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Justin Lussy Paluku,1,2 Susan A Bartels,3,4 Benjamin Kasereka Kataliko,2 Cathy Mufungizi Furaha,1,2 Barthelemy Kasi Aksanti,2 Benjamin Kambale Kalole,2 Eugénie Mukekulu Kamabu,5 Chrispin Musubao Lwanzo,2 Jonathan ML Kasereka,6 Olivier Mukuku,7 Zacharie Kibendelwa Tsongo,8 Stanis Okitotsho Wembonyama,9,10 Charles Wembonyama Mpoy,11 Jeannot Sihalikyolo Juakali12 1Department of Obstetrics and Gynecology, University of Goma, Goma, Democratic Republic of the Congo; 2Department of Obstetrics and Gynecology, HEAL Africa Hospital, Goma, Democratic Republic of the Congo; 3Department of Emergency Medicine, Queen’s University, Kingston, Canada; 4Department of Public Health Sciences, Queen’s University, Kingston, Canada; 5Department of Internal Medicine, HEAL Africa Hospital, Goma, Democratic Republic of the Congo; 6Department of Orthopedics and Trauma, HEAL Africa Hospital, Goma, Democratic Republic of the Congo; 7Department of Maternal and Child Health, High Institute of Medical Techniques, Lubumbashi, Democratic Republic of the Congo; 8Department of Internal Medicine, University of Kisangani, Kisangani, Democratic Republic of the Congo; 9Department of Pediatrics, University of Lubumbashi, Lubumbashi, Democratic Republic of the Congo; 10Department of Public Health, University of Lubumbashi, Lubumbashi, Democratic Republic of the Congo; 11Department of Obstetrics and Gynecology, University of Lubumbashi, Lubumbashi, Democratic Republic of the Congo; 12Department of Obstetrics and Gynecology, University of Kisangani, Kisangani, Democratic Republic of the CongoCorrespondence: Justin Lussy Paluku, Email justin.paluku@unigom.ac.cdPurpose: The aim of this study was to assess quality of life (QoL) using the WHOQOL-BREF questionnaire among obstetric fistula (OF) patients before and after surgical repair of OF (SROF).Methods: A longitudinal cohort study was conducted between November 2022 and October 2023 in the Democratic Republic of the Congo (DRC) among OF patients to assess their QoL before and after SROF. A systematic sampling technique was used to recruit a total of 158 OF patients. The WHOQOL-BREF questionnaire assessed general health, life experience, as well as physical, social, psychological, and environmental domains.Results: The mean age among the 158 respondents was 33.51 ± 9.63 years, and 77.85% of them lived in rural areas. In terms of surgical outcomes, 80.38% had closure of the OF with regained continence, 5.7% had closure of the OF with persistent incontinence, and 13.9% had a failed surgical repair. Overall mean QoL scores were higher after OF surgical repair (3.83, standard deviation [SD]=0.89) in comparison to pre-operative (1.58, SD=0.63) (p< 0.001). These QoL improvements included physical (mean score 66.32 post-surgery versus 28.37 before, p< 0.001), social (mean score 64.92 post-surgery versus 27.90 before, p< 0.001), psychological (mean score 68.09 post-surgery versus 21.28 before, p< 0.001), environmental (mean score 48.41 post-surgery versus 16.91 before p< 0.001), and general domains. Patients with a successful OF repair had a better QoL score than those with a closed fistula but ongoing incontinence or those for whom surgery failed to close the fistula.Conclusion: The present study showed that among OF patients, all QoL domains were impaired before surgical repair and significantly improved after surgery. Successful OF closure alleviates the consequences of OF and helps to restore patients’ wellbeing. Our findings call for improved access to high-quality surgical repair services as a fundamental right for OF patients.Keywords: quality of life, obstetric fistula, surgical repair, questionnaire WHOQOL-BREF, DRC

Aim: Nonrestorative low anterior resection (n‐rLAR) (also known as low Hartmann's) is performed for rectal cancer when a poor functional outcome is anticipated or there have been problems when constructing the anastomosis. Compared with restorative LAR (rLAR), little oncological outcome data are available for n‐rLAR. The aim of this study was to compare oncological outcomes between rLAR and n‐rLAR for primary rectal cancer. Method: This was a nationwide cross‐sectional comparative study including all elective sphincter‐saving LAR procedures for nonmetastatic primary rectal cancer performed in 2011 in 71 Dutch hospitals. Oncological outcomes of patients undergoing rLAR and n‐rLAR were collected in 2015; the data were evaluated using Kaplan–Meier survival analysis and the results compared using log‐rank testing. Uni‐ and multivariable Cox regression analysis was used to evaluate the association between the type of LAR and oncological outcome measures. Results: A total of 1197 patients were analysed, of whom 892 (75%) underwent rLAR and 305 (25%) underwent n‐rLAR. The 3‐year local recurrence (LR) rate was 3% after rLAR and 8% after n‐rLAR (P < 0.001). The 3‐year disease‐free survival and overall survival rates were 77% (rLAR) vs 62% (n‐rLAR) (P < 0.001) and 90% (rLAR) vs 75% (n‐rLAR) (P < 0.001), respectively. In multivariable Cox analysis, n‐rLAR was independently associated with a higher risk of LR (OR = 2.95) and worse overall survival (OR = 1.72). Conclusion: This nationwide study revealed that n‐rLAR for rectal cancer was associated with poorer oncological outcome than r‐LAR. This is probably a noncausal relationship, and might reflect technical difficulties during low pelvic dissection in a subset of those patients, with oncological implications. [ABSTRACT FROM AUTHOR]

The purpose of this study was to develop a rapid and fully automatic method for the assessment of microvascular density and perfusion in sidestream dark field (SDF) images. We modified algorithms previously developed by our group for microvascular density assessment and introduced a new method for microvascular perfusion assessment. To validate the new algorithm for microvascular density assessment, we reanalyzed a selection of SDF video clips (n = 325) from a study in intensive care patients and compared the results to (semi-)manually found microvascular densities. The method for microvascular perfusion assessment (temporal SDF image contrast analysis, tSICA) was tested in several video simulations and in one high quality SDF video clip where the microcirculation was imaged before and during circulatory arrest in a cardiac surgery patient. We found that the new method for microvascular density assessment was very rapid (<30 s/clip) and correlated excellently with (semi-)manually measured microvascular density. The new method for microvascular perfusion assessment (tSICA) was shown to be limited by high cell densities and velocities, which severely impedes the applicability of this method in real SDF images. Hence, here we present a validated method for rapid and fully automatic assessment of microvascular density in SDF images. The new method was shown to be much faster than the conventional (semi-)manual method. Due to current SDF imaging hardware limitations, we were not able to automatically detect microvascular perfusion. [ABSTRACT FROM AUTHOR]

Purpose: Exercise testing is often used to assess cardiac function during physical exertion to obtain diagnostic information. However, this procedure is limited to measuring the electrical activity of the heart using electrocardiography and intermittent blood pressure (BP) measurements and does not involve the continuous assessment of heart functioning. In this study, we compared continuous beat-to-beat pulse contour analysis to monitor noninvasive cardiac output (CO) during exercise with inert gas rebreathing and respired gas analysis.Methods: Nineteen healthy male volunteers were subjected to bicycle ergometry testing with increasing workloads. Cardiac output was deter- mined noninvasively by continuous beat-to-beat pulse contour analysis (Nexfin) and by inert gas rebreathing, and estimated using the respired gas analysis method. The effects of the rebreathing maneuver on heart rate (HR), stroke volume (SV), and CO were evaluated.Results: The CO values derived from the Nexfin- and inert gas rebreathing methods were well correlated (r = 0.88, P < 0.01) and the limits of agreement were 30.3% with a measurement bias of 0.4 ± 1.8 L/min. Nexfin- and respired gas analysis-derived CO values correlated even better (r = 0.94, P < 0.01) and the limits of agreement were 21.5% with a measurement bias of -0.70 ± 1.6 L/min. At rest, the rebreathing maneuver increased HR by 13 beats/min (P < 0.01), SV remained unaffected (P = 0.7), while CO increased by 1.0 L/min (P < 0.01). Rebreathing did not affect these parameters during exercise.Conclusions: Nexfin continuous beat-to-beat pulse contour analysis is an appropriate method for noninvasive assessment of CO during exercise. [ABSTRACT FROM AUTHOR]

The Democratic Republic of Congo hosts the longest-running and largest United Nations peacekeeping mission in history. The United Nations also has reckoned with sexual exploitation and abuse in its own ranks and, in 2003, recognized its importance with a Bulletin which became known as the 'zero tolerance policy'. Policymakers and researchers have paid little sustained attention, however, to children fathered by peacekeepers. In this article, we share the results of our mixed-methods SenseMaker® research with community members who interact with peacekeeping personnel and interviews with 58 women who are raising children fathered by peacekeepers. Despite the United Nations policies in place, most women did not report children fathered by peacekeepers and did not receive systematic support. The analysis reveals a large gap between the aspirations of the 'zero tolerance policy' and its operationalization in the Democratic Republic of Congo. We uncovered deep poverty and insecurity as both driving and resulting from women's sexual encounters with peacekeepers, with support needs largely unmet. We argue that there is a lack of enforcement of the United Nations policies, jurisdictional complexity and inaccessible justice, as well as significant gaps between the United Nations' approach to investigating and supporting children fathered by peacekeepers and the expectations of mothers, resulting in worsened life conditions for mothers and their children., (© The Author(s) 2023.)

Introduction: Visible minorities, a growing segment of Canada's population, have voiced concerns about experiencing racism while receiving care in the emergency department (ED). Understanding the ED care experiences of visible minorities is crucial to improving care and reducing health disparities., Methods: From June to August 2021, we collected data from participants in Kingston, Ontario using a sensemaking approach. Individuals who had accessed emergency care or accompanied someone else to the ED in the prior 24 months were eligible to participate. After sharing a brief narrative about their care experience, participants interpreted the experience by plotting their perspectives on a variety of pre-determined questions. Here, we conducted a thematic analysis of narratives involving patients who identified as visible minorities and complemented it with quantitative analysis of the participants' interpretative responses. This mixed-methods approach highlighted the distinct experiences of visible minority participants in relation to a comparison group., Results: Of the 1973 unique participants, 117 identified as a visible minority and 949 participants did not identify with an equity-deserving group (comparison group). Visible minority participants were more likely to report that too little attention was paid to their identity and more likely to express a desire for a balance between receiving the best medical care and being treated with kindness and respect. Visible minorities' ED experiences were also more likely to be impacted by how emergency staff behaved. Qualitative analysis revealed negative experiences of feeling uninformed and disempowered, facing judgement and discrimination, and experiencing language barriers. Positive experiences of receiving compassionate care from staff also emerged., Conclusion: Visible minority perceptions of ED care were often negative and mainly focused on staff treatment. Cultural competency and language translation services are key areas for improvement to make ED care more accessible and equitable.

In 2018, the Canadian Association of Emergency Physicians (CAEP) academic symposium included developing recommendations on supporting global emergency medicine (EM) in Canadian departments and divisions. Members of CAEP's Global EM committee created a four-part series to be published in CJEM that would build upon the symposium recommendations. The objective is to offer practical tools to EM physicians interested in becoming involved in Global EM, as well as provide departments with successful Canadian case examples that foster, facilitate, and grow Global EM efforts. This submission is the fourth paper of the series which focuses on education and continuing professional development for Global EM. It includes resources for resident global EM electives, fellowship training and ongoing or additional CPD training for practicing EM physicians. It also highlights the importance of pre-departure training and other required elements of engaging responsibly in Global EM work., (© 2024. The Author(s), under exclusive licence to the Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Background: Persons with disabilities (PWD) are more likely to visit the emergency department (ED) and often have complex health needs when accessing care in the ED. Yet there is limited understanding of ED care experiences among PWD, especially in a Canadian context. The aim of this study was to examine the ED care experiences of PWD in contrast to a comparison group in Kingston, Ontario to better understand their health care needs., Methods: A mixed-methods study with a community-based participatory approach examining participants' past ED care experiences (within 24 months) was conducted in Kingston, ON. Quantitative data from those with disabilities and those from the comparison group were compared using chi squared tests to identify differences between groups. An inductive and deductive thematic analysis approach was used to identify themes in the shared qualitative data. Convergence of findings across quantitative and qualitative data was undertaken., Results: A total of 175 participants identified as having a disability. In contrast with the comparison group ( N  = 949), PWD were more likely to report being given too little attention to their needs ( p  < 0.001), that it was more important to be treated with kindness/respect than to receive the best possible medical care ( p  < 0.001), to report feelings of disrespect and/or judgement ( p  < 0.001), and that better understanding of personal identity/situation/culture and better communication would improve ED care. Qualitative analysis highlighted the following themes: poor communication between PWD and health care providers (HCP), compassionate medical care received, perceived HCP negative attitudes/beliefs related to having a disability and substance misuse, and perceived HCP lack of knowledge/skill to treat the unique health needs of PWD., Conclusion: Findings highlight the need to improve ED care for PWD. Future quality improvement initiatives should focus on incorporating a deeper understanding of disability into medical education and emergency medicine (EM) residency education, designing curricula that emphasize cultural humility, and implementing community-based placements providing opportunities for health professionals to work with and learn from PWD., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Haque, Gaspari, Bobbette, Walker and Bartels.)

Introduction: With global cesarean section rates rising, there's concern about increase in obstetric vesico-uterine fistula (OVUF). Very little is known about this anatomoclinical entity of obstetric fistula in Africa in general and in DRC in particular. Our purpose was to describe the epidemiological, clinical, and therapeutic aspects of OVUF in the Democratic Republic of the Congo (DRC)., Methods: This was a descriptive cross-sectional study. Data were collected from patients who presented with OVUF across seven provinces of the DRC (North Kivu, Haut-Uélé, Kasai Central, Kwilu, Maniema, Nord-Ubangi and Sankuru) from January 2017 to December 2022. Study variables were epidemiological, clinical, and therapeutic features., Results: Of 1,267 patients presenting with obstetric fistulas, 355 (28.0%) had OVUF. The mean age was 32.9 ± 11.6 years, 80.6% of patients (286/355) lived in rural areas, and the majority had a low level of education (40% no formal education, 30.1% primary school, 28.7% secondary school). In total, 64.8% of patients were primiparous (230/355) and in all (100%) cases, OVUF was caused iatrogenically during cesarean delivery. Majority (76.3%) of patients laboured for one day or less (mean duration 1.0 ± 0.5 days) before giving birth, and the fetus died in 58.3% of cases. In 35.8% of cases, the fistula had lasted more than 10 years (mean age 10.1 ± 10.0 years) before repair. A proportion of 88.2% (n = 313) of OVUF was isolated while 11.3% (n = 40) was associated with a uretero-vaginal fistula. In 82.8% (n = 294) of cases the OVUF was single. The average fistula size was 2.4 ± 1.0 cm (range: 0.5 and 5.5 cm) and 274 (77.2%) fistulas measured between 1.5 and 3 cm, with 14.9% (n = 53) of them larger than 3 cm. Fibrosis was present in 65.1% of cases, cervical involvement was absent in 97.7% and post-operative complications were absent in 94.4%. In all cases, the OVUF was surgically repaired abdominally with a success rate of 97.5% (346/355)., Conclusion: The proportion of OVUF is relatively high in the DRC. Most affected patients were young, under-educated, primiparous women living in rural areas. Cesarean section was the sole identified cause of OVUF which was isolated, single, without fibrosis, in majority of cases. Abdominal repair of OVUF was very effective, with good results in almost all cases. Teaching young doctors working mainly in remote areas how to perform safe cesarean section is needed to reduce incidence of OVUF in DRC., (© 2024. The Author(s).)

Background: Adverse childhood experiences (ACEs), in combination with adverse community environments, can result in traumatic stress reactions, increasing a person's risk for chronic physical and mental health conditions. Family resilience refers to the ability of families to withstand and rebound from adversity; it involves coping with disruptions as well as positive growth in the face of sudden or challenging life events, trauma, or adversities. This study aimed to identify factors contributing to family and community resilience from the perspective of families who self-identified as having a history of adversity and being resilient during the COVID-19 pandemic., Methods: This study used Photovoice, a visual participatory research method which asks participants to take photographs to illustrate their responses to a research question. Participants consisted of a maximum variation sample of families who demonstrated family level resilience in the context of the pair of ACEs during the COVID-19 pandemic. Family members were asked to collect approximately five images or videos that illustrated the facilitators and barriers to well-being for their family in their community. Semi-structured in-depth interviews were conducted using the SHOWeD framework to allow participants to share and elucidate the meaning of their photos. Using thematic analysis, two researchers then independently completed line-by-line coding of interview transcripts before collaborating to develop consensus regarding key themes and interpretations., Results: Nine families were enrolled in the study. We identified five main themes that enhanced family resilience: (1) social support networks; (2) factors fostering children's development; (3) access and connection to nature; (4) having a space of one's own; and (5) access to social services and community resources., Conclusions: In the context of additional stresses related to the COVID-19 pandemic, resilient behaviours and strategies for families were identified. The creation or development of networks of intra- and inter-community bonds; the promotion of accessible parenting, housing, and other social services; and the conservation and expansion of natural environments may support resilience and health., (© 2024. The Author(s).)

Background: It is estimated that since 2014, approximately 7.3 million Venezuelan migrants/refugees have left the country. Although both male and female migrants/refugees are vulnerable, female migrants/refugees are more likely to face discrimination, emotional, physical, and sexual violence. Currently there is a lack of literature that explores the experiences of pregnant Venezuelan migrants/refugees. Our aim is to better understand the experience of this vulnerable population to inform programming., Methods: In the parent study, Spryng.io's sensemaking tool was used to gain insight into the gendered migration experiences of Venezuelan women/girls. A total of 9339 micronarratives were collected from 9116 unique participants in Peru, Ecuador and Brazil from January to April 2022. For the purpose of this analysis, two independent reviewers screened 817 micronarratives which were identified by the participant as being about someone who was pregnant, ultimately including 231 as part of the thematic analysis. This was an exploratory study and an open thematic analysis of the narratives was performed., Results: The mean age and standard deviation of our population was 25.77 ± 6.73. The majority of women in the sample already had at least 1 child (62%), were married at the time of migration (53%) and identified as low socio-economic status (59%). The qualitative analysis revealed the following main themes among pregnant Venezuelan migrants/refugees: xenophobia in the forms of racial slurs and hostile treatment from health-care workers while accessing pregnancy care; sexual, physical, and verbal violence experienced during migration; lack of shelter, resources and financial support; and travelling with the hopes of a better future., Conclusion: Pregnant Venezuelan migrants/refugees are a vulnerable population that encounter complex gender-based and societal issues that are rarely sufficiently reported. The findings of this study can inform governments, non-governmental organizations, and international organizations to improve support systems for pregnant migrants/refugees. Based on the results of our study we recommend addressing xenophobia in health-care centres and the lack of shelter and food in host countries at various levels, creating support spaces for pregnant women who experience trauma or violence, and connecting women with reliable employment opportunities and maternal healthcare., (© 2024. The Author(s).)

Introduction: Obstetric fistula (OF) repair surgery aims to restore the anatomical and functional integrity of the urinary tract, allowing affected women to regain their dignity and quality of life. However, in some cases, this surgical repair may fail. The objective of this study was to develop a predictive score to identify factors associated with the failure of surgical repair of obstetric urethro-vaginal fistula (FSROUVF) in the Democratic Republic of the Congo (DRC)., Methods: This is an analytical cross-sectional study of 358 patients with obstetric urethro-vaginal fistula (OUVF) who received surgical repair. We conducted bivariate and multivariate analyses. Score discrimination was assessed using the receiver operating characteristic (ROC) curve, C-index, and score calibration according to the Hosmer-Lemeshow test., Results: Surgical repair of OUVF failed in 24.86% of cases (89/358). After logistic modelling, 6 criteria predicted FSROUVF: the use of intravaginal indigenous products (AOR = 3.59; 95% CI: 1.51-8.53), the presence of fibrosis (AOR = 6.37; 95% CI: 1.70-23.82), the presence of 2 or more fistulas in the same patient (AOR = 7.03; 95% CI: 3.14-15.72), the total urethral damage (AOR = 3.29; 95% CI: 1.36-7.95), the fistula size > 3 cm (AOR = 5.65; 95% CI: 2.12-15.01), and the postoperative infection (AOR = 351.10; 95% CI: 51.15-2409.81). A score of 0 to 14 was obtained, with a value ≤5 points indicating a low risk of FSROUVF, a value between 6 and 8 indicating a moderate risk, and a value ≥9 points corresponding to a high risk of FSROUVF. The area under the ROC curve of the score is 0.938 with a sensitivity of 60.67%, a specificity of 96.28%, a positive predictive value of 84.38%, and a negative predictive value of 88.10%., Conclusion: We report a FSROUVF rate in the DRC approaching a quarter of operative patients. Predictors of failure included fibrosis, presence of 2 or more fistulas, total urethral involvement, fistula size greater than 3 cm, postoperative infection, and use of intravaginal indigenous products. These factors are constitutive of the HEAL Africa score, which once validated, may have value in pre-operative counselling of patients. This study could be valuable for policy and strategies to address the problem of OUVF in the DRC and in resource limited settings more generally., (© 2024. The Author(s).)

Introduction: Equity-deserving groups (EDGs) face societal barriers, including healthcare barriers within the emergency department (ED), due to discrimination. Most patient-care experience research considers only a single-axis perspective, neglecting multifaceted impacts of discrimination, or intersectionality., Methods: Detailed is a secondary analysis of a mixed-methods, cross-sectional study conducted at the Kingston Health Sciences Centre (KHSC) between June and August 2021. A quantitative analysis was conducted to identify differences between participants who did not identify as equity-deserving (controls), and those who identified with 1, 2, or 3 EDGs, respectively. The research team conducted thematic analysis on the shared micronarratives to contextualize the quantitative results. The research team also held focus groups with community partners that served EDGs to gain their insights on study findings and add their perspectives to the captured themes., Results: Comparing 1973 individuals belonging to none, 1, 2, or 3 EDGs revealed significant differences in patient-perceived attention to their needs ( P  < .001), patient-control in health care decision-making ( P  = .001), and whether quality medical care or experiencing kindness/respect was more important ( P  = .003). Three themes were identified: stigma and discrimination , lack of patient-centered care , and need for improved patient-provider communication ., Conclusion: The study's findings contribute to a sparse body of evidence on EDG-care experiences in the ED through an intersectionality lens. Future research efforts should evaluate the complex interactions of specific EDG memberships to improve care experiences., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The UN's Zero Tolerance Policy, which bans all relationships between UN staff and locals, portrays all relationships as exploitative, fails to account for nuances in these relationships and does not acknowledge the agency of local women or communities. This study uses community-based qualitative data from eastern DRC that shares narratives on a wide variety of consensual relationships between peacekeepers and local women. Our paper uses a data-driven approach, including a post-colonial feminist lens, and ideas of structural agency to provide an expanded definition of agency that invites readers to re-examine their views of women in conflict settings. Finally, we provide clear recommendations for the UN and other international non-governmental agencies on policies related to sexual exploitation and abuse.

Background: People who use substances (PWUS) encounter significant barriers to accessing care for their complex health needs. As a result, emergency departments (EDs) often become the first point of healthcare access for many PWUS and are a crucial setting for the study of health inequities. This study aimed to understand the ED healthcare experiences of PWUS with the intent of informing ways of improving the delivery of equitable care., Methods: This qualitative study was part of a larger cross-sectional, mixed-methods study that examined ED experiences among diverse underserved and equity-deserving groups (EDGs) within Kingston, Ontario, Canada. Participants shared and self-interpreted a story about a memorable ED or UCC visit within the preceding 24 months. Data from participants who self-identified as having substance use experiences was analyzed through inductive thematic analysis., Results: Of the 1973 unique participants who completed the survey, 246 participants self-identified as PWUS and were included in the analysis. Most participants were < 45 years of age (61%), male (53%), and white/European (57%). 45% identified as a person with a disability and 39% frequently struggled to make ends meet. Themes were determined at the patient, provider, and system levels., Patient: history of substance use and experience of intersectionality negatively influenced participants' anticipation and perception of care. Provider: negative experiences were linked to assumption making, feelings of stigma and discrimination, and negative perceptions of provider care. Whereas positive experiences were linked to positive perceptions of provider care. System: timeliness of care and the perception of inadequate mental health resources negatively impacted participants' care experience. Overall, these themes shaped participants' trust of ED staff, their desire to seek care, and their perception of the care quality received., Conclusions: PWUS face significant challenges when seeking care in the ED. Given that EDs are a main site of healthcare utilization, there is an urgent need to better support staff in the ED to improve care experiences among PWUS. Based on the findings, three recommendations are proposed: (1) Integration of an equity-oriented approach into the ED, (2) Widespread training on substance use, and (3) Investment in expert resources and services to support PWUS., (© 2023. The Author(s).)

Intimate partner violence (IPV) is a public health problem that has devastating physical, psychological, and economic consequences. The emergency department (ED) is an important point of contact for individuals experiencing IPV. However, there are few studies synthesizing interactions between patients experiencing IPV and providers. We aimed to summarize the existing evidence regarding (1) ED care experiences of patients with a history of IPV and (2) experiences of ED providers interacting with them. The secondary aim of this review was to evaluate high-quality care barriers and facilitators and to elucidate common causes of care avoidance. A literature search of peer-reviewed electronic databases was undertaken. Inclusion criteria consisted of studies detailing IPV-related patient or provider experiences surrounding ED visits. Articles published before 2000 or unavailable in English/French were excluded. A total of 772 studies were screened, yielding a final number of 41 studies. Negative patient experiences arose from individual-, institutional-, and system-level issues, commonly including adverse provider behavior. Negative provider experiences stemmed from individual-, institutional-, and system-level issues, such as a lack of knowledge and lack of infrastructure. Facilitators to positive patient experiences included interacting with empathetic providers, having privacy, and receiving timely specialized care. Facilitators to positive provider experiences included feeling well-equipped to manage IPV and having policies leading to appropriate care. Negative ED care experiences reveal inadequate care quality, ultimately leading to secondary victimization of individuals experiencing IPV. This review also uncovered important literature gaps regarding experiences of those who identify as equity-deserving., Competing Interests: Declaration of Conflicting InterestsThe author declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

This literature review synthesises existing evidence and offers a thematic analysis of primary care and emergency department experiences of lesbian, gay, bisexual, transgender, queer and/or any other sexual or gender minority (LGBTQ+) individuals in Canada. Articles detailing first-person primary or emergency care experiences of LGBTQ + patients were included from EMBASE, MEDLINE, PsycINFO and CINHAL. Studies published before 2011, focused on the COVID-19 pandemic, unavailable in English, non-Canadian, specific to other healthcare settings, and/or only discussing healthcare provider experiences were excluded. Critical appraisal was performed following title/abstract screening and full-text review by three reviewers. Of sixteen articles, half were classified as general LGBTQ + experiences and half as trans-specific experiences. Three overarching themes were identified: discomfort/disclosure concerns, lack of positive space signalling, and lack of healthcare provider knowledge. Heteronormative assumptions were a key theme among general LGBTQ + experiences. Trans-specific themes included barriers to accessing care, the need for self-advocacy, care avoidance, and disrespectful communication. Only one study reported positive interactions. LGBTQ + patients continue to have negative experiences within Canadian primary and emergency care - at the provider level and due to system constraints. Increasing culturally competent care, healthcare provider knowledge, positive space signals, and decreasing barriers to care can improve LGBTQ + experiences.

Background: Early reports raised alarms that intimate partner violence (IPV) increased during the COVID-19 pandemic, but initial studies showed that visits to emergency departments (EDs) decreased. This study assessed the impact of the prolonged pandemic and its associated restrictions on both rates of urgent care-seeking and injury severity for IPV., Methods: Data from the Kingston Health Sciences Centre's (KHSC) ED were utilized to compare IPV presentations during 'Pre-COVID' (December 17, 2018 - March 16, 2020) and 'COVID' (March 17, 2020 - June 16, 2021), as well as three periods of heightened local restrictions: 'Lockdown-1' (March 17 - June 12, 2020), 'Lockdown-2' (December 26, 2020 - February 10, 2021) and 'Lockdown-3' (April 8 - June 2, 2021). The primary outcomes were incidence rate of IPV visits and injury severity, which was assessed using the Clinical Injury Extent Score (CIES) and Injury Severity Score (ISS)., Results: A total of 128 individuals were included. This sample had mean age of 34 years, was comprised of mostly women (97%), and represented a variety of intimate relationship types. Some individuals presented multiple times, resulting in a total of 139 acute IPV presentations. The frequency of IPV visits during COVID was similar to the Pre-COVID time period (67 vs. 72; p = 0.67). Incidence rate was 13% higher during COVID, though this difference was non-significant (6.66 vs. 5.90; p = 0.47). IPV visit frequency varied across lockdown periods (11 in Lockdown-1, 12 in Lockdown-2 and 6 in Lockdown-3), with the highest incidence rate during Lockdown-2 (12.71). There were more moderate and severe injuries during COVID compared to Pre-COVID, but mean CIES was not statistically significantly different (1.91 vs. 1.69; p = 0.29), nor was mean ISS (11.88 vs. 12.52; p = 0.73)., Conclusions: During the 15-months following the start of COVID-19, there were small, but non-significant increases in both incidence rate and severity of IPV presentations to the KHSC ED. This may reflect escalation of violence as pandemic restrictions persisted and requires further investigation., (© 2023. The Author(s).)

Purpose: This systematic review investigates the methodological and ethical implications of using remote data collection tools to measure sexual/reproductive health (SRH) and gender-based violence (GBV) outcomes among women and girls in humanitarian and fragile settings. Methods: We included empirical studies of all design types that collected any self-reported primary data related to SRH/GBV using information and communication technology, in the absence of in-person interactions, from women and girls in humanitarian and fragile settings. The search was run in March 2021 without filters or limits in Ovid Medline, Embase, Web of Science, Clinicaltrials.gov, and Scopus. Quality was assessed using an adapted version of the MMAT tool. Two reviewers independently determined whether each full text source met the eligibility criteria, and conflicts were resolved through consensus. A-priori extraction fields concerned methodological rigor and ethical considerations. Results: 21 total studies were included. The majority of studies were quantitative descriptive, aiming to ascertain prevalence. Telephone interviews, online surveys, and mobile applications, SMS surveys, and online discussion forums were used as remote data collection tools. Key methodological considerations included the overuse of non-probability samples, lack of a defined sampling frame, the introduction of bias by making eligibility contingent on owning/accessing technology, and the lack of qualitative probing. Ethical consideration pertained to including persons with low literacy, participant safety, use of referral services, and the gender digital divide. Conclusion: Findings are intended to guide SRH/GBV researchers and academics in critically assessing methodological and ethical implications of using remote data collection tools to measure SRH and GBV in humanitarian and fragile settings.

Background: Global Health opportunities are popular, with many reported benefits. There is a need however, to identify and situate Global Health competencies within postgraduate medical education. We sought to identify and map Global Health competencies to the CanMEDS framework to assess the degree of equivalency and uniqueness between them., Methods: JBI scoping review methodology was utilized to identify relevant papers searching MEDLINE, Embase, and Web of Science. Studies were reviewed independently by two of three researchers according to pre-determined eligibility criteria. Included studies identified competencies in Global Health training at the postgraduate medicine level, which were then mapped to the CanMEDS framework., Results: A total of 19 articles met criteria for inclusion (17 from literature search and two from manual reference review). We identified 36 Global Health competencies; the majority (23) aligned with CanMEDS competencies within the framework. Ten were mapped to CanMEDS roles but lacked specific key or enabling competencies, while three did not fit within the specific CanMEDS roles., Conclusions: We mapped the identified Global Health competencies, finding broad coverage of required CanMEDS competencies. We identified additional competencies for CanMEDS committee consideration and discuss the benefits of their inclusion in future physician competency frameworks., Competing Interests: None of the authors have any conflicts of interest to declare., (© 2023 Pritchard, Alavian, Soogoor, Bartels, Hall; licensee Synergies Partners.)

Background: Emergency departments (EDs) serve an integral role in healthcare, particularly for vulnerable populations. However, marginalized groups often report negative ED experiences, including stigmatizing attitudes and behaviours. We engaged with historically marginalized patients to better understand their ED care experiences., Method: Participants were invited to complete an anonymous mixed-methods survey about a previous ED experience. We analysed quantitative data including controls and equity-deserving groups (EDGs) - those who self-identified as: (a) Indigenous; (b) having a disability; (c) experiencing mental health issues; (d) a person who uses substances; (e) a sexual and gender minority; (f) a visible minority; (g) experiencing violence; and/or (h) facing homelessness - to identify differences in their perspectives. Differences between EDGs and controls were calculated with chi squared tests, geometric means with confidence ellipses, and the Kruskal-Wallis H test., Results: We collected a total of 2114 surveys from 1973 unique participants, 949 controls and 994 who identified as equity-deserving. Members of EDGs were more likely to attribute negative feelings to their ED experience (p < 0.001), to indicate that their identity impacted the care received (p < 0.001), and that they felt disrespected and/or judged while in the ED (p < 0.001). Members of EDGs were also more likely to indicate that they had little control over healthcare decisions (p < 0.001) and that it was more important to be treated with kindness/respect than to receive the best possible care (p < 0.001)., Conclusion: Members of EDGs were more likely to report negative ED care experiences. Equity-deserving individuals felt judged and disrespected by ED staff and felt disempowered to make decisions about their care. Next steps will include contextualizing findings using participants' qualitative data and identifying how to improve ED care experiences among EDGs to make it more inclusive and better able to meet their healthcare needs., (© 2023. The Author(s).)

Sexual abuse and exploitation (SEA) perpetrated by UN peacekeepers while on mission is a violation of human rights and undermines the goal of upholding human rights in countries that host peacekeeping missions. In addition to survivors, children fathered by peacekeepers are also victims of SEA that need protection. Stigma poses negative life course consequences for SEA survivors and their peacekeeper-fathered children. However, there is a considerable lack of empirical research concerning the stigma experiences of SEA survivors and their children in post-colonial contexts. The present study addresses this knowledge gap by drawing on The United Nations Stabilization Mission in Haiti as a case study to examine the lived experiences of stigma among SEA survivors and their resultant children. Using 18 qualitative semi-structured interviews conducted in 2017 with Haitian women raising peacekeeper-fathered children, we organized qualitative codes according to Link and Phelan's conceptual model of stigma. The stigmatization process was explored through the themes of labeling, stereotyping, separation, and status loss and discrimination, as described by Link and Phelan. In addition, we nuanced the lived experiences of stigma by discussing the buffering roles of familial acceptance, skin phenotype, and the Haitian context. The findings have implications for the UN. We advocate that stigma be recognized and acted upon as a fundamental protection concern for SEA survivors and their children. Accordingly, the UN has an obligation to provide stigma-related supports for victims and complainants as well as to facilitate long-term child support for the children left behind by peacekeepers.

Sexual exploitation and abuse (SEA) of women and girls by United Nations (UN) peacekeepers is an international concern. However, the typical binary measurement of SEA (indicating that it occurred, or it did not) disregards varying exposure levels and the complex circumstances surrounding the interaction. To address this gap, we constructed an index to quantify the degree to which local women and girls were exposed to UN-peacekeeper perpetrated SEA. Using survey data ( n  = 2867) from the Democratic Republic of Congo (DRC), eight indicators were identified using a combination of qualitative (thematic analysis of narrative data) and quantitative variables. With further development, this index may offer a more comprehensive and nuanced perspective of peacekeeper-perpetrated SEA that can better inform SEA prevention and intervention efforts.

Children fathered and abandoned by United Nations peacekeepers are an unintended consequence of peacekeeping operations. Research suggests that the social identity of peacekeeper-fathered children (PKFC) is complex and contradictory. While economically disadvantaged, PKFC's biracial background confers elements of racial privilege. Using the Democratic Republic of Congo as a case study, the present research evaluates the impact of racial differences on PKFC's social standing. Drawing on in-depth interviews with a racially heterogeneous sample of 35 PKFC and 60 mothers, we analyse how race and poverty interact and cause PKFC's conflicting social role. The data demonstrates that being of mixed race leads to the expectation of a higher living standard. Since most PKFC live in extreme economic deprivation, their anticipated privilege contrasts with reality. We found that the stigmatizing effects of poverty were amplified by biracial identification, leading to additional disadvantage, epitomised in the term "Muzungu aliye homba" [white child gone bankrupt]. The findings add to research on 'children born of war' and show the role of culture in shaping youth's social identities. Based on PKFC's intersecting burdens, we make policy recommendations that address the nexus of race and poverty., (© 2022. The Author(s).)

Emergency departments (EDs) are an important source of care for people with mental health (MH) concerns. It can be challenging to treat MH in EDs, and there is little research capturing both patient and provider perspectives of these experiences. We sought to summarize the evidence on ED care experiences for people with MH concerns in North America, from both patient and provider perspectives. Medline and EMBASE were searched using PRISMA guidelines to identify primary studies. Two reviewers conducted a qualitative assessment of included papers and inductive thematic analysis to identify common emerging themes from patient and provider perspectives. Seventeen papers were included. Thematic analysis revealed barriers and facilitators to optimal ED care, which were organized into three themes each with sub-themes: (1) interpersonal factors, including communication, patient-staff interactions, and attitudes and behaviours; (2) environmental factors, including accommodations, wait times, and restraint use; and (3) system-level factors, including discharge planning, resources and policies, and knowledge and expertise. People with MH concerns and ED healthcare providers (HCPs) share converging perspectives on improving ED connections with community resources and diverging perspectives on the interplay between system-level and interpersonal factors. Examining both perspectives simultaneously can inform improvements in ED care for people with MH concerns.

In 2010 following a catastrophic earthquake, Haiti saw the beginning of what would become the world's largest cholera epidemic. Nepalese United Nations peacekeepers were later implicated as the source of cholera. Our research examines Haitian community beliefs and perceptions, six-and-a-half years after the outbreak began, regarding the origin of Haiti's cholera outbreak. A narrative capture tool was used to record micronarratives of Haitian participants surrounding ten United Nations bases across Haiti. Seventy-seven micronarratives focused on cholera were selected for qualitative analysis from a larger dataset. Three themes emerged: who introduced cholera to Haiti, how cholera was introduced to Haiti, and preventative measures against cholera. With varying levels of confidence, the origins of the epidemic were conceptualised as directly resulting from the actions of the United Nations and Nepalese peacekeepers, exhibiting a distrust of foreign intervention in Haiti and frustration with inadequate water and sanitation infrastructure that facilitated widespread transmission of cholera. This study reinforces the need for additional transparent communication from the UN to address ongoing misconceptions surrounding the cholera outbreak, action to clean water and sanitation practices in Haiti, and for the voices of Haitian citizens to be heard and included in reforming foreign aid delivery in the country.

In 2010, Haiti experienced one of the deadliest cholera outbreaks of the 21st century. United Nations (UN) peacekeepers are widely believed to have introduced cholera, and the UN has formally apologized to Haitians and accepted responsibility. The current analysis examines how Haitian community members experienced the epidemic and documents their attitudes around accountability. Using SenseMaker, Haitian research assistants collected micronarratives surrounding 10 UN bases in Haiti. Seventy-seven cholera-focused micronarratives were selected for a qualitative thematic analysis. The five following major themes were identified: (1) Cholera cases and deaths; (2) Accessing care and services; (3) Protests and riots against the UN; (4) Compensation; and (5) Anti-colonialism. Findings highlight fear, frustration, anger, and the devastating impact that cholera had on families and communities, which was sometimes compounded by an inability to access life-saving medical care. Most participants believed that the UN should compensate cholera victims through direct financial assistance but there was significant misinformation about the UN's response. In conclusion, Haiti's cholera victims and their families deserve transparent communication and appropriate remedies from the UN. To rebuild trust in the UN and foreign aid, adequate remedies must be provided in consultation with victims.

Competing Interests: Neither of the authors have a conflict of interest to report.

Background: Hepatitis B infection is a major health concern in Myanmar. Hepatitis B birth dose vaccination to prevent mother-to-child transmission is not universal, especially in births outside of health care facilities. Little is documented about delivery of immunization programs in rural Myanmar or in conflict-affected regions. To address this gap, this study describes the implementation of a novel community delivered neonatal hepatitis B immunization program in rural Karenni State, Myanmar., Methods: A mixed-methods study assessed the effectiveness and feasibility of hepatitis B birth dose immunization program. 1000 pregnant women were screened for hepatitis B virus (HBV) infection using point of care testing. Neonates of HBV positive mothers were immunized with a three dose HBV vaccine schedule at birth, 1, and 6 months of age. HBV testing was completed for children at 9 months to assess for infection. Descriptive statistics were collected including demographic data of mothers, neonatal vaccination schedule completion, and child HBV positivity at 9 months. Qualitative data examining barriers to implementation were collected through semi-structured interviews, participant-observation, and analysis of program documents. Themes were codified and mapped onto the Consolidated Framework for Implementation Research., Results: 46 pregnant women tested HBV positive leading to 40 live births. 39 women-child dyads were followed until the 9-month age mark. With the exception of two neonates who received their birth dose past 24 hours, all children received their vaccines on time. None of the 39 children tested positive for HBV at nine months. Themes regarding barriers included adaptability of the program to the rural setting, friction with other stakeholders and not meeting all needs of the community. Identified strengths included good communication and leadership within the implementing ethnic health organization., Conclusion: A community delivered neonatal HBV vaccination program by ethnic health organizations is feasible and effective in rural Myanmar., Competing Interests: The authors have declared that no competing interests exist.

Background: Sexual exploitation and abuse (SEA) by UN peacekeepers perpetrated against local women and girls is a concern in the Democratic Republic of Congo (DRC). While stigma associated with sexual and gender-based violence is well documented more broadly, little is known about stigma associated with peacekeeper-perpetrated SEA., Methods: The aim of this study was to examine how the degree of exposure to SEA affects community perceptions of a woman or girl's (1) social status (public stigma) and (2) institutional support in her community (structural stigma). Two poisson regression models with robust variance estimation were constructed utilizing community survey data of SEA experiences from eastern DRC (n = 2867) to quantify these associations. Relevant demographic variables were assessed for confounding and effect modification., Results: The prevalence of public and structural stigma were 62.9 and 19.3% respectively across the sample. A positive relationship was demonstrated between level of exposure of SEA and diminished social status in which women and girls experiencing moderate levels of SEA were at the greatest risk of public stigmatization after adjusting for confounding (RR: 1.94; CI: 1.66-2.26). Similarly, a positive relationship between exposure to SEA and inadequate institutional support was shown for female narrators wherein women and girls experiencing a high degree of SEA were 6.53 times as likely to receive inadequate support (RR: 6.53; CI: 3.63, 11.73). This contrasted with male narrated stories for whom there was no significant association between the SEA exposure level and institutional support., Conclusions: Women/girls with high exposure levels to UN peacekeeper-perpetrated SEA are at the highest risk of public and structural stigmatization, which should be more routinely considered when conceptualizing the consequences of SEA in peacekeeping contexts. The frequent occurrence of both public and structural stigma, coupled with the varying perceptions by sex, demonstrates the need for a multi-faceted approach for stigma reduction., (© 2021. The Author(s).)

Background: The United Nations Organization Stabilization Mission in the Democratic Republic of Congo (MONUSCO) has been marred by widespread allegations of sexual exploitation and abuse (SEA) of women and girls by UN peacekeepers. There is minimal research conducted on the perceptions of communities most affected by the SEA themselves, and even less about those below the age of 18., Methods: Using mixed-methods data, we examined the perceptions of adolescents aged 13-17 on how the lives of women and girls have been affected by the presence of UN peacekeepers within the DRC. SenseMaker, a mixed-methods narrative capture tool, was used to survey participants around six United Nations bases across eastern DRC. Each participant shared a story about the experiences of Congolese women and girls in relation to MONUSCO personnel and interpreted their own stories by answering a series of questions. Patterns of adolescent perspectives (aged 13-17) were analyzed in comparison to all other age groups and emerging qualitative themes were mapped onto quantitative variables., Results: Quantitative data showed that adolescents were more likely, in comparison to all other age groups, to perceive interactions between peacekeepers and women/girls as being initiated by the woman/girl, that the MONUSCO personnel was perceived to be able to offer protection, and that the interactions between local women/girls and peacekeepers were sexual in nature. Three qualitative themes emerged: poverty bringing peacekeepers and women/girls together, material/financial gain through transactional sex and sex work, and support-seeking actions of affected women/girls., Conclusions: Our mixed methods data illustrate the problematic finding that adolescents facing poverty may perceive SEA as protective through the monetary and material support gained. These findings contribute to the growing body of literature on peacekeeping economies and have implications for the prevention of, and response to, peacekeeper-perpetrated SEA., (© 2021. The Author(s).)

Background: The current crisis in Syria has led to unprecedented displacement, with neighbouring Lebanon now hosting more than 1.5 million conflict-affected migrants from Syria. In many situations of displacement, adolescent girls are a vulnerable sub-group. This study explores and describes the self-reported unmet needs of Syrian adolescent girls who migrated to Lebanon between 2011 and 2016., Methods: This mixed-methods study focusing on the unmet needs of adolescent girls was part of a larger research project on child marriage among Syrian migrants in Lebanon. Participants were recruited using purposive sampling in three field locations in Lebanon by locally trained research assistants. One hundred eighty-eight Syrian adolescent girls chose to tell qualitative stories about their own experiences. Using handheld tablets and an application called "Sensemaker" stories were audio-recorded and later transcribed. Participants were asked to then self-interpret their stories by answering specific quantitative survey-type questions. Demographic information was also collected. NVivo was used to undertake deductive coding of the qualitative data using Maslow's Hierarchy of Needs as an analytic frame., Results: Among the 188 self-reported stories from adolescent girls, more than half mentioned some form of unmet need. These needs ranged across the five levels of Maslow's Hierarchy from physiological, safety, belonging, esteem and self-actualization. Nearly two thirds of girls mentioned more than one unmet need and the girls' expressed needs varied by marital status and time since migration. Unmet esteem needs were expressed in 22% of married, and 72% of unmarried girls. Belongingness needs were expressed by 13% of girls who migrated in the last 1-3 years and 31% of those who migrated in the previous 4-5 years., Conclusion: Many needs of displaced Syrian adolescent girls remain unmet in this situation of now protracted displacement. Girls most commonly expressed needs for love and belonging followed closely by needs for safety and basic resources. The level and type of unmet need differed by marital status and time since displacement. Unmet needs have been associated elsewhere with physical illness, life dissatisfaction, post-traumatic stress, depression, anxiety and even death. These results can inform integrated interventions and services specifically targeting adolescent girls and their families in the protracted migration situation now facing Lebanon., (© 2021. The Author(s).)

In 2017, malaria accounted for 435 000 deaths worldwide. Eleven percent (11%) of these deaths occurred in the Democratic Republic of Congo (DRC), where malaria continues to be a leading cause of morbidity and mortality. Children are amongst the most vulnerable to malaria, which causes 40% of childhood deaths in the country. Although many risk factors for developing malaria have been identified, there is a paucity of data available on the sociodemographic risk factors for pediatric malaria. A cross-sectional study including 131 febrile children aged 2 months to 14 years presenting to Heal Africa Hospital due to febrile illness. Guardians of participants answered a questionnaire about household and maternal characteristics, as well as child symptomatology. Malaria status was confirmed via blood smear. Results were analyzed using the chi-square test, likelihood ratios and a logistic regression. The absence of father as head of household (p=0.011) and gestational malaria (p=0.044) were significantly associated with pediatric malaria. This study provides insight into sociodemographic risk factors associated with pediatric malaria in the DRC. While further investigation is required, this study highlights the benefit of considering these factors when approaching the febrile child. A pediatric malaria assessment tool incorporating socio-demographics, symptoms and physical exam findings may guide investigations to reduce unnecessary testing and provide better patient-centred care., Competing Interests: The authors declare no competing interests., (Copyright: Mumbere Hangi Stan et al.)

Introduction and Objectives : It is well-documented that single mothers in sub-Saharan Africa face unique psychosocial challenges which can lead to child health and developmental disadvantages, often impacting life trajectories for both the mother and child. Years of instability, conflict, and widespread poor governance within the Democratic Republic of Congo (DRC) have resulted in magnified challenges for parents, making it more difficult to provide supportive and effective parenting. To address gaps in knowledge regarding the specific challenges experienced and adaptations made among single mothers raising children in contexts of adversity, the present study aimed to investigate the phenomenon of single mother parenting in the DRC. Methods : Cognitive Edge SenseMaker, a mixed-method data collection tool, was used to collect self-interpreted narratives among parents in eastern DRC. Quantitative SenseMaker data were uploaded into Tableau, a data organization and analysis tool, to visualize differences in response patterns between single mother ( n = 263) and two-parent family study participants ( n = 182). Single mother micronarratives ( n = 251) were then coded line-by-line and analyzed thematically. Qualitative themes identified in the single mother micronarratives were used to facilitate a deeper and more nuanced understanding of key quantitative SenseMaker findings. Findings and Conclusions : Our study found that single mothers experienced immense challenges raising children in the DRC, including financial-, health- and parenting-related hardships. Single mothers described negative emotions and higher levels of household adversity while providing for their children in situations of extreme poverty compared to two-parent family respondents. Self-reliance was exhibited among most single mothers in an attempt to overcome challenges, primarily financial barriers, and to prioritize the health and well-being of their children. However, many children still lacked access to sufficient food, education, and healthcare. Limited governmental and social security support for single mothers was identified as contributing to heightened challenges and the self-reliance observed among single mothers. Findings emphasize that additional research and attention should be directed towards identifying the specific needs of, and available resources for, single mothers in different localities in an effort to inform policies and programs that best support families.

Introduction: Peacekeeper-perpetrated sexual exploitation and abuse (SEA) in the Democratic Republic of Congo (DRC) account for 36% of the global reports of formal SEA allegations to the UN between 2007 and 2021. However, formally reported SEA represents only a fraction of that which occurs, and community experiences of peacekeeper-perpetrated SEA are likely different than those reflected in official UN documents., Methods: Using mixed-methods, cross-sectional data collected in the DRC in 2018, we used descriptive analysis and multivariate Poisson regression with robust error estimates to examine the participant and narrative characteristics associated with sharing an experience about peacekeeper-perpetrated SEA., Results: Participants in Bukavu (adjusted relative risk (aRR) 0.85, 95% CI 0.79 to 0.91) and Kalemie (aRR 0.75, 95% CI 0.69 to 0.81) were less likely to share narratives about sexual interactions, while civilian UN personnel (aRR 1.16, 95% CI 1.00 to 1.34) were slightly more likely to be implicated in narratives about sexual interactions. Narratives in which the outcome was deemed fair to the woman/girl were more likely to be about sexual interactions (aRR 1.07, 95% CI 1.02 to 1.12). Both the regression analysis and the participants' interpretation of the shared narratives illustrated the significant role poverty played in SEA, suggesting that the outcomes of sexual interactions may have been deemed fair since affected women/girls were perceived to have benefited financially/materially., Conclusion: There is significant variation between host communities in the likelihood of sharing narratives about SEA, which could prove useful for informing more targeted SEA prevention initiatives. Narratives about sexual interactions with UN personnel were more often deemed to have fair outcomes for the affected women/girls, likely related to ongoing poverty in host communities and perceived financial/material gain. These findings highlight how extreme poverty may impact perceptions around informed consent as well as fairness and require further study. Perceptions around fair outcomes would disincentivise formal reporting, which needs to be considered when devising community-based complaint networks., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Peacekeeping missions have been marred by reports of sexual exploitation and abuse (SEA) against local community members. However, there is limited research on how SEA against women/girls versus men/boys is perceived in peacekeeping host societies. In 2017 we collected micro-narratives in Haiti and then conducted a thematic analysis to understand how peacekeeper-perpetrated SEA was perceived by local community members comparing SEA against women/girls versus SEA against men/boys. Both male and female participants used language which suggested the normalization, in Haitian society, of both transactional sex with and rape of women/girls by UN personnel. In contrast, peacekeeper-perpetrated SEA against men/boys was viewed as unacceptable and was associated with homosexuality and related stigmatization. Overall, our results suggest that in Haiti, inequitable gender norms, the commodification of female sexuality, and homophobia result in SEA against males being recognized as a wrong that elicits outrage, while SEA against women/girls has been normalized. It is important to address the normalization of SEA against women/girls to prevent future violence and to recognize that SEA is also perpetrated against men/boys. Survivor-centered programs, sensitive to the needs of both male and female survivors, are required., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Bartels, King and Lee.)

Background: In sub-Saharan Africa, the use of modern contraception (MC) is a critical intervention aimed at reducing mortality rates associated with unintended, high-risk pregnancies. However, among Congolese women aged 15-49, the prevalence of MC use is low. Research suggests that women's general participation in decision-making is important in increasing MC use. However, little is known about the specific role of women's decision-making power over their own health care and how it relates to MC use. Thus, this study aimed to investigate the relationship between women's decision-making power over their own health care and use of MC., Methods: A cross-sectional secondary data analysis was conducted using the most recent data from the 2013-2014 Democratic Republic of the Congo (DRC) Demographic and Health Survey. Women who were considered in need of contraception based on their family planning preferences were included in the study population (N = 6422). Multivariate logistic regression was used to determine whether women's decision-making power over their own health care was associated with the use of MC., Results: Only one in ten women reported using a modern method of contraception. Logistic regression showed that women who made decisions alone regarding their own health care were more likely to use MC than women who had no say in these decisions, even after controlling for important covariates (OR 1.48; 95% CI 1.00, 2.17)., Conclusion: The results of this study lend further support that promoting women's autonomy and right to independently make decisions regarding their own health may be important in increasing the use of MC in the DRC. However, in order to effectively empower women to negotiate for the use of MC, qualitative research is needed to further assess the relationship between decision-making power and MC use., (© 2021. The Author(s).)

Background: Both conflict and non-conflict sexual violence have been well described in the Democratic Republic of Congo (DRC). However, there is little empiric data comparing sexual violence patterns for males and females in the DRC, and little is known about how post-sexual assault care experiences may differ between the two sexes., Methods: This was a retrospective, registry-based study at HEAL Africa Hospital. Researchers extracted and analyzed available data for all patients seeking post-sexual assault care between July 2013 and December 2017. Comparative analysis was conducted using SAS to document patterns of sexual violence among male and female survivors and to describe the clinical management of males and females seeking post-assault care., Results: Between July 2013 and December 2017, the hospital provided post-sexual assault care to 1766 patients (1623 female and 93 male). Female survivors were more likely to be minors under the age 18 (p < 0.0001) with a mean age 16.5 years versus 22.3 years for males. For both sexes, approximately half of all perpetrators were civilians who were known to the survivor (friends, family members, colleagues or neighbors). After sexual assault, males (79.6%) were more likely than females (55.7%) to present to the hospital within 72 h (p-value < 0.0001). Among female patients, 12% had a positive pregnancy test at the time of presentation and another 43% received emergency contraception. Male survivors were more likely to test positive for HIV (p-value = 0.0032) and to receive HIV post-exposure prophylaxis as well as prophylactic antibiotics (p-value < 0.0001)., Conclusions: In this single-centre registry, non-conflict-related sexual violence affected both women and girls as well as men and boys in North Kivu with civilian-perpetrated assaults being most common, and girls under the age of 18 being disproportionately affected. Overall, delays to seeking post-assault care appear to have decreased over time, although females presented later than males. These differences, as well as sex discrepancies in receiving HIV prophylaxis and prophylactic antibiotics, are not well understood. Additional research is needed to understand these phenomena such that equitable and optimal care can be ensured for both female and male sexual violence survivors., (© 2021. The Author(s).)

Pregnancy is associated with several physical and psychosocial challenges that influence women's health and wellbeing. However, prenatal mental health has received little attention. Therefore, this study examined the prevalence and correlates of prenatal depression, anxiety and current suicidal behaviors among pregnant women in the Volta Region of Ghana. Two hundred and fourteen ( n = 214) pregnant women recruited from two hospitals responded to the hospital depression and anxiety scale (HADS), the insomnia severity index, and a set of psycho-behavioral, socioenvironmental and demographic characteristic questions. Chi-squared, bivariate and multivariate logistic regression were used for data analysis. Prevalence of prenatal depression, anxiety and current suicidal behaviors was 50.5%, 35.5% and 3.3%, respectively. After controlling for other variables, average monthly income, insomnia, non-nutritious food consumption (pica), and body image satisfaction were significantly associated with depression. Marital status, insomnia, lifetime suicidal behavior and partner support were significantly associated with anxiety. Current partner abuse was the only factor significantly associated with current suicidal behavior. The high prevalence rates of anxiety and depression among pregnant women and intimate partner violence remain important maternal health issues in the region. Therefore, brief mental health screening and counseling services should be integrated into prenatal healthcare services.

The UN maintains a zero-tolerance policy on sexual interactions between peacekeepers and beneficiaries of assistance. Our research describes the lived experience of engaging sexually with UN peacekeepers during Mission des Nations Unies pour la Stabilisation en Haiti (MINUSTAH) from the perspectives of Haitian women/girls. Eighteen semi-structured interviews were conducted with Haitian women raising children fathered by MINUSTAH peacekeepers. Transcripts were analyzed according to empirical phenomenology.Adverse socio-economic conditions were key contextual factors. Three themes related to the nature of the sexual interactions emerged: sexual violence, transactional sex, and long-term transactional relationships imbedded in perceptions of love. Most sexual interactions were transactional and nuanced since the peacekeeper assumed the role of romantic and material provider. Sexual consent was conceptualised as the ability to weigh the benefits and consequences of engaging sexually with peacekeepers. Sexual violence was identified among minors and in instances of sexual abuse.This study provides empirical evidence to support a nuanced understanding of sexual relationships between women/girls and peacekeepers. In addition to holding peacekeepers accountable, a harm-reduction approach that aims to raise awareness for peacekeeping codes of conduct and provide comprehensive reproductive and sexual education should be considered.

Background : The term 'last mile' has been used across disciplines to refer to populations who are farthest away, most difficult to reach, or last to benefit from a program or service. However, last mile research lacks a shared understanding around its conceptualization. Objectives : This project used a concept mapping process to answer the questions: what is last mile research in global health and, how can it be used to make positive change for health equity in the last mile? Methods : Between July and December 2019, a five-stage concept mapping exercise was undertaken using online concept mapping software and an in-person consensus meeting. The stages were: establishment of an expert group and focus prompt; idea generation; sorting and rating; initial analysis and final consensus meeting. Results : A group of 15 health researchers with experience working with populations in last mile contexts and who were based at the Matariki Network institutions of Queen's University, CAN and Dartmouth College, USA took part. The resulting concept map had 64 unique idea statements and the process resulted in a map with five clusters. These included: (1) Last mile populations; (2) Research methods and approaches; (3) Structural and systemic factors; (4) Health system factors, and (5) Broader environmental factors. Central to the map were the ideas of equity, human rights, health systems, and contextual sensitivity. Conclusion : This is the first time 'last mile research' has been the focus of a formal concept mapping exercise. The resulting map showed consensus about who last mile populations are, how research should be undertaken in the last mile and why last mile health disparities exist. The map can be used to inform research training programs, however, repeating this process with researchers and members from different last mile populations would also add further insight.

Objectives: Global Health (GH) electives offer unique learning opportunities; however, risks to trainees and host populations should be minimized through pre-departure training and post-elective debriefing. In a 2016 study, only three Canadian residency programs mandated such training, although specific data on Emergency Medicine (EM) programs is lacking. This study aimed to identify GH elective requirements and perceived training gaps among EM programs., Methods: We conducted two email surveys (one each for EM program directors [PDs] and residents) regarding training requirements and perceived gaps for GH electives. We also contacted university postgraduate medical education (PGME) and GH offices, via their online publicized emails, to assess university-wide requirements and resources., Results: Nine PDs responded, with 78% reporting having residents participate in GH electives. Many PDs (67%) believed residents were moderately prepared for GH electives, while 33% felt they were unprepared to some degree. Forty seven out of an estimated 380 EM residents responded with 35% having completed a GH elective during residency. Of those, only one (6%) reported feeling very prepared, and 43% believed there was a need to improve trainings. Uncertainty around training requirements was reported, and residents identified challenges faced on electives, as well as priority topics for training. Responses from PGME and GH offices indicated that pre-departure training and post-elective debriefing were required or available at more universities than was indicated by the PD and resident respondents. However university requirements varied widely, with some exclusively requiring basic travel information and Health and Safety checklists or modules. The disparate responses indicate that residents and PDs may either be unaware of university requirements or not utilize available training resources for GH electives., Conclusions: Although Canadian EM residents participate in GH electives, the majority of training programs do not require pre-departure training or post-elective debriefing. PDs and residents report varying levels of preparedness, and residents acknowledge a variety of challenges during GH electives. This information can be used to inform pre-departure training and post-elective debriefing and encourage EM residents to access available university-wide training., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Pritchard et al.)

Background: The United Nations (UN) Organization Stabilization Mission in the Democratic Republic of Congo (MONUSCO) comprises the largest and longest serving peacekeeping operation to date. Since the launch of the mission in 1999, sexual relations between UN peacekeepers and the local population regularly occur; some resulting in children being conceived. Reports have indicated that women and girls bearing children from such relations face difficult socio-economic realities. The present study is the first to explore the situation of peacekeeper fathered children (PKFC) through a qualitative analysis that includes interview material from mothers and child participants., Methods: The article uses theories from stigma research to illustrate how children conceived through sexual relations with UN peacekeepers integrate into social networks. We conducted a case study of mothers and their PKFC at different sites of UN peacekeeping (UNPK) in eastern Democratic Republic of Congo (DRC). Based on 95 in-depth interviews held in 2018, a thematic qualitative analysis examined experiences of stigma and discrimination. In order to understand the challenges of mothers and children from a transgenerational perspective, we evaluated perceptions of rejection rooted in the mother-child relationship., Results: Of the mothers and children surveyed, a large majority struggled with stigmatizing behaviour by family and/or community members. PKFC perceived their discrimination to be based upon their mixed ethnicity, fatherlessness, illegitimacy at birth, as well as a lack of resources and opportunity. Mothers most often attributed their stigma to economic deprivation, extra-marital sexual relations, single parenting and being associated with UNPK. Parallels in the experiences of mothers and children suggest a bi-directional transmission of status loss and stigma between generations., Conclusions: This is the first empirical study to compare the situation of PKFC and their mothers in any country of UNPK deployment. The findings highlight multiple burdens that affect their daily lives and illustrate an interplay between drivers of stigmatization for mothers and children. The overarching needs identified are financial, and these call for action regarding policies and programmes that provide resources to those concerned. The results further demonstrate the need for psychosocial support that considers transgenerational dynamics and both mothers and children as core addressees of assistance.