BACKGROUND: Antimicrobial resistance is of great global public health concern. In order to address the paucity of antibiotic consumption data and antimicrobial resistance surveillance systems in hospitals in humanitarian settings, we estimated antibiotic consumption in six hospitals with the aim of developing recommendations for improvements in antimicrobial stewardship programs.
METHODS: Six hospitals supported by Médecins sans Frontières were included in the study: Boost-Afghanistan, Kutupalong-Bangladesh, Baraka and Mweso-Democratic Republic of Congo, Kule-Ethiopia, and Bentiu-South Sudan. Data for 36,984 inpatients and antibiotic consumption data were collected from 2018 to 2020. Antibiotics were categorized per World Health Organization Access Watch Reserve classification. Total antibiotic consumption was measured by Defined Daily Doses (DDDs)/1000 bed-days.
RESULTS: Average antibiotic consumption in all hospitals was 2745 DDDs/1000 bed-days. Boost hospital had the highest antibiotic consumption (4157 DDDs/1000 bed-days) and Bentiu the lowest (1598 DDDs/1000 bed-days). In all hospitals, Access antibiotics were mostly used (69.7%), followed by Watch antibiotics (30.1%). The most consumed antibiotics were amoxicillin (23.5%), amoxicillin and clavulanic acid (14%), and metronidazole (13.2%). Across all projects, mean annual antibiotic consumption reduced by 22.3% during the study period, mainly driven by the reduction in Boost hospital in Afghanistan.
CONCLUSIONS: This was the first study to assess antibiotic consumption by DDD metric in hospitals in humanitarian settings. Antibiotic consumption in project hospitals was higher than those reported from non-humanitarian settings. Routine systematic antibiotic consumption monitoring systems should be implemented in hospitals, accompanied by prescribing audits and point-prevalence surveys, to inform about the volume and appropriateness of antibiotic use and to support antimicrobial stewardship efforts in humanitarian settings.

BACKGROUND: Abortion-related complications remain a main cause of maternal mortality. There is little evidence on the availability and quality of post-abortion care (PAC) in humanitarian settings. We assessed the quality of PAC in two hospitals supported by an international organization in Jigawa State (Nigeria) and Bangui (Central African Republic, CAR).
METHODS: We mapped indicators corresponding to the eleven domains of the WHO Maternal and Newborn Health quality-of-care framework to assess inputs, processes (provision and experience of care), and outcomes of PAC. We measured these indicators in four components of a cross-sectional multi-methods study: 1) an assessment of the hospitals\' PAC signal functions, 2) a survey of the knowledge, attitudes, practices, and behavior of 140 Nigerian and 84 CAR clinicians providing PAC, 3) a prospective review of the medical records of 520 and 548 women presenting for abortion complications and, 4) a survey of 360 and 362 of these women who were hospitalized in the Nigerian and CAR hospitals, respectively.
RESULTS: Among the total 27 PAC signal functions assessed, 25 were available in the Nigerian hospital and 26 in the CAR hospital. In both hospitals, less than 2.5% were treated with dilatation and sharp curettage. Over 80% of women received blood transfusion or curative antibiotics when indicated. However, antibiotics were given to about 30% of patients with no documented indication. Among discharged women in CAR, 99% received contraceptive counseling but only 39% did in Nigeria. Over 80% of women in Nigeria reported positive experiences of respect and preservation of dignity. Conversely, in CAR, 37% reported that their privacy was always respected during examination and 62% reported short or very short waiting time before seeing a health provider. In terms of communication, only 15% felt able to ask questions during treatment in both hospitals. The risk of abortion-near-miss happening ≥ 24h after presentation was 0.2% in Nigeria and 1.1% in CAR. Only 65% of women in the Nigerian hospital and 34% in the CAR hospital reported that the staff provided them best care all the time.
CONCLUSIONS: Our comprehensive assessment identified that these two hospitals in humanitarian settings provided lifesaving PAC. However, hospitals need to strengthen the patient-centered approach engaging patients in their own care and ensuring privacy, short waiting times and quality provider-patient communication. Health professionals would benefit from instituting antibiotic stewardships to prevent antibiotic-resistance.
In humanitarian contexts, abortion complications are a leading cause of maternal mortality. Providing quality post-abortion care (PAC) is therefore an important part of needed services. We assessed the quality of PAC in two hospitals supported by an international organization in Jigawa State (Nigeria) and Bangui (Central African Republic). We measured quality indicators in four components: 1) an assessment of the equipment and human resources available in hospitals, 2) a survey of the knowledge, attitudes, practices, and behavior of clinicians providing PAC, 3) an assessment of the medical care provided by clinicians to women presenting with abortion complications and, 4) a survey of a subgroup of these women who were hospitalized. Both hospitals had almost all the equipment and human resources necessary to provide post-abortion care. Less than 2.5% of women received a non-recommended method to evacuate their uterus in both hospitals. More than 80% of women received a blood transfusion or antibiotics when they needed them. However, 30% of women received antibiotics without written justification and only 15% of women reported being able to ask questions about their treatment. Overall, only 65% of Nigerian women and 34% of Central African women said that the staff provided them with the best care all the time. The fact that less than 2% of women experienced a very severe complication 24 hours or more after their arrival at the two hospitals suggests that the care provided was lifesaving. But they urgently need to adopt a better patient-centered approach as well as to improve the rational management of antibiotics.

BACKGROUND: Maternal and Perinatal Death Surveillance and Response (MPDSR) systems provide an opportunity for health systems to understand the determinants of maternal and perinatal deaths in order to improve quality of care and prevent future deaths from occurring. While there has been broad uptake and learning from low- and middle-income countries, little is known on how to effectively implement MPDSR within humanitarian contexts - where disruptions in health service delivery are common, infrastructural damage and insecurity impact the accessibility of care, and severe financial and human resource shortages limit the quality and capacity to provide services to the most vulnerable. This study aimed to understand how contextual factors influence facility-based MPDSR interventions within five humanitarian contexts.
METHODS: Descriptive case studies were conducted on the implementation of MPDSR in Cox\'s Bazar refugee camps in Bangladesh, refugee settlements in Uganda, South Sudan, Palestine, and Yemen. Desk reviews of case-specific MPDSR documentation and in-depth key informant interviews with 76 stakeholders supporting or directly implementing mortality surveillance interventions were conducted between December 2021 and July 2022. Interviews were recorded, transcribed, and analyzed using Dedoose software. Thematic content analysis was employed to understand the adoption, penetration, sustainability, and fidelity of MPDSR interventions and to facilitate cross-case synthesis of implementation complexities.
RESULTS: Implementation of MPDSR interventions in the five humanitarian settings varied in scope, scale, and approach. Adoption of the interventions and fidelity to established protocols were influenced by availability of financial and human resources, the implementation climate (leadership engagement, health administration and provider buy-in, and community involvement), and complex humanitarian-health system dynamics. Blame culture was pervasive in all contexts, with health providers often facing punishment or criminalization for negligence, threats, and violence. Across contexts, successful implementation was driven by integrating MPDSR within quality improvement efforts, improving community involvement, and adapting programming fit-for-context.
CONCLUSIONS: The unique contextual considerations of humanitarian settings call for a customized approach to implementing MPDSR that best serves the immediate needs of the crisis, aligns with stakeholder priorities, and supports health workers and humanitarian responders in providing care to the most vulnerable populations.

Little is known regarding economic impacts of intimate partner violence (IPV) in humanitarian settings, especially the labor market burden. Examining costs of IPV beyond the health burden may provide new information to help with resource allocation for addressing IPV, including within conflict zones. This paper measures the incidence and prevalence of different types of IPV, the potential relationship between IPV and labor market activity, and estimating the cost of these IPV-associated labor market differentials.
The association between labor market outcomes, IPV experience, and conflict exposure among women ages 15-49 in Nigeria were studied using the 2018 Nigeria Demographic and Health Survey and 2013-17 Uppsala Conflict Data Program data. Descriptive analysis was used to identify patterns of IPV and labor outcomes by region. Based on this, multivariable logistic regression models were used to estimate the association between labor market participation and lifetime IPV exposure. These models were combined with earnings data from the United Nations Human Development Report 2021/2022 and a top-down costing approach to quantify the impacts in terms of lost productivity to the Nigerian economy.
Substantial differences in IPV exposure and labor market outcomes were found between conflict and non-conflict-affected areas. Women with past year or lifetime exposure to physical, emotional, or \"any\" IPV were more likely to withdraw from the labor market in the past year, although no differences were found for sexual IPV or conflict-affected regions. We estimate an average reduction of 4.14% in the likelihood of working, resulting in nearly $3.0 billion USD of lost productivity, about 1% of Nigeria\'s total economic output.
Increased odds of labor market withdraw were associated with several measures of IPV. Withdrawal from the formal labor market sector has a substantial associated economic cost for all of Nigerian society. If stronger prevention measures reduce the incidence of IPV against women in Nigeria, a substantial portion of lost economic costs likely could be reclaimed. These costs underscore the economic case, alongside the moral imperative, for stronger protections against IPV for girls and women in Nigeria.

BACKGROUND: Artificial intelligence (AI) and machine learning (ML) technology design and development continues to be rapid, despite major limitations in its current form as a practice and discipline to address all sociohumanitarian issues and complexities. From these limitations emerges an imperative to strengthen AI and ML literacy in underserved communities and build a more diverse AI and ML design and development workforce engaged in health research.
OBJECTIVE: AI and ML has the potential to account for and assess a variety of factors that contribute to health and disease and to improve prevention, diagnosis, and therapy. Here, we describe recent activities within the Artificial Intelligence/Machine Learning Consortium to Advance Health Equity and Researcher Diversity (AIM-AHEAD) Ethics and Equity Workgroup (EEWG) that led to the development of deliverables that will help put ethics and fairness at the forefront of AI and ML applications to build equity in biomedical research, education, and health care.
METHODS: The AIM-AHEAD EEWG was created in 2021 with 3 cochairs and 51 members in year 1 and 2 cochairs and ~40 members in year 2. Members in both years included AIM-AHEAD principal investigators, coinvestigators, leadership fellows, and research fellows. The EEWG used a modified Delphi approach using polling, ranking, and other exercises to facilitate discussions around tangible steps, key terms, and definitions needed to ensure that ethics and fairness are at the forefront of AI and ML applications to build equity in biomedical research, education, and health care.
RESULTS: The EEWG developed a set of ethics and equity principles, a glossary, and an interview guide. The ethics and equity principles comprise 5 core principles, each with subparts, which articulate best practices for working with stakeholders from historically and presently underrepresented communities. The glossary contains 12 terms and definitions, with particular emphasis on optimal development, refinement, and implementation of AI and ML in health equity research. To accompany the glossary, the EEWG developed a concept relationship diagram that describes the logical flow of and relationship between the definitional concepts. Lastly, the interview guide provides questions that can be used or adapted to garner stakeholder and community perspectives on the principles and glossary.
CONCLUSIONS: Ongoing engagement is needed around our principles and glossary to identify and predict potential limitations in their uses in AI and ML research settings, especially for institutions with limited resources. This requires time, careful consideration, and honest discussions around what classifies an engagement incentive as meaningful to support and sustain their full engagement. By slowing down to meet historically and presently underresourced institutions and communities where they are and where they are capable of engaging and competing, there is higher potential to achieve needed diversity, ethics, and equity in AI and ML implementation in health research.

UNASSIGNED: The increasing emergencies and humanitarian challenges have worsened the mental health condition of women in the Eastern Mediterranean Region.
UNASSIGNED: To assess the prevalence, determinants and interventions to address mental health among women in fragile and humanitarian settings in the Eastern Mediterranean Region.
UNASSIGNED: Using the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines, we reviewed 59 peer-reviewed published studies (PubMed, IMEMR) and grey literature (WHO/IRIS) from January 2001 to February 2023, focusing on women\'s mental health in the Eastern Mediterranean Region. We then conducted a descriptive analysis of the sociodemographic characteristics.
UNASSIGNED: Among the 59 studies reviewed, only 13 of the 48 peer-reviewed studies focused primarily on women\'s mental health, 11 grey literature records mostly presented grouped regional data, 11 of the 25 studies on mental health among migrants were about those taking refuge in high-income countries. The average prevalence of mental disorders from 32 cross-sectional studies on women aged 12-75 years was 49%, average prevalence of anxiety was 68%, post-traumatic stress disorder was 52%, and depression was 43%. Women exhibited higher level depression than men. Age, educational disparities, and limited access to services were important risk factors for mental health disorder. Several promising interventions emerged.
UNASSIGNED: More efforts should be made to provide customized, context-specific solutions to the mental health challenges of women in humanitarian and fragile settings in the Eastern Mediterranean Region, including allocation of more resources to mental health programmes, addressing barriers, enhancing mental health surveillance, and reduction of stigma.
استعراض منهجي للصحة النفسية للنساء في الأوضاع الهشة والإنسانية بإقليم شرق المتوسط.
فوزيه رباني ،عائشة زاهدي ،آمنه صديقي ،صنم شاه ،زل میرعلي ،خالد سعيد ،محمد عفيفي.
UNASSIGNED: أدى تزايد حالات الطوارئ والتحديات الإنسانية إلى تردِّي حالة الصحة النفسية للنساء في إقليم شرق المتوسط.
UNASSIGNED: هدفت هذه الدراسة الى تقييم معدل انتشار حالات الصحة النفسية بين النساء في الأوضاع الهشة والإنسانية بإقليم شرق المتوسط، ومُُحدِّدات تلك الحالات، والتدخلات المطلوبة لمعالجتها.
UNASSIGNED: باستخدام المبادئ التوجيهية للعناصر الموصى بها لإعداد تقارير الاستعراض المنهجي والتحليلات التلوية (PRISMA)، استعرضنا 59 من الدراسات المنشورة المُحكَّمة (موقع PubMed، موقع الفهرس الطبي لإقليم شرق المتوسط «IMEMR») والمؤلفات غير الرسمية (منظمة الصحة العالمية/ المستودع المؤسسي لتبادل المعلومات) التي تشمل المدة من يناير / كانون الثاني 2001 إلى فبراير / شباط 2023 وتركِّز على الصحة النفسية للمرأة في إقليم شرق المتوسط. ثم أجرينا تحليلًًا وصفيًّا للخصائص الاجتماعية السكانية.
UNASSIGNED: من بين الدراسات التي استُعرضت وبلغ عددها 59، فإن 13 فقط من الدراسات المحكَّمة البالغ عددها 48 ركَّزت في الأساس على الصحة النفسية للمرأة، في حين أن 11 من سجلات المؤلفات غير الرسمية عرضت في الغالب بيانات إقليمية مجمَّعة، كما أن 11 من أصل 25 دراسة عن الصحة النفسية بين المهاجرين تناولت النساء اللاتي لجأن إلى بلدان مرتفعة الدخل. وفي 32 دراسة مقطعية على النساء اللاتي تتراوح أعمارهن بين 12 و75 عامًا، كان متوسط انتشار الاضطرابات النفسية 49٪، ومتوسط انتشار القلق 68٪، واضطراب الكرب التالي للصدمات 52٪، والاكتئاب 43٪. وكانت مستويات الاكتئاب لدى النساء أعلى منها لدى الرجال. كما أن العمر، وتفاوت المستوى التعليمي، ومحدودية إتاحة الخدمات كانت من عوامل الخطر المهمة المؤدية إلى اضطرابات الصحة النفسية. كما ظهرت عدة تدخلات واعدة.
UNASSIGNED: ينبغي بذل مزيد من الجهود لتوفير حلول مصممة خصيصًا ومحدَّدة السياق لتحديات الصحة النفسية التي تواجهها النساء في الأوضاع الإنسانية والهشة بإقليم شرق المتوسط، ومنها تخصيص مزيد من الموارد لبرامج الصحة النفسية، والتصدي للعقبات، وتعزيز ترصد الصحة النفسية، والحد من الوصم الاجتماعي.
Analyse systématique en matière de santé mentale des femmes dans les contextes de fragilité et de crise humanitaire de la Région de la Méditerranée orientale.
UNASSIGNED: Les situations d\'urgence et les défis humanitaires croissants ont aggravé la situation relative à la santé mentale des femmes dans la Région de la Méditerranée orientale.
UNASSIGNED: Évaluer la prévalence, les déterminants et les interventions en matière de santé mentale chez les femmes en situation de fragilité et de crise humanitaire dans la Région de la Méditerranée orientale.
UNASSIGNED: À l\'aide des lignes directrices PRISMA (Preferred Reporting Items for Systematic Review and Meta-analysis), nous avons passé en revue 59 études évaluées par des pairs publiées (PubMed, IMEMR) et la littérature grise (OMS/IRIS) qui étaient axées sur la santé mentale des femmes dans la Région de la Méditerranée orientale, entre janvier 2001 et février 2023. Nous avons ensuite procédé à une analyse descriptive des caractéristiques sociodémographiques.
UNASSIGNED: Parmi les 59 études examinées, seules 13 des 48 études évaluées par des pairs portaient principalement sur la santé mentale des femmes, 11 dossiers appartenant à la littérature grise présentaient principalement des données régionales regroupées, 11 des 25 études sur la santé mentale chez les migrants concernaient les personnes qui cherchaient refuge dans les pays à revenu élevé. La prévalence moyenne des troubles mentaux, déterminée à partir de 32 études transversales portant sur des femmes âgées de 12 à 75 ans, était de 49 % ; la prévalence moyenne de l\'anxiété était de 68 % ; celle des troubles de stress post-traumatique s\'élevait à 52 % ; et celle de la dépression à 43 %. Les femmes présentaient des niveaux de dépression plus élevés que les hommes. L\'âge, les disparités en matière d\'éducation et l\'accès limité aux services constituent des facteurs de risque importants pour les troubles de santé mentale. Plusieurs interventions prometteuses sont apparues.
UNASSIGNED: Davantage d\'efforts devraient être consentis pour fournir des solutions personnalisées et adaptées au contexte concernant les problèmes de santé mentale des femmes vivant dans des situations de crise humanitaire et de fragilité dans la Région de la Méditerranée orientale, notamment en allouant davantage de ressources aux programmes de santé mentale, en s\'attaquant aux obstacles, en améliorant la surveillance dans ce domaine et en réduisant la stigmatisation.

Victoria Hand Project (VHP) is a Canadian charity with a mission to provide 3D printed prosthetic arms to people in-need across the world, by partnering with prosthetic care providers. This article explores the journey of VHP, sharing insights, lessons learned, ongoing directions, and the impact of 3D printing on prosthetic care for people with upper-limb amputation. Benefits such as affordability and customization are explored, as well as the challenges encountered, including quality control and the steep learning curve associated with working in the digital 3D space. Through this article, the potential of 3D printing to continue to transform the field of assistive technology and prosthetic and orthotic applications is underscored, especially when used for collaborative, humanitarian initiatives.

Challenges in delivering evidence-based programming in humanitarian crises require new strategies to enhance implementation science for better decision-making. A recent scoping review highlights the scarcity of peer-reviewed studies on implementation in conflict zones. In this commentary, we build on this scoping review and make five recommendations for advancing implementation science for humanitarian settings. These include (1) expanding existing frameworks and tailoring them to humanitarian dynamics, (2) utilizing hybrid study designs for effectiveness-implementation studies, (3) testing implementation strategies, (4) leveraging recent methodological advancements in social and data science, and (5) enhancing training and community engagement. These approaches aim to address gaps in understanding intervention effectiveness, scale, sustainability, and equity in humanitarian settings. Integrating implementation science into humanitarian research is essential for informed decision-making and improving outcomes for affected populations.

BACKGROUND: The ongoing crisis in Syria has divided the country, leading to significant deterioration of the healthcare infrastructure and leaving millions of people struggling with poor socioeconomic conditions. Consequently, the affordability of healthcare services for the population has been compromised. Cancer patients in Northwest Syria have faced difficulties in accessing healthcare services, which increased their financial distress despite the existence of humanitarian health and aid programs. This study aimed to provide insights into how humanitarian assistance can alleviate the financial burdens associated with cancer treatment in conflict-affected regions.
METHODS: This research employed a quantitative, quasi-experimental design with a pre-test-post-test approach, focusing on evaluating the financial toxicity among cancer patients in Northwest Syria before and after receiving humanitarian aid. The study used purposeful sampling to select participants and included comprehensive demographic data collection. The primary tool for measuring financial toxicity was the Comprehensive Score for Financial Toxicity (FACIT-COST) tool, administered in Arabic. Data analysis was conducted using SPSS v25, employing various statistical tests to explore relationships and impacts.
RESULTS: A total of 99 cancer patients were recruited in the first round of data collection, out of whom 28 patients affirmed consistent receipt of humanitarian aid throughout the follow-up period. The results of the study revealed that humanitarian aid has no significant relationship with reducing the financial toxicity experienced by cancer patients in Northwest Syria. Despite the aid efforts, many patients continued to face significant financial distress.
CONCLUSIONS: The research findings indicate that current humanitarian assistance models might not sufficiently address the complex financial challenges faced by cancer patients in conflict zones. The research emphasizes the need for a more comprehensive and integrated approach in humanitarian aid programs. The study highlights the importance of addressing the economic burdens associated with cancer care in conflict settings and calls for a re-evaluation of aid delivery models to better serve the needs of chronic disease patients. The findings suggest a need for multi-sectoral collaboration and a systemic approach to improve the overall effectiveness of humanitarian assistance in such contexts.

BACKGROUND: As crises escalate worldwide, there is an increasing demand for innovative solutions to enhance humanitarian outcomes. Within this landscape, digital health tools have emerged as promising solutions to tackle certain health challenges. The integration of digital health tools within the international humanitarian system provides an opportunity to reflect upon the system\'s paternalistic tendencies, driven largely by Global North organisations, that perpetuate existing inequities in the Global South, where the majority of crises occur. The Participation Revolution, a fundamental pillar of the Localisation Agenda, seeks to address these inequities by advocating for greater participation from crisis-affected people in response efforts. Despite being widely accepted as a best practice; a gap remains between the rhetoric and practice of participation in humanitarian response efforts. This study explores the extent and nature of participatory action within contemporary humanitarian digital health projects, highlighting participatory barriers and tensions and offering potential solutions to bridge the participation gap to enhance transformative change in humanitarian response efforts.
METHODS: Sixteen qualitative interviews were conducted with humanitarian health practitioners and experts to retrospectively explored participatory practices within their digital health projects. The interviews were structured and analysed according to the Localisation Performance Measurement Framework\'s participation indicators and thematically, following the Framework Method. The study was guided by the COREQ checklist for quality reporting.
RESULTS: Varied participatory formats, including focus groups and interviews, demonstrated modest progress towards participation indicators. However, the extent of influence and power held by crisis-affected people during participation remained limited in terms of breadth and depth. Participatory barriers emerged under four key themes: project processes, health evidence, technology infrastructure and the crisis context. Lessons for leveraging participatory digital health humanitarian interventions were conducting thorough pre-project assessments and maintaining engagement with crisis-affected populations throughout and after humanitarian action.
CONCLUSIONS: The emerging barriers were instrumental in shaping the limited participatory reality and have implications: Failing to engage crisis-affected people risks perpetuating inequalities and causing harm. To advance the Participation Revolution for humanitarian digital health response efforts, the major participatory barriers should be addressed to improve humanitarian efficiency and digital health efficacy and uphold the rights of crisis-affected people.