in navigating the health care system over one year. Students participated in monthly reflection exercises to process experiences and attended monthly seminars facilitated by expert faculty and guests. Ou...
Objective Experts have proposed core curriculum components for international emergency medicine (... more Objective Experts have proposed core curriculum components for international emergency medicine (IEM) fellowships. This study examined perceptions of program directors (PDs) and fellows on whether IEM fellowships cover these components, whether their perspectives differ and the barriers preventing fellowships from covering them. Methods From 1 November 2011 to 30 November 2011, a survey was administered to PDs, current fellows and recent graduates of the 34 US IEM fellowships. Respondents quantified their fellowship experience in six proposed core curriculum areas: emergency medicine (EM) systems development, EM education, humanitarian assistance, public health, emergency medical services and disaster medicine. Analysis was performed regarding what per cent of programmes fulfil the six curriculum areas. A paired t test determined the difference between PDs’ and fellows’ responses. Agreement between PDs and fellows within the same programme was determined using a κ statistic. Results...
Over the past few decades there has been a steady growth in funding for global health, yet genera... more Over the past few decades there has been a steady growth in funding for global health, yet generally little is known about funding for global health research. As part of the 2013 Academic Emergency Medicine consensus conference, a session was convened to discuss emergency care research funding in the global health context. Overall, the authors found a lack of evidence available to determine funding priorities or quantify current funding for acute care research in global health. This article summarizes the initial preparatory research and reports on the results of the consensus conference focused on identifying challenges and strategies to improve funding for global emergency care research. The consensus conference meeting led to the creation of near- and long-term goals to strengthen global emergency care research funding and the development of important research questions. The research questions represent a consensus view of important outstanding questions that will assist emergency care researchers to better understand the current funding landscape and bring evidence to the debate on funding priorities of global health and emergency care. The four key areas of focus for researchers are: 1) quantifying funding for global health and emergency care research, 2) understanding current research funding priorities, 3) identifying barriers to emergency care research funding, and 4) using existing data to quantify the need for emergency services and acute care research. This research agenda will enable emergency health care scientists to use evidence when advocating for more funding for emergency care research.
(1) definition of indicators of the effectiveness of information sharing enabled by a technologic... more (1) definition of indicators of the effectiveness of information sharing enabled by a technological solution; (2) classification of the types of information to be shared during disaster response; (3) classification of mechanisms for information sharing (including traditional mechanisms); and (4) assessments of which methods are best suited to which types of information. Basic level, ICT-based information-sharing ensures that individual data items are delivered to everyone involved, but does not process the data into information. More advanced systems can collate information (e.g., produce reports indicating how many persons are suffering from a particular condition). With derived level information-sharing, the ICT system can perform possibly complex computations to calculate higher-level measures and indicators based on combinations of basic data items. This presentation will discuss how derived level information-sharing can be linked to the concept of indicators of function and basic societal functions (BSF), as defined in the Utstein Style. Conclusions: Information and communications technology-based systems have a key role in supporting effective coordination and control in disaster response. The framework presented here can act as a common reference for the design and assessment of such systems.
Introduction:In the aftermath of Hurricane Katrina, a significant number of faith-based organizat... more Introduction:In the aftermath of Hurricane Katrina, a significant number of faith-based organizations (FBOs) that were not a part of the formal National Response Plan (NRP) initiated and sustained sheltering operations.Objective:The objective of this study was to examine the sheltering opera-tions of FBOs, understand the decision-making process of FBO shelters, and identify the advantages and disadvantages of FBO shelters.Methods:Verbal interviews were conducted with FBO shelter leaders. Inclusion criteria were: (1) opening in response to the Katrina disaster; (2) oper-ating for more than three weeks; and (3) being a FBO. Enrolled shelters were examined using descriptive data methods.Results:The majority of shelters operating in Mississippi up to three weeks post-Katrina were FBO-managed. All of the operating FBO shelters in Mississippi that met the inclusion criteria were contacted with a response rate of 94%. Decisions were made by individuals or small groups in most shelters rega...
Background: Organizations working in conflict-affected areas have a need to monitor and evaluate ... more Background: Organizations working in conflict-affected areas have a need to monitor and evaluate their programs, however this is often difficult due to the logistical challenges of conflict areas. Lot quality assurance sampling may be a suitable method of assessing programs in these situations. Methods: We conducted a secondary data analysis of information collected during Medair's routine program management functions. Medair's service area in West Darfur, Sudan was divided into seven supervisory areas. Using the available population information, a sampling frame was developed and interviews were conducted from randomly selected caretakers of children in each supervisory area every six months over 19 months. A survey instrument with questions related to key indicators for immunizations and maternal, newborn, and child health was used for the interviews. Based on Medair's goals for each indicator, decision rules were calculated for the indicators; these decision rules determined which supervisory areas and indicators performed adequately in each assessment period. Pearson's chi-squared tests, adjusted for the survey design using STATA "svy: tab" commands, were used to detect overall differences in coverage in this analysis. Results: The coverage of tetanus toxoid vaccination among pregnant women increased from 47.2 to 69.7 % (p value = 0.046), and births attended by a skilled health professional increased from 35.7 to 52.7 % (p value = 0.025) from the first to last assessment periods. Measles vaccinations declined from 72.0 to 54.1 % (p value = 0.046). The estimated coverage for the proportion of women receiving a postpartum dose of vitamin A (54.7 to 61.3 %, p value = 0.44); pregnant women receiving a clean delivery kit (54.6 to 47.1 %, p value = 0.49); and pentavalent vaccinations (49.7 to 42.1 %, p value = 0.28) did not significantly change. Conclusions: Lot quality assurance sampling was a feasible method for Medair staff to evaluate and optimize primary health programs in a conflict-affected area. Medair managers were able to collect, analyze, and disseminate data to staff alongside the routine work of the organization. These results suggest LQAS may be used in other complex humanitarian emergencies in which there are logistical challenges and limited resources.
Refugees and internally displaced persons who are affected by armed-conflict are at increased vul... more Refugees and internally displaced persons who are affected by armed-conflict are at increased vulnerability to some forms of sexual violence or other types of gender-based violence. A validated, brief and easy-to-administer screening tool will help service providers identify GBV survivors and refer them to appropriate GBV services. To date, no such GBV screening tool exists. We developed the 7-item ASIST-GBV screening tool from qualitative research that included individual interviews and focus groups with GBV refugee and IDP survivors. This study presents the psychometric properties of the ASIST-GBV with female refugees living in Ethiopia and IDPs in Colombia. Several strategies were used to validate ASIST-GBV, including a 3 month implementation to validate the brief screening tool with women/girls seeking health services, aged ≥15 years in Ethiopia (N = 487) and female IDPs aged ≥ 18 years in Colombia (N = 511). High proportions of women screened positive for past-year GBV accordin...
Background: Kabul has over 12,000 people who inject drugs (PWID), most of them heroin users, and ... more Background: Kabul has over 12,000 people who inject drugs (PWID), most of them heroin users, and opioid substitution therapy has recently been introduced as an effective method to reduce opioid use. We aimed to evaluate a pilot Opioid Substitution Therapy Pilot Program (OSTPP) in Kabul, Afghanistan, particularly to (1) describe characteristics of the participants enrolled in the program and (2) identify factors associated with client retention in the OSTPP. Findings: Two cross-sectional surveys evaluated participants attending the OSTPP at baseline (n = 83) and 18 months after (n = 57). Questionnaires assessed socio-demographic, drug use behavior, and general and mental health factors. After 18 months, 57 participants remained in the OSTPP. Participants lost to follow-up were younger (p < 0.01) and married (p < 0.01) and had no family contact (p < 0.01). Participants at 18 months reported no criminal activity in the last month and only two (3.5 %) reported heroin use in the last month, constituting significant decreases from baseline. Conclusions: While preliminary results are promising, further evaluation is needed to determine the feasibility of implementing OSTPP in this setting and effectiveness in reducing injection risk behaviors in Afghanistan.
Gender-based violence (GBV) is prevalent among, though not specific to, conflict affected populat... more Gender-based violence (GBV) is prevalent among, though not specific to, conflict affected populations and related to multifarious levels of vulnerability of conflict and displacement. Colombia has been marked with decades of conflict, with an estimated 5.2 million internally displaced persons (IDPs) and ongoing violence. We conducted qualitative research to understand the contexts of conflict, displacement and dynamics with GBV. This as part of a multi-phase, mixed method study, in collaboration with UNHCR, to develop a screening tool to confidentially identify cases of GBV for referral among IDP women who were survivors of GBV. Qualitative research was used to identify the range of GBV, perpetrators, contexts in conflict and displacement, barriers to reporting and service uptake, as well as to understand experiences of service providers. Thirty-five female IDPs, aged 18 years and older, who self-identified as survivors of GBV were enrolled for in-depth interviews in San Jose de Gua...
Injecting drug use is the primary mode of HIV transmission and acquisition in Afghanistan. People... more Injecting drug use is the primary mode of HIV transmission and acquisition in Afghanistan. People who inject drugs (PWID) in the country have been characterized by high risk injecting behavior and a high burden of HCV infection. We aimed to estimate the burden of HIV, HCV, and other infectious diseases and to identify the correlates of HIV and HCV infection among PWID living in three major Afghan cities in 2009. Epidemiologic data was collected among PWID for the integrated biological and behavioral surveillance (IBBS) survey between May and August, 2009 in three Afghan cities. Data were collected using a structured questionnaire and biologic specimens to screen for HIV, HBV, HCV, syphilis, and HSV-2 using rapid testing kits. Multiple logistic regression models were constructed to identify correlates of infection. Among 548 participants, pooled HIV prevalence was 7.1% (Mazar-i-Sharif: 1.0%, Kabul: 3.1%, Herat: 18.4%) and HCV prevalence was 40.3%. Almost all participants with HIV inf...
Objective: It is in order to examine associations between social desirability (SD) and self-repor... more Objective: It is in order to examine associations between social desirability (SD) and self-reports of abstinence among youths in rural Ethiopia. Methods: Youths of ages 15-24 (114 participants) were administered questionnaire to assess HIV knowledge and primary abstinence and a modified Marlowe-Crowne Social Desirability Scale to assess SD bias. The relationships between SD groups (dichotomized into high and low) and abstinence by various characteristics were assessed by using Fisher's exact p-values. Results: The odds of individuals reporting abstinence were 13.2 times greater in the high SD group compared to the low SD group (p-value 0.002) when adjusted for education, gender, age group, and HIV knowledge. The differences in abstinence between the high and low SD score groups were also examined for selected variables. Conclusions: Individuals who exhibited more SD bias were more likely to report primary abstinence. SD bias should be considered when conducting self-reported surveys to measure the effectiveness of HIV prevention programs.
Background: Comparisons between refugees receiving health care in settlement-based facilities and... more Background: Comparisons between refugees receiving health care in settlement-based facilities and persons living in host communities have found that refugees have better health outcomes. However, data that compares utilization of health services between refugees and the host population, and across refugee settlements, countries and regions is limited. The paper will address this information gap. The analysis in this paper uses data from the United Nations High Commissioner of Refugees (UNHCR) Health Information System (HIS). Methods: Data about settlement populations and the use of outpatient health services were exported from the UNHCR health information system database. Tableau Desktop was used to explore the data. STATA was used for data cleaning and statistical analysis. Differences in various indicators of the use of health services by region, gender, age groups, and status (host national vs. refugee population) were analyzed for statistical significance using generalized estimating equation models that adjusted for correlated data within refugee settlements over time. Results: Eighty-one refugee settlements were included in this study and an average population of 1.53 million refugees was receiving outpatient health services between 2008 and 2009. The crude utilization rate among refugees is 2.2 visits per person per year across all settlements. The refugee utilization rate in Asia (3.5) was higher than in Africa on average (1.8). Among refugees, females have a statistically significant higher utilization rate than males (2.4 visits per person per year vs. 2.1). The proportion of new outpatient attributable to refugees is higher than that attributable to host nationals. In the Asian settlements, only 2% outpatient visits, on average, were attributable to host community members. By contrast, in Africa, the proportion of new outpatient (OPD) visits by host nationals was 21% on average; in many Ugandan settlements, the proportion of outpatient visits attributable to host community members was higher than that for refugees. There was no statistically significant difference between the size of the male and female populations across refugee settlements. Across all settlements reporting to the UNHCR database, the percent of the refugee population that was less than five years of age is 16% on average. Conclusions: The availability of a centralized database of health information across UNHCR-supported refugee settlements is a rich resource. The SPHERE standard for emergencies of 1-4 visits per person per year appears to be relevant for Asia in the post-emergency phase, but not for Africa. In Africa, a post-emergency standard of 1-2 visits per person per year should be considered. Although it is often assumed that the size of the female population in refugee settlements is higher than males, we found no statistically significant difference between the size of the male and female populations in refugee settlements overall. Another assumption-that the under-fives make up 20% of the settlement population during the emergency phase-does not appear to hold for the post-emergency phase; under-fives made up about 16% of refugee settlement populations.
Background High levels of gender-based violence (GBV) persist among conflict-affected populations... more Background High levels of gender-based violence (GBV) persist among conflict-affected populations and within humanitarian settings and are paralleled by under-reporting and low service utilization. Novel and evidence-based approaches are necessary to change the current state of GBV amongst these populations. We present the findings of qualitative research, which were used to inform the development of a screening tool as one potential strategy to identify and respond to GBV for females in humanitarian settings. Methods Qualitative research methods were conducted from January-February 2011 to explore the range of experiences of GBV and barriers to reporting GBV among female refugees. Individual interview participants (n=37) included female refugees (≥15 years), who were survivors of GBV, living in urban or one of three camps settings in Ethiopia, and originating from six conflict countries. Focus group discussion participants (11 groups; 77 participants) included health, protection an...
Background: Studies of HIV often use self-reported surveys to measure sexual knowledge, attitudes... more Background: Studies of HIV often use self-reported surveys to measure sexual knowledge, attitudes, and practices. However, the self-reported data are vulnerable to social desirability (SD), a propensity of individuals to report favorable responses. The Marlowe-Crowne Social Desirability Scale (MC-SDS) was developed as a measure of the effect of social desirability, but it has not been adapted for or used in Africa. This study aimed to apply the MC-SDS nested in an HIV behavioral intervention program and to measure its reliability in four African countries. Methods: The MC-SDS was adapted based on consultations with local stakeholders and pilot tested in Ethiopia, Kenya, Mozambique, and Uganda. Trained interviewers administered the modified 28-item MC-SDS survey to 455 men and women (ages 15-24 years). The scores for the social desirability scales were calculated for all participants. An analysis of the internal consistency of responses was conducted using the Cronbach's α coefficient. Acceptable internal consistency was defined as an α coefficient of ≥ 0.70. Results: Mean social desirability scores ranged from a low of 15.7 in Kenya to a high of 20.6 in Mozambique. The mean score was 17.5 for Uganda and 20.6 for Mozambique. The Cronbach's α coefficients were 0.63 in Kenya, 0.66 in Mozambique, 0.70 in Uganda, and 0.80 in Ethiopia. Conclusions: The MC-SDS can be effectively adapted and implemented in sub-Saharan Africa. The reliability of responses in these settings suggest that the MC-SDS could be a useful tool for capturing potential SD in surveys of HIV related risk behaviors.
Study objective: Anecdotal evidence suggests that the population displaced to shelters from Hurri... more Study objective: Anecdotal evidence suggests that the population displaced to shelters from Hurricane Katrina had a significant burden of disease, socioeconomic vulnerability, and marginalized health care access. For agencies charged with providing health care to at-risk displaced populations, knowing the prevalence of acute and chronic disease is critical to direct resources and prevent morbidity and mortality. Methods: We performed a 2-stage 18-cluster sample survey of 499 evacuees residing in American Red Cross shelters in Louisiana 2 weeks after landfall of Hurricane Katrina. In stage 1, shelters with a population of more than 100 individuals were randomly selected, with probability proportional to size sampling. In stage 2, 30 adult heads of household were randomly chosen within shelters by using a shelter log or a map of the shelter where no log existed. Survey questions focused on demographics, socioeconomic indicators, acute and chronic burden of disease, and health care access. Results: Two thirds of the sampled population was single, widowed, or divorced; the majority was female (57.6%) and black (76.4%). Socioeconomic indicators of under-and unemployment (52.9%), dependency on benefits or assistance (38.5%), lack of home ownership (66.2%), and lack of health insurance (47.0%) suggested vulnerability. One third lacked a health provider. Among those who arrived at shelters with a chronic disease (55.6%), 48.4% lacked medication. Hypertension, hypercholesterolemia, diabetes, pulmonary disease, and psychiatric illness were the most common chronic conditions. Risk factors for lacking medications included male sex (odds ratio [OR] 1.58; 95% confidence interval [CI] 0.96 to 2.59) and lacking health insurance (OR 2.25; 95% CI 1.21 to 4.20). More than one third (34.5%) arrived at the shelter with symptoms warranting immediate medical intervention, including dehydration (12.0%), dyspnea (11.5%), injury (9.4%), and chest pain (9.7%). Risk factors associated with presenting to shelters with acute symptoms included concurrent chronic disease with medication (OR 2.60; 95% CI 1.98 to 3.43), concurrent disease and lacking medication (OR 2.22; 95% CI 1.36 to 3.63), and lacking health insurance (OR 1.83; 95% CI 1.10 to 3.02). Conclusion: A population-based understanding of vulnerability, health access, and chronic and acute disease among the displaced will guide disaster health providers in preparation and response. [Ann Emerg Med.
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Papers by Alexander Vu