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Background: Vaccination is a key public health intervention that can reduce excess mortality in humanitarian contexts. Vaccine hesitancy is thought to be a significant problem requiring demand side interventions. Participatory Learning and Action (PLA) approaches have proven effective in reducing perinatal mortality in low income settings and we aimed to apply an adapted approach in Somalia., Methods: A randomised cluster trial was implemented in camps for internally displaced people near Mogadishu, from June to October 2021. An adapted PLA approach (hPLA) was used in partnership with indigenous 'Abaay-Abaay' women's social groups. Trained facilitators ran 6 meeting cycles that addressed topics of child health and vaccination, analysed challenges, and planned and implemented potential solutions. Solutions included a stakeholder exchange meeting involving Abaay-Abaay group members and services providers from humanitarian organisations. Data was collected at baseline and after completion of the 3 month intervention cycle., Results: Overall, 64.6% of mothers were group members at baseline and this increased in both arms during the intervention (p = 0.016). Maternal preference for getting young children vaccinated was >95% at baseline and did not change. The hPLA intervention improved the adjusted maternal/caregiver knowledge score by 7.9 points (maximum possible score 21) compared to the control (95% CI 6.93, 8.85; p < 0.0001). Coverage of both measles vaccination (MCV1) (aOR 2.43 95% CI 1.96, 3.01; p < 0.001) and completion of the pentavalent vaccination series (aOR 2.45 95% CI 1.27, 4.74; p = 0.008) also improved. However, adherence to timely vaccination did not (aOR 1.12 95% CI 0.39, 3.26; p = 0.828). Possession of a home-based, child health record card increased in the intervention arm from 18 to 35% (aOR 2.86 95% CI 1.35, 6.06; p = 0.006)., Conclusion: A hPLA approach, run in partnership with indigenous social groups, can achieve important changes in public health knowledge and practice in a humanitarian context. Further work to scale up the approach and address other vaccines and population groups is warranted., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Cash transfer programmes are increasingly used in humanitarian contexts to help address people's needs across multiple sectors. However, their impact on the key objectives of reducing malnutrition and excess mortality remains unclear. mHealth interventions show great promise in many areas of public health, but evidence for their impact on reducing the risk factors for malnutrition is uncertain. We therefore implemented a trial to determine the impacts of 2 interventions in a protracted humanitarian context, a cash transfer conditionality and mHealth audio messages., Methods and Findings: A 2 × 2 factorial cluster-randomised trial was implemented in camps for internally displaced people (IDP) near Mogadishu, Somalia, starting in January 2019. The main study outcomes were assessed at midline and endline and included coverage of measles vaccination and the pentavalent immunisation series, timely vaccination, caregiver's health knowledge, and child diet diversity. Twenty-three clusters (camps) were randomised to receive or not receive conditional cash transfers (CCTs) and an mHealth intervention, and 1,430 households were followed up over 9 months. All camps received cash transfers made at emergency humanitarian level (US$70/household/month) for 3 months followed by a further 6 months at a safety net level (US$35). To be eligible to receive cash, households in camps receiving CCT were required to take their children <5 years age to attend a single health screening at a local clinic and were issued with a home-based child health record card. Participants in camps receiving the mHealth intervention were asked (but not required) to listen to a series of audio messages about health and nutrition that were broadcast to their mobile phone twice a week for 9 months. Participants and investigators were not blinded. Adherence to both interventions was monitored monthly and found to be high (>85%). We conducted intention-to-treat analysis. During the humanitarian intervention phase, the CCT improved coverage of measles vaccination (MCV1) from 39.2% to 77.5% (aOR 11.7, 95% CI [5.2, 26.1]; p < 0.001) and completion of the pentavalent series from 44.2% to 77.5% (aOR 8.9, 95% CI [2.6, 29.8]; p = < 0.001). By the end of the safety net phase, coverage remained elevated from baseline at 82.2% and 86.8%, respectively (aOR 28.2, 95% CI [13.9, 57.0]; p < 0.001 and aOR 33.8, 95% CI [11.0, 103.4]; p < 0.001). However, adherence to timely vaccination did not improve. There was no change in the incidence of mortality, acute malnutrition, diarrhoea, or measles infection over the 9 months of follow-up. Although there was no evidence that mHealth increased Mother's knowledge score (aOR 1.32, 95% CI [0.25, 7.11]; p = 0.746) household dietary diversity increased from a mean of 7.0 to 9.4 (aOR 3.75, 95% CI [2.04, 6.88]; p < 0.001). However, this was not reflected by a significant increase in child diet diversity score, which changed from 3.19 to 3.63 (aOR 2.1, 95% CI [1.0, 4.6]; p = 0.05). The intervention did not improve measles vaccination, pentavalent series completion, or timely vaccination, and there was no change in the incidence of acute malnutrition, diarrhoea, measles infection, exclusive breastfeeding, or child mortality. No significant interactions between the interventions were found. Study limitations included the limited time available to develop and test the mHealth audio messages and the necessity to conduct multiple statistical tests due to the complexity of the study design., Conclusions: A carefully designed conditionality can help achieve important public health benefits in humanitarian cash transfer programmes by substantially increasing the uptake of child vaccination services and, potentially, other life-saving interventions. While mHealth audio messages increased household diet diversity, they failed to achieve any reductions in child morbidity, malnutrition, or mortality., Trial Registration: ISRCTN ISRCTN24757827. Registered November 5, 2018., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Grijalva-Eternod et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: People in humanitarian emergencies are likely to experience excess mortality but information on the causes of death is often unreliable or non-existent. This study aimed to provide evidence on the causes of death among children younger than 5 years in camps for internally displaced people in southern Somalia, during periods of protracted displacement and emergency influx amid the 2017 drought and health emergency., Methods: We did a prospective, cohort study in 25 camps in the Afgooye corridor, on the outskirts of Mogadishu, Somalia. All internally displaced children aged 6-59 months were included and followed up with monthly household visits by community health workers. Nutrition, health, and vaccination status were ascertained and verbal autopsy interviews were done with the caregivers of deceased children. We calculated death rates in these children and used verbal autopsy to establish the cause-specific mortality fraction (CSMF). Bayesian InterVA software was used to assign likely causes to each death., Findings: Between March, 2016, and March, 2018, 3898 children were followed up. 153 deaths were recorded during 34 746 person-months of observation. The death rate among children younger than 5 years exceeded emergency thresholds (>2 deaths per 10 000 children per day), reaching a peak of seven deaths per 10 000 children per day during the emergency influx. Verbal autopsy data were gathered for 80% of deaths, and the CSMF for the three leading causes of death were diarrhoeal diseases (25·9%), measles (17·8%), and severe malnutrition (8·8%). Coverage of measles vaccination during the first 3 months of the emergency was 42% and the CSMF for measles doubled during the influx. During protracted displacement, symptoms that could be attributable to HIV/AIDS related deaths accounted for 1·6% of the CSMF., Interpretation: It is feasible to establish a health and nutrition surveillance system that ascertains causes of death, using verbal autopsy, in this humanitarian context. These data can inform policy, response planning, and priority setting. The high mortality rate from infectious diseases and malnutrition among children younger than 5 years suggests the need for strengthening a range of public health interventions, including vaccination and provision of water, sanitation, and hygiene., Funding: UK Department of International Development., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Forced evictions are common in conflict-affected settings. More than 500 internally displaced persons (IDPs) are evicted daily in Mogadishu. Context specific research is necessary to inform responsive humanitarian interventions and to monitor the effectiveness of these interventions on IDPs health., Objective: This study explored the causes of forced evictions and their health impacts among IDPs in southern Somalia., Methods: We used a qualitative approach, conducting 20 semi-structured interviews, six key informant interviews and four focus group discussions. We used maximum variation sampling to include a wide range of participants and used the framework approach and Nvivo software to analyse the data., Results: In this context, landlords often rented land without proper tenure agreements, resulting in risk of forced evictions. Informal tenure agreements led to fluctuations in rent, and IDPs were evicted because tenancy laws were inadequate and failed to protect IDP rights. IDP settlements often increased the value of land by clearing scrub, and landlords often sought to profit from this by evicting IDPs at short notice if a buyer was found for the land. The effect of eviction on an already marginalised population was wide ranging, increasing their exposure to violence, loss of assets, sexual assault, disruption of livelihoods, loss of social networks and family separation. Evicted IDPs reported health issues such as diarrhoea, malaria, pneumonia, measles and skin infections, as well as stress, anxiety, psychological distress and trauma., Conclusion: Forced evictions remain one of the biggest challenges for IDPs as they exacerbate existing vulnerabilities. Prioritizing implementation of legal protection for IDP tenure rights is necessary to prevent unlawful evictions of IDPs. Humanitarian agencies should aim to respond more effectively to protect evictees and provide support to prevent poor health outcomes. Further quantitative research is needed to further examine the relationship between forced evictions and health outcomes.

Background: The prevalence of acute malnutrition is often high in emergency-affected populations and is associated with elevated mortality risk and long-term health consequences. Increasingly, cash transfer programmes (CTP) are used instead of direct food aid as a nutritional intervention, but there is sparse evidence on their nutritional impact. We aim to understand whether CTP reduces acute malnutrition and its known risk factors., Methods/design: A non-randomised, cluster-controlled trial will assess the impact of an unconditional cash transfer of US$84 per month for 5 months, a single non-food items kit, and free piped water on the risk of acute malnutrition in children, aged 6-59 months. The study will take place in camps for internally displaced persons (IDP) in peri-urban Mogadishu, Somalia. A cluster will consist of one IDP camp and 10 camps will be allocated to receive the intervention based on vulnerability targeting criteria. The control camps will then be selected from the same geographical area. Needs assessment data indicates small differences in vulnerability between camps. In each trial arm, 120 households will be randomly sampled and two detailed household surveys will be implemented at baseline and 3 months after the initiation of the cash transfer. The survey questionnaire will cover risk factors for malnutrition including household expenditure, assets, food security, diet diversity, coping strategies, morbidity, WASH, and access to health care. A community surveillance system will collect monthly mid-upper arm circumference measurements from all children aged 6-59 months in the study clusters to assess the incidence of acute malnutrition over the duration of the intervention. Process evaluation data will be compiled from routine quantitative programme data and primary qualitative data collected using key informant interviews and focus group discussions. The UK Department for International Development will provide funding for this study. The European Civil Protection and Humanitarian Aid Operations will fund the intervention. Concern Worldwide will implement the intervention as part of their humanitarian programming., Discussion: This non-randomised cluster controlled trial will provide needed evidence on the role of unconditional CTP in reducing the risk of acute malnutrition among IDP in this context., Trial Registration: ISRCTN29521514 . Registered 19 January 2016.