Ruwan Ratnayake

Acknowledgement of manuscript reviewers 2007–2013

Contributing reviewersThe editors of Conflict and Health would like to thank all our reviewers who have contributed to the journal from Volume 1 (2007) to Volume 7 (2013).

Conflict and Health: seven years of advancing science in humanitarian crises

Conflict and Health began in 2007 with an aim to provide a forum to document public health responses during and after conflict across the world. The journal has published over 120 articles that span the range of public health domains including, but not limited to, infectious disease control, reproductive health and sexual and gender-based violence, mental health, health system reconstruction, and ethics in emergencies. The growth of Conflict and Health has taken place during a time of increasing focus on evidence-based approaches to reducing mortality and morbidity in humanitarian emergencies, and increasing prominence of open-access peer-reviewed literature (1-3).

Effects of a community scorecard on improving the local health system in Eastern Democratic Republic of Congo: qualitative evidence using the most significant change technique

BackgroundMore than a decade of conflict has weakened the health system in the Democratic Republic of Congo and decreased its ability to respond to the needs of the population. Community scorecards have been conceived as a way to increase accountability and responsiveness of service providers, but there is limited evidence of their effects, particularly in fragile and conflict-affected contexts. This paper describes the implementation of community scorecards within a community-driven reconstruction project in two provinces of eastern Democratic Republic of Congo.MethodsBetween June 2012 and November 2013, 45 stories of change in the health system were collected from village development committee, health committee, community members (20 men and 18 women) and healthcare providers (n = 7) in 25 sites using the Most Significant Change technique. Stories were analyzed qualitatively for content related to the types and mechanisms of change observed.ResultsThe most salient changes were related to increased transparency and community participation in health facility management, and improved quality of care. Quality of care included increased access to services, improved patient-provider relationships, improved performance of service providers, and improved maintenance of physical infrastructure. Changes occurred through many different mechanisms including provider actions in response to information, pressure from community representatives, or supervisors; and joint action and improved collaboration by health facility committees and providers.ConclusionsAlthough it is often assumed that confrontation is a primary mechanism for citizens to change state-provided services, this study demonstrates that healthcare providers may also be motivated to change through other means. Positive experiences of community scorecards can provide a structured space for interface between community members and the health system, allowing users to voice their opinions and preferences and bridge information gaps for both users and frontline healthcare providers. When solutions to problems identified through the scorecard are locally accessible, users and healthcare providers are able to work together to implement mutually acceptable solutions that improve quality of health services, and make them more responsive to users’ needs.

What is the scope for addressing menstrual hygiene management in complex humanitarian emergencies? A global review

Global attention on improving the integration of menstrual hygiene management (MHM) into humanitarian response is growing. However, there continues to be a lack of consensus on how best to approach MHM inclusion within response activities. This global review assessed the landscape of MHM practice, policy, and research within the field of humanitarian response. This included an analysis of the limited existing documentation and research on MHM in emergencies and global key informant interviews (n=29) conducted with humanitarian actors from relevant sectors (water, sanitation, and hygiene; women’s protection; child protection; health; education; non-food items; camp management). The findings indicate that despite a growing dialogue around MHM in emergencies, there remains a lack of clarity on the key components for a complete MHM response, the responsible sectoral actors to implement MHM activities, and the most effective interventions to adapt in emergency contexts, and insufficient guidance on monitoring ...

Understanding the menstrual hygiene management challenges facing displaced girls and women: findings from qualitative assessments in Myanmar and Lebanon

BackgroundThere is a significant gap in empirical evidence on the menstrual hygiene management (MHM) challenges faced by adolescent girls and women in emergency contexts, and on appropriate humanitarian response approaches to meet their needs in diverse emergency contexts. To begin filling the gap in the evidence, we conducted a study in two diverse contexts (Myanmar and Lebanon), exploring the MHM barriers facing girls and women, and the various relevant sectoral responses being conducted (e.g. water, sanitation and hygiene (WASH), Protection, Health, Education and Camp Management).MethodsTwo qualitative assessments were conducted: one in camps for internally displaced populations in Myanmar, and one with refugees living in informal settlements and host communities in Lebanon. Key informant interviews were conducted with emergency response staff in both sites, and focus group discussion and participatory mapping activities conducted with adolescent girls and women.ResultsKey findings included that there was insufficient access to safe and private facilities for MHM coupled with displacement induced shifts in menstrual practices by girls and women. Among staff, there was a narrow interpretation of what an MHM response includes, with a focus on supplies; significant interest in understanding what an improved MHM response would include and acknowledgement of limited existing MHM guidance across various sectors; and insufficient consultation with beneficiaries, related to discomfort asking about menstruation, and limited coordination between sectors.ConclusionsThere is a significant need for improved guidance across all relevant sectors for improving MHM response in emergency context, along with increased evidence on effective approaches for integrating MHM into existing responses.

Assessment of Community Event–Based Surveillance for Ebola Virus Disease, Sierra Leone, 2015

Case detection improved, but many false alerts were generated, suggesting a need for additional staff training.

Measuring local determinants of acute malnutrition in Chad: a case-control study

Abstract Background In 2010, Guera District, Chad recorded a prevalence of global acute malnutrition of 16·1% and severe acute malnutrition (SAM) of 4·9%, both signs of a critical nutritional situation. To improve malnutrition, a problem-tree analysis is normally used to propose causal factors. We used a case-control study and qualitative methods to determine causes of SAM and their effect sizes with an aim of providing evidence for programming. Methods A matched case-control study was conducted within a coverage assessment (the semi-quantitative evaluation of access and coverage [SQUEAC]) of a therapeutic feeding programme. Qualitative information on the determinants of SAM was translated into hypotheses and standardised indicators to be evaluated in the case-control study. Villages were selected using the centric systematic area sampling method. Within villages, all current or recovering SAM cases among children 6–59 months were found through snowball sampling with seed informants who had knowledge of childrens health. Two to three controls meeting the matching criteria (within ±3 months and same neighbourhood) were selected. Interviews with carers were conducted with a structured questionnaire. A sample of 40 cases and two controls per case was sufficient to detect a fourfold increase in odds. Conditional logistic regression with backwards stepwise elimination of non-significant variables was used to evaluate potential causal factors. Findings 62 cases and 157 controls were enrolled. The odds of reporting fever and diarrhoea in the previous 2 weeks was eight (odds ratio 7·55, 95% CI 2·64–21·62) and eleven times (10·72, 4·27–26·88) higher among SAM cases. Interpretation Diarrhoea and fever represent multiple causes that contribute, with other factors, to the development of SAM and warrant a specific focus for programmes. Preventative recommendations include hygiene promotion and the routine use of bednets for under-5s. Identification of the timing of the onset of disease and malnutrition is difficult and we may only show association and not cause. The ability of the matched study to detect differences among factors that do not vary at the community level (eg, use of an unprotected water source) needs to be considered. Funding Humanitarian Aid and Civil Protection department of the European Commission (ECHO) and the USAID Office of Foreign Disaster Assistance (OFDA).

Improving Ebola infection prevention and control in primary healthcare facilities in Sierra Leone: a single-group pretest post-test, mixed-methods study

Background Accomplishing infection prevention and control (IPC) in health facilities in Sub-Saharan Africa is challenging. Owing to poor IPC, healthcare workers (HCWs) were frequently infected during Sierra Leones Ebola epidemic. In late 2014, IPC was rapidly and nationally scaled up. We carried out workshops in sampled facilities to further improve adherence to IPC. We investigated HCW experiences and observed practice gaps, before and after the workshops. Methods We conducted an uncontrolled, before and after, mixed-methods study in eight health facilities in Bo and Kenema Districts during December 2014 and January 2015. Quantitative methods administered to HCWs at baseline and follow-up included a survey on attitudes and self-efficacy towards IPC, and structured observations of behaviours. The intervention involved a workshop for HCWs to develop improvement plans for their facility. We analysed the changes between rounds in survey responses and behaviours. We used interviews to explore attitudes and self-efficacy throughout the study period. Results HCWs described IPC as ‘life-saving’ and personal protective equipment (PPE) as uncomfortable for providers and frightening for patients. At baseline, self-efficacy was high (median=4/strongly agree). Responses reflecting unfavourable attitudes were low for glove use (median=1/strongly disagree, IQR, 1–2) and PPE use with ill family members (median=1, IQR, 1–2), and mixed for PPE use with ill HCWs (median=2/disagree, IQR, 1–4). Observations demonstrated consistent glove reuse and poor HCW handwashing. The maintenance of distance (RR 1.09, 95% CI 1.02 to 1.16) and patient handwashing (RR 1.19, 95% CI 1.3 to 1.25) improved to >90%. Conclusions We found favourable attitudes towards IPC and gaps in practice. Risk perceptions of HCWs and tendencies to ration PPE where chronic supply chain issues normally lead to PPE stock-outs may affect practice. As Sierra Leones Ebola Recovery Strategy aims to make all facilities IPC compliant, socio-behavioural improvements and a secure supply chain are essential.

Rebuilding people-centred maternal health services in post-Ebola Liberia through participatory action research

ABSTRACT During the March 2014–January 2016 Ebola crisis in Liberia, Redemption Hospital lost 12 staff and became a holding facility for suspected cases, prompting violent hostility from the surrounding New Kru Town community, in the capital city Monrovia. Inpatient services were closed for 6 months, leaving the population without maternity care. In January 2015, Redemption reopened, but utilization was low, especially for deliveries. A key barrier was community trust in health workers which worsened during the epidemic. The New Kru Town council, Redemption Hospital, the International Rescue Committee, and Training and Research Support Centre initiated participatory action research (PAR) in July 2015 to build communication between stakeholder groups, and to identify impacts of the epidemic and shared actions to improve the system. The PAR involved pregnant women, community-based trained traditional midwives (TTMs) and traditional birth attendants (TBAs), and community leaders, as well as health workers. Qualitative data and a pre-post survey of PAR participants and community members assessed changes in relationships and maternal health services. The results indicated that Ebola worsened community-hospital relations and pre-existing weaknesses in services, but also provided an opportunity to address these when rebuilding the system through shared action. Findings suggest that PAR generated evidence and improved communication and community and health worker interaction.

“We and the nurses are now working with one voice”: How community leaders and health committee members describe their role in Sierra Leone’s Ebola response

BackgroundAcross low-income settings, community volunteers and health committee members support the formal health system - both routinely and amid emergencies - by engaging in health services such as referrals and health education. During the 2014–2015 Ebola epidemic, emerging reports suggest that community engagement was instrumental in interrupting transmission. Nevertheless, literature regarding community volunteers’ roles during emergencies generally, and Ebola specifically, is scarce. This research outlines what this cadre of the workforce did, how they coped, and the facilitators and barriers they faced to providing care in Sierra Leone.MethodsThirteen focus group discussions (FGD) were conducted with community members (including members of Health Management Committees (HMC)) near the height of the Ebola epidemic in two districts of Sierra Leone: Bo and Kenema. Conducted in either Krio or Mende, each FGD lasted an average of two hours and was led by a trained moderator who was accompanied by a note taker. All FGDs were audio recorded, transcribed, and translated into English by the data collection team. Analysis followed a modified framework approach, which entailed coding (both inductive and deductive), arrangement of codes into themes, and drafting, distribution and discussion of analytic summaries across the study team.ResultsCommunity volunteers and HMC members described engaging in labor-related tasks (e.g. building isolation structures, digging graves) and administrative/community-outreach tasks (e.g. screening, contact tracing, and encouraging care seeking within facilities). Through their dual orientation as community members and as individuals linked to the health system, respondents described building community trust and support for Ebola prevention and treatment, while also enabling formal health workers to better understand and address people’s fears and needs. Community volunteers’ main concerns included inadequate communication with - and a sense of being forgotten by - the health system, negative perceptions of their role within their communities, and concerns regarding the amount and nature of their compensation.Discussion & ConclusionRespondents described commitment to supporting their health system and their communities during the Ebola crisis. The health system could more effectively harness the potential of local responders by recognizing community strengths and weaknesses, as well as community volunteers’ motivations and limitations. Clarifying the roles, responsibilities, and remuneration of health volunteers to the recipients themselves, facility-based staff, and the wider community will enable organizations that partner with health committees to bolster trust, manage expectations, and reinforce collaboration.