Emergency medical teams provide urgent medical and surgical care in emergencies characterized by a surge in trauma or disease. Rehabilitation has historically not been included in the acute phase of care, as teams have either not perceived it as their responsibility or have relied on external providers, including local services and international organizations, to provide services. Low- and middle-income countries, which often have limited rehabilitation capacity within their health system, are particularly vulnerable to disaster and are usually ill-equipped to address the increased burden of rehabilitation needs that arise. The resulting unmet needs for rehabilitation culminate in unnecessary complications for patients, delayed recovery, reduced functional outcomes, and often impede return to daily activities and life roles. Recognizing the systemic neglect of rehabilitation in global emergency medical response, the World Health Organization, in collaboration with key operational partners and experts, developed technical standards and recommendations for rehabilitation which are integrated into the WHO verification process for EMTs. This protocol report presents: 1) the rationale for the development of the standards and accompanying recommendations; 2) the methodology of the development process; 3) the minimum standards and other significant content included in the document; 4) challenges encountered during development and implementation; and 5) current and next steps to continue strengthening the inclusion of rehabilitation in emergency medical response.
Introduction: An all-of-society approach to disaster risk reduction emphasizes inclusion and engagement in preparedness activities. A common recommendation is to promote household preparedness through the preparation of a ‘grab bag’ or ‘disaster kit’, that can be used to shelter-in-place or evacuate. However, there are knowledge gaps related to how this strategy is being used around the world as a disaster risk reduction strategy, and what evidence there is to support recommendations.
Methods: In this paper, we present an exploratory study undertaken to provide insight into how grab bag guidelines are used to promote preparedness in Canada, China, England, Japan, and Scotland, and supplemented by a literature review to understand existing evidence for this strategy.
Results: There are gaps in the literature regarding evidence on grab bag effectiveness. We also found variations in how grab bag guidelines are promoted across the five case studies.
Discussion: While there are clearly common items recommended for household grab bags (such as water and first aid kits), there are gaps in the literature regarding: 1) the evidence base to inform guidelines; 2) uptake of guidelines; and 3) to what extent grab bags reduce demands on essential services and improve disaster resilience.
Introduction: Flooding is a common natural disaster affecting 77.8 million people and claiming the lives of 4,731 people globally in 2016. During times of flood, drowning is a leading cause of death. Flooding is a known risk factor for river drowning in Australia. With little known about river usage in Australia, this study aimed to examine the links between person demographics and self-reported participation in two flood-related behaviours, driving through floodwaters and swimming in a flooded river. Methods: A self-reported questionnaire was administered to adult river users at four high-risk river drowning locations; Alligator Creek, Townsville, Queensland; Murrumbidgee River, Wagga Wagga, New South Wales; Murray River, Albury, New South Wales; and Hawkesbury River, Windsor, New South Wales. Univariate and chi square analysis was undertaken with a 95% confidence interval (p<0.05). All river users surveyed, were also breathalysed to record an estimate of their blood alcohol content (BAC) on their expired breath. Results: 688 river users responded to the questionnaire; 676 (98.3%) answered the driving question and 674 (98.0%) answered the swimming in floodwaters questions. Of the respondents, 35.7% stated they had driven through floodwater and 18.7% had swum in a flooded river. Males were more likely (p<0.001) to report having undertaken both activities. Australian-born respondents were more likely to report having driven through floodwaters (p=0.006). Those aged 18-24 years old and those residing in outer regional areas were more likely (p<0.001) to have swum in a flooded river. Those who self-reported participating in both driving through floodwaters (p=0.001) and swimming in a flooded river (p<0.001) were significantly more likely to record contributory levels of alcohol (i.e. a BAC ≥0.05%) when breathalysed at the river. Discussion: Ensuring the safe movement of people during floods is difficult, particularly for those living in regional Australia, due in part to long distances travelled and reduced investment in infrastructure such as bridges. With males and females equally exposed, more effective prevention strategies must target both sexes and may include improved education on when it is safe to drive through (low depth, still water, stable road base) and when it is not (e.g. deep water, moving water and unstable road base). This study identified one in five respondents had swum in a flooded river, most commonly young people aged 18-24 years, with participants signficantly more likely to have recorded contributory levels of alcohol when breathalysed. Further research should examine the reasons behind participation in this behaviour, including the role of alcohol. Conclusion: Preventing drowning in floodwaters is an international challenge, made more difficult by people driving through or swimming in floodwaters. Strategies for driving through floodwaters should educate both males and females on when it is safe to drive through floodwaters and when it is not. Further research is required to improve knowledge of the poorly understood behaviour of swimming in flooded rivers.
Introduction: As the years of displacement accumulate, the burden of secondary stressors (i.e., stressors not directly related to war) increase on the shoulders of millions of refugees, who do not have the option of either returning home due to war or having a sustainable livelihood in the host countries. This paper aims to shed light on the overlooked importance of secondary stressors among refugees of conflict in developing countries; it will do this by highlighting the experience of Syrian refugees in Jordan, and developing a typology of these stressors.
Methods: We approached this issue using two levels of exploration. In study 1, we used participant observation and 15 in-depth interviews in Irbid, Jordan. Data were analysed qualitatively using thematic analysis to explore the different types of stressors. In study 2, a questionnaire survey among Syrian refugees in Jordan (n = 305) was used to collect data about a wide range of stressors. Responses were subjected to factor analysis to examine the extent to which the stressors could be organized into different factors.
Results: The thematic analysis suggested three different types of secondary stressors: financial (money related), environmental (exile structures and feelings created by it), and social (directly related to social relations). The factor analysis of the survey data produced a similar typology, where secondary stressors were found to be grouped into four main factors (financial, services, safety, and relations with out-groups). The final result is a typology of 33 secondary stressors organised in three main themes.
Discussion: Syrian refugees in Jordan suffer the most from financial stressors, due to loss of income and high living expenses. Environmental stressors arise from exile and are either circumstantial (e.g., services and legal requirements) or created by this environment (e.g., instability and lack of familiarity). Social stressors were observed among a considerable section of refugees, varying from stressors due to being targeted as a refugee by the locals (e.g., discrimination) to more traumatic stressors that came from both locals and other refugees (e.g., assault). The typology of secondary stressors suggested by the present analysis needs to be investigated in a larger sample of refugees of conflict in other countries in the Middle East, in order to determine its generality. We suggest that it is a basis for a framework for practitioners and academics working with refugees in the region.
Key words: Armed conflict, Syrian, Jordan, refugees, forced displacement, exile, daily stressors, secondary stressors, trauma, typology.
Introduction: Studies show that natural disasters influence voters’ perception of incumbent politicians. To investigate whether voters are prone to punish politicians for events that are out of their control, this study was conducted in the previously unstudied context of Croatia, and by considering some of the methodological issues of previous studies. Method: Matching method technique was used, which ensures that affected and non-affected areas are matched on several control variables. The cases of natural disaster in the present study were floods that affected Croatia in 2014 and 2015. Results: Main results showed that, prior to matching, floods had an impact on voting behaviour in the 2014 and 2015 elections. Voters from flooded areas decreased their support for the incumbent government and president in the elections following the floods. However, once we accounted for differences in control variables between flooded and non-flooded areas, the flood effect disappeared. Furthermore, results showed that neither the presence nor the amount of the government’s relief spending had an impact on voting behaviour. Discussion: Presented results imply that floods did not have an impact on the election outcome. Results are interpreted in light of the retrospective voter model.
Introduction: The development of depressive symptoms among the population of civilians who were not directly involved in recovery or rescue efforts following the 9/11 World Trade Center (WTC) terrorist attacks is not comprehensively understood. We performed a meta-analysis that examined the associations between multiple risk factors and depressive symptoms after the 9/11 WTC terrorist attacks in New York City among civilians including survivors, residents, and passersby.
Methods: PubMed, Google Scholar, and the Cochrane Library were searched from September, 2001 through July, 2016. Reviewers identified eligible studies and synthesized odds ratios (ORs) using a random-effects model.
Results: The meta-analysis included findings from 7 studies (29,930 total subjects). After adjusting for multiple comparisons, depressive symptoms were significantly associated with minority race/ethnicity (OR, 1.40; 99.5% Confidence Interval [CI], 1.04 to 1.88), lower income level (OR, 1.25; 99.5% CI, 1.09 to 1.43), post-9/11 social isolation (OR, 1.68; 99.5% CI, 1.13 to 2.49), post-9/11 change in employment (OR, 2.06; 99.5% CI, 1.30 to 3.26), not being married post-9/11 (OR, 1.59; 99.5% CI, 1.18 to 2.15), and knowing someone injured or killed (OR, 2.02; 99.5% CI, 1.42 to 2.89). Depressive symptoms were not significantly associated with greater age (OR, 0.86; 99.5% CI, 0.70 to 1.05), no college degree (OR, 1.32; 99.5% CI, 0.96 to 1.83), female sex (OR, 1.24; 99.5% CI, 0.98 to 1.59), or direct exposure to WTC related traumatic events (OR, 1.26; 99.5% CI, 0.69 to 2.30).
Discussion: Findings from this study suggest that lack of post-disaster social capital was most strongly associated with depressive symptoms among the civilian population after the 9/11 WTC terrorist attacks, followed by bereavement and lower socioeconomic status. These risk factors should be identified among civilians in future disaster response efforts.
Introduction: Three jurisdictional earthquake resilience planning initiatives respectively conducted in California, Washington State, and Oregon are compared: SPUR Resilient City (SPUR), Resilient Washington State (RWS), and Oregon Resilience Plan (ORP). This paper presents an exploratory analysis that reveals divergent and convergent themes across the resilience planning initiatives, with the goal of informing similar initiatives in the future.
Methods: Data for this exploratory study comes primarily from the reports produced by the initiatives, but also initiative presentations, limited correspondence with initiative organizers for clarifications, and personal experience. Extensive computer-assisted text analysis was done to analyze, synthesize, and visualize the content of the SPUR, RWS, and ORP reports Results: The SPUR initiative was the inspiration for both RWS and ORP. As such, an evolution of ideas is evident from the first initiative (SPUR) to the most recent (ORP). While the SPUR initiative was a model for the RWS and ORP initiatives, the process and outcomes of the latter two initiatives were more similar than to the original SPUR initiative. Both the RWS and ORP initiatives were significantly smaller in scope. These two initiatives also made creation of recovery-based performance measurement frameworks–timetables of expected and desired recovery estimates–even more central to the process of identifying seismic resilience recommendations.
Discussion: The SPUR, RWS, and ORP initiatives have had demonstrated impact on jurisdictional pre-event planning, mitigation, and preparedness efforts. However, the impact of the specific innovations developed by the three earthquake resilience planning initiatives is not clear because of the limited degree that the resilience definition and performance measurement framework for each initiative were explicitly integrated to produce the respective recommendations. For example, Washington State’s Seismic Safety Committee made recommendations similar to their RWS recommendations as part of past initiatives that did not use a resilience lens or a recovery-based performance measurement framework.
Conclusion: More systematic research into the innovative elements of the SPUR, RWS, and ORP initiatives, such as development of the recovery-based performance measurement frameworks, is warranted given the initiatives’ popularity and influence on the National Institute of Standards and Technology’s Community Resilience Planning Guide.
Background: Emergency preparedness at all levels (individuals and communities) is the corner stone of effective response to the increasing trends of global disasters due to man-made and natural hazards. It is determined by different factors, including (among others) past direct and indirect exposures to hazards. This study was carried out in Dire Dawa town, Ethiopia, which in the past experienced frequent flooding events, yet dearth of information exists about preparedness in the area. The aim of the study was to assess the levels of emergency preparedness for flood hazards at households and communities levels.
Methods: The study was conducted in a qualitative approach and was conducted in Dire Dawa town, which has been divided into nine administrative-units called Kebeles. Two focus group discussions were held in two of these units (Kebele-05 and 06), each focus group comprising twelve people (all above 18 years of age), and in total 24 people (13 females and 11 males) took part in the study. Open ended questions were used that could guide the discussions, and the discussions were audio-taped and transcribed. The results were translated from local language to English and qualitatively presented.
Results: The findings of focus group discussions showed that the local government in collaboration with the federal government built the flood protection dams in areas where flood hazards have been thought to be repeatedly wreaking havoc, specifically after the flood disaster of the year 2006. In addition, in Kebele-05, where one Non-Governmental Organization (NGO) was operating on flood hazards prevention and mitigation program, some non-structural emergency preparedness measures were undertaken by the communities. These non-structural measures (the major ones) entailed: establishment of committees recruited from residents and training them to raise awareness among communities on emergency preparedness; some residents made changes to their own houses (retrofitted) and put sandbags around their houses to temporarily protect the flooding; establishment of communication channels between communities to alarm each other in the event of flood disaster; and reforestation of the already deforested mountainous areas surrounding the town. However, concerns were raised by study participants about strengths of the constructed flood protection dams. Furthermore, the non-structural emergency preparedness measures identified by this study were not comprehensive; for example, residents were not trained in first aid, first aid kits were not provided, there was no linkage being established between communities and health facilities so as to provide emergency medical care to victims in the event of flood disaster.
Discussion: The findings of this study concur with some of the previous quantitative studies’ results in that the past direct and indirect disaster experiences invoke preparedness intention and actual preparedness for flood hazards at individuals, communities and organizations levels. The only one quantitative and behavioral based study conducted thus far in Dire Dawa town reported the strong association of past flood disaster experience with household emergency preparedness. Among the residents there was a tendency to rely on the dams to be constructed with “good quality” and “higher strength” than making preparedness efforts on their own at their households. Structural measures such as building of dams, dikes, levees, and channel improvements could be means of mitigation measures; however, solely relying on these measures could have far reaching consequences.
Conclusions: To mitigate flood hazards, dams were built and in addition, in Kebele-05 where an NGO was operating, some non-structural emergency preparedness measures were undertaken. In the course of construction of flood protection dams, ensuring communities’ involvement is needed; and at the same time undertaking comprehensive non-structural emergency preparedness measures in all Kebeles is highly recommended.
Key words: Emergency, Preparedness, Flood, Dire Dawa, Ethiopia.
Background. Five years of conflict in Syria have led to 13.5 million people in need of humanitarian assistance and 6.6 million internally displaced people. Humanitarian needs are ever-increasing as an inability to maintain humanitarian corridors and ceasefires continue. In light of the protracted nature of the conflict, immense needs, and dearth of large-scale data, we undertook this assessment to inform humanitarian response.
Methods. A survey of accessible areas, which were largely urban and government controlled, was undertaken from April – June 2016 to identify unmet needs and assistance priorities. A cluster design with probability sampling was used to attain a final sample of 2,405 households from ten of fourteen governorates; 31 of 65 (47.7%) districts were included that are home to 38.1% of people in need (PiN).
Results. Overall 45% of households received assistance in the preceding month; receipt of aid was lowest in al-Hasakeh (17%). Shelter was a concern, with 48% of households having shelter need(s); the unmet shelter needs were highest in the West Coast, Rif Damascus and al-Hasakeh. Food security was a major concern where 64% had unmet food needs and 65% at least one indicator of concern; food insecurity was most severe in Rif Damascus and the West Coast. Water was also a concern with 36% of households reporting inconsistent access and 48% no access to water for several day periods; water needs were highest in Aleppo.
Discussion. This assessment included accessible populations in predominantly urban and government controlled areas, which are likely to have better access to services and fewer needs than populations in rural locations or areas not controlled by the government. The humanitarian situation in inaccessible and non-government controlled areas is likely to be considerably worse, thus findings should not be generalized. An expanded humanitarian response is desperately needed for Syrians to better endure the conflict.
Introduction: In 2015, following an influx of population into Kobanê in northern Syria, Médecins Sans Frontières (MSF) in collaboration with the Kobanê Health Administration (KHA) initiated primary healthcare activities. A vaccination coverage survey and vaccine-preventable disease (VPD) risk analysis were undertaken to clarify the VPD risk and vaccination needs. This was followed by a measles Supplementary Immunization Activity (SIA). We describe the methods and results used for this prioritisation activity around vaccination in Kobanê in 2015.
Methods: We implemented a pre-SIA survey in 135 randomly-selected households in Kobanê using a vaccination history questionnaire for all children <5 years. We conducted a VPD Risk Analysis using MSF ‘Preventive Vaccination in Humanitarian Emergencies’ guidance to prioritize antigens with the highest public health threat for mass vaccination activities. A Measles SIA was then implemented and followed by vaccine coverage survey in 282 randomly-selected households targeting children <5 years.
Results: The pre-SIA survey showed that 168/212 children (79.3%; 95%CI=72.7-84.6%) had received one vaccine or more in their lifetime. Forty-three children (20.3%; 95%CI: 15.1-26.6%) had received all vaccines due by their age; only one was <12 months old and this child had received all vaccinations outside of Syria. The VPD Risk Analysis prioritised measles, Haemophilus Influenza type B (Hib) and Pneumococcus vaccinations. In the measles SIA, 3410 children aged 6-59 months were vaccinated. The use of multiple small vaccination sites to reduce risks associated with crowds in this active conflict setting was noted as a lesson learnt. The post-SIA survey estimated 82% (95%CI: 76.9-85.9%; n=229/280) measles vaccination coverage in children 6-59 months.
Discussion: As a result of the conflict in Syria, the progressive collapse of the health care system in Kobanê has resulted in low vaccine coverage rates, particularly in younger age groups. The repeated displacements of the population, attacks on health institutions and exodus of healthcare workers, challenge the resumption of routine immunization in this conflict setting and limit the use of SIAs to ensure sustainable immunity to VPDs. We have shown that the risk for several VPDs in Kobanê remains high.
Conclusion: We call on all health actors and the international community to work towards re-establishment of routine immunisation activities as a priority to ensure that children who have had no access to vaccination in the last five years are adequately protected for VPDs as soon as possible.