Publications

    6/15/2022. “Improving water, sanitation, and hygiene (WASH), with a focus on hand hygiene, globally for community mitigation of COVID-19.” PLOS Water. Read PublicationAbstract

    Continuity of key water, sanitation, and hygiene (WASH) infrastructure and WASH practices—for example, hand hygiene—are among several critical community preventive and mitigation measures to reduce transmission of infectious diseases, including COVID-19 and other respiratory diseases. WASH guidance for COVID-19 prevention may combine existing WASH standards and new COVID-19 guidance. Many existing WASH tools can also be modified for targeted WASH assessments during the COVID-19 pandemic. We partnered with local organizations to develop and deploy tools to assess WASH conditions and practices and subsequently implement, monitor, and evaluate WASH interventions to mitigate COVID-19 in low- and middle-income countries in Latin America and the Caribbean and Africa, focusing on healthcare, community institution, and household settings and hand hygiene specifically. Employing mixed-methods assessments, we observed gaps in access to hand hygiene materials specifically despite most of those settings having access to improved, often onsite, water supplies. Across countries, adherence to hand hygiene among healthcare providers was about twice as high after patient contact compared to before patient contact. Poor or non-existent management of handwashing stations and alcohol-based hand rub (ABHR) was common, especially in community institutions. Markets and points of entry (internal or external border crossings) represent congregation spaces, critical for COVID-19 mitigation, where globally-recognized WASH standards are needed. Development, evaluation, deployment, and refinement of new and existing standards can help ensure WASH aspects of community mitigation efforts that remain accessible and functional to enable inclusive preventive behaviors.

    Sean M Kivlehan, Amy Allen, Olha Viun, Dmitry A Makarov, Daniel Schnorr, Sonny Patel, Sergii A Ryzhenko, Phuong Pham, and Timothy B Erickson. 6/14/2022. “Evaluation of change in emergency care knowledge and skills among front-line healthcare providers in Ukraine with the Basic Emergency Care course: a pretest/post-test study.” BMJ Open. Read PublicationAbstract

    Objective: Evaluate the change in participant emergency care knowledge and skill confidence after implementation of the WHO-International Committee of the Red Cross (ICRC) Basic Emergency Care (BEC) course.

    Design: Pretest/post-test quasi-experimental study.

    Setting: Mechnikov Hospital in Dnipro, Ukraine.

    Participants: Seventy-nine participants engaged in the course, of whom 50 (63.3%) completed all assessment tools. The course was open to healthcare providers of any level who assess and treat emergency conditions as part of their practice. The most common participant profession was resident physician (24%), followed by health educator (18%) and prehospital provider (14%).

    Interventions: The 5-day WHO-ICRC BEC course.

    Primary and secondary outcome measures: Change in pre-course and post-course knowledge and skill confidence assessments. Open-ended written feedback was collected upon course completion and analysed for common themes.

    Results: Participant knowledge assessment scores improved from 19 (IQR 15–20) to 22 (IQR 19–23) on a 25-point scale (p<0.001). Participant skill confidence self-assessment scores improved from 2.5 (IQR 2.1–2.8) to 2.9 (IQR 2.5–3.3) on a 4-point scale (p<0.001). The most common positive feedback themes were high-quality teaching and useful skill sessions. The most common constructive feedback themes were translation challenges and request for additional skill session time.

    Conclusions: This first implementation of the WHO-ICRC BEC course for front-line healthcare providers in Ukraine was successful and well received by participants. This is also the first report of a BEC implementation outside of Africa and suggests that the course is also effective in the European context, particularly in humanitarian crisis and conflict settings. Future research should evaluate long-term knowledge retention and the impact on patient outcomes. Further iterations should emphasise local language translation and consider expanding clinical skills sessions.

    Vincenzo Bollettino and Lea Ivy Manzanero. 3/2022. “Climate Change and Civil-Military Coordination in the Philippines: How climate change disasters will impact aid delivery in areas affected by conflict.” Climate, Disaster and Development Journal. Read PublicationAbstract

    The Philippines is one of the most disaster-prone countries in the world and frequently ranks among the top three countries most impacted by disasters. Ongoing conflict with non-state armed actors results in scenarios where civilians are impacted by both conflict and natural hazards. The result is a situation where civilian relief agencies operate in proximity to the military. We argue that there is an important need for principled civil-military coordination in these contexts to ensure the integrity of security operations to support peace and stability while preserving the independence of humanitarian actors serving crisis-affected populations.


    The research reveals significant challenges in protecting the integrity of independence of both military and humanitarian actors in areas impacted by both conflict and disaster and underscores the need for principled humanitarian civil-military coordination to avert threats to both humanitarian aid workers and disaster affected populations. The findings are particularly relevant to South East Asia where the use of military in disaster response is common. The findings also underscore the need for research on the role of militaries in responding to disasters in light of anticipated impacts of climate change. 

    HHI Resilient Communities. 3/2022. Symposium Report: The Impacts of the COVID-19 Pandemic on Vulnerable Communities in the Philippines.Abstract

    The COVID-19 pandemic has caused the loss of millions of lives, disrupted the global economy, and created secondary impacts on livelihoods, education, and mental health across the globe. No country or economic group has been immune to the direct impacts of the pandemic, but marginalized communities are particularly vulnerable to the secondary impacts including some public health measures like extended lockdowns. Marginalized populations are those excluded from mainstream social, economic, educational, political, and/or cultural life. They can be excluded or discriminated due to multiple factors such as their race, ethnicity, age, gender identity, sexual orientation, disability, religion, language, and/or displacement, among others. The Harvard Humanitarian Initiative's (HHI) Resilient Communities Program sought to understand how vulnerable or marginalized communities in the Philippines experienced COVID-19, and how communities coped and adapted in response to direct and indirect effects of COVID-19, including public health measures. To do this, HHI invited Filipino authors exploring this central question to submit papers for consideration to be selected to present and share in a symposium. In addition to its research objectives, the symposium sought to connect researchers and practitioners to create a network of professionals dedicated to serving the needs of marginalized communities in the country.

    Watch the full symposium: https://www.youtube.com/watch?v=4zC1FzWRUuo

    Markus Enenkel and Andrew Kruczkiewicz. 2/2022. “The humanitarian sector needs clear job profiles for climate science translators – more than ever during a pandemic.” Bulletin of the American Meteorological Society. Read PublicationAbstract
    A new generation of “climate science translators” (CSTs) is currently evolving, both as independent professionals and affiliated with humanitarian agencies. While people in this role represent an opportunity to foster communication and collaboration between climate science, humanitarian decision-support, policy and decision making, there are neither clear job profiles, nor established criteria for success. Based on an analysis of job opportunities published on one of the largest humanitarian and development aid job portals we show that the demand for CSTs has been increasing since 2011. Subsequently, we present a characterization of core skills for the next generation of CSTs aiming to establish a space for not only current CSTs to thrive, but also a path for future translators to follow, with milestones and opportunities for recognition.
    Jocelyn Kelly, Emily Ausubel, Emma Kenny, Meredith Blake, Christine Heckman, Sonia Rastogi, and Vandana Sharma. 9/2021. “Measuring gender-based violence risk mitigation in humanitarian settings: results from a comprehensive desk review and systematic mapping.” BMJ Open. Read PublicationAbstract

    Objectives: To systematically document measurement approaches used in the monitoring and evaluation of gender-based violence (GBV) risk mitigation activities, categorise the types of available literature produced by sector, identify existing tools and measures and identify knowledge gaps within the humanitarian sector.

    Design: Systematic mapping and in-depth review.

    Data sources: Pubmed, Global Health, PsychInfo, ReliefWeb, OpenGrey (grey literature), Google Scholar, Web of Science (Social Science Index)

    Eligibility criteria: a structured search strategy was systematically applied to 17 databases as well as registers, websites and other resources to identify materials published between 1 January 2005 and 15 May 2019.

    Data extraction and synthesis: Those resources that met the inclusion criteria underwent a comprehensive full-text review. A detailed matrix was developed and key data from each resource were extracted to allow for the assessment of patterns in thematic areas.

    Results: A total of 2108 documents were screened. Overall, 145 documents and 112 tools were reviewed, representing 10 different humanitarian sectors. While numerous resources exist, many lack sufficient information on how to monitor outputs or outcomes of GBV risk mitigation activities. There is also limited guidance on how to integrate the measurement of GBV risk mitigation into existing monitoring and evaluation frameworks. Those reports that aimed to measure GBV risk mitigation activities mostly employed qualitative methods and few measured the impact of a GBV risk mitigation with robust research designs.

    Conclusions: Recent efforts to adapt humanitarian response to COVID-19 have highlighted new and existing challenges for GBV risk mitigation. There is a significant gap in the evidence base around the effectiveness of GBV risk mitigation across all sectors. Understanding and strengthening measurement approaches in GBV risk mitigation remains a critical task for humanitarian response.

    Agnes Usoro, Benjamin Aiwonodagbon, Jonathan Strong, Sean Kivlehan, Babatunde A. Akodu, and Ayobami Olufadeji. 8/2021. “Perspectives on the current state of Nigeria’s emergency care system among participants of an emergency medicine symposium: a qualitative appraisal.” BMJ Open. Read PublicationAbstract

    Emergency care systems provide timely and relevant care to the acutely ill and injured. Published commentaries have characterised deficiencies in the Nigerian emergency care system and offered potential solutions but have not included the perspectives of the Nigerian public. A more inclusive approach that includes feedback from the public may help improve the Nigerian emergency care system through better understanding of the needs, values and expectations of the community.

    The participants in this study identified shortcomings and opportunities to improve prehospital care, hospital care and health system governance. The results of this study may help healthcare professionals, policy makers and community leaders identify gaps in the emergency care system and offer solutions in harmony with the needs, values and expectations of the community. If successful, these community-informed interventions may serve as a model to improve emergency care systems throughout Africa.

    Luissa Vahedi, Jessica Anania, and Jocelyn Kelly. 8/2021. Gender-Based Violence and COVID-19 in Fragile Settings: A Syndemic Model. Read PublicationAbstract
    The long-standing pandemic of gender-based violence has been worsened by COVID-19 and related containment measures, particularly in fragile settings marked by conflict, poverty, and weak infrastructure. At the same time, the implementation of gender-insensitive COVID-19 control policies can exacerbate the community transmission of COVID-19. These interactions form a syndemic—two or more pandemics whose interactions compound the severity of each. This report identifies the key avenues through which these two pandemics have synergistic effects and offers recommendations for mitigating their impact.
    Indi Trehan, Sean M. Kivlehan, Kamna S. Balhara, Joseph Bonney, Braden J. Hexom, Amelia Y. Pousson, Nana Serwaa A. Quao, Megan M. Rybarczyk, Anand Selvam, Benjamin D. Nicholson, Nidhi Bhaskar, Torben K. Becker, and Global Emergency Medicine Literature Review (GEMLR) Group. 7/2021. “Global Emergency Medicine: A Scoping Review of the Literature from 2020.” Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine. Read PublicationAbstract

    Objective: To identify, screen, highlight, review, and summarize some of the most rigorously conducted and impactful original research and review articles in global emergency medicine (EM) published in 2020 in the peer-reviewed and gray literature.

    Methods: A broad systematic search of peer-reviewed publications related to global EM indexed on PubMed and in the gray literature was conducted. The titles and abstracts of the articles on this list were screened by members of the Global Emergency Medicine Literature Review team to identify those that met our criteria of original research or review articles in the domains of Disaster and Humanitarian Response, Emergency Care in Resource-Limited Settings, and Emergency Medicine Development. Those articles that met these screening criteria were then scored using one of three scoring templates appropriate to the article type. Those articles that scored in the top 5% then underwent in-depth narrative summarization.

    Results: The 2020 GEMLR search initially identified 35,970 articles, more than 50% more than last year’s search. From these, 364 were scored based on their full text. Nearly three-fourths of the scored articles constituted original research, of which nearly three-fourths employed quantitative research methods. Nearly 10% of the articles identified this year were directly related to COVID-19. Research involving Emergency Care in Resource-Limited Settings again constituted most of the articles in this year’s review, accounting for more than 60% of the literature scored. A total of 20 articles underwent in-depth narrative critiques.

    Conclusions: The number of studies relevant to global EM identified by our search was very similar to last year. Revisions to our methodology to identify a broader range of research were successful in identifying more qualitative research and studies related to Disaster and Humanitarian Response. The number of COVID-19-related articles is likely to continue to increase in subsequent years.

    Indi Trehan, Sean M. Kivlehan, Kamna S. Balhara, Joseph Bonney, Braden J. Hexom, Amelia Y. Pousson, Nana Serwaa A. Quao, Megan M. Rybarczyk, Anand Selvam, Benjamin D. Nicholson, Nidhi Bhaskar, Torben K. Becker, and Global Emergency Medicine Literature Review (GEMLR) Group. 7/2021. “Global Emergency Medicine: A Scoping Review of the Literature from 2020.” Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine. Read PublicationAbstract

    Objective: To identify, screen, highlight, review, and summarize some of the most rigorously conducted and impactful original research and review articles in global emergency medicine (EM) published in 2020 in the peer-reviewed and gray literature.

    Methods: A broad systematic search of peer-reviewed publications related to global EM indexed on PubMed and in the gray literature was conducted. The titles and abstracts of the articles on this list were screened by members of the Global Emergency Medicine Literature Review team to identify those that met our criteria of original research or review articles in the domains of Disaster and Humanitarian Response, Emergency Care in Resource-Limited Settings, and Emergency Medicine Development. Those articles that met these screening criteria were then scored using one of three scoring templates appropriate to the article type. Those articles that scored in the top 5% then underwent in-depth narrative summarization.

    Results: The 2020 GEMLR search initially identified 35,970 articles, more than 50% more than last year’s search. From these, 364 were scored based on their full text. Nearly three-fourths of the scored articles constituted original research, of which nearly three-fourths employed quantitative research methods. Nearly 10% of the articles identified this year were directly related to COVID-19. Research involving Emergency Care in Resource-Limited Settings again constituted most of the articles in this year’s review, accounting for more than 60% of the literature scored. A total of 20 articles underwent in-depth narrative critiques.

    Conclusions: The number of studies relevant to global EM identified by our search was very similar to last year. Revisions to our methodology to identify a broader range of research were successful in identifying more qualitative research and studies related to Disaster and Humanitarian Response. The number of COVID-19-related articles is likely to continue to increase in subsequent years.

    Phuong Pham, Vincenzo Bollettino, Patrick Vinck, Ariana Marnicio, Lea Ivy Manzanero, Mark Toldo, Rachel Dickinson, Alexis Smart, and Evan Bloom. 10/2020. “Network Analysis of Actors Working to Support Disaster Preparedness and Resilience in the Philippines”.Abstract
    The Harvard Humanitarian Initiative (HHI) partnered with Root Change to conduct a network analysis of actors working to support disaster preparedness and resilience in the Philippines. The study design is modeled after a summative phase external evaluation that HHI conducted in 2016-2017 on the START Network’s Disasters and Emergency Preparedness Program (DEPP). Network analysis techniques applied in this evaluation have been adapted from the DEPP work to analyze the disaster resilience network in coastal Bangladesh under the Resilient Communities Program. In this report, we present the network analysis and methods used. We also detail findings and recommendations for HHI and other in-country partners about how these results can inform programs to strengthen disaster resilience and climate change in the Philippines.
    Abdulrazzaq Al-Saiedi, Kevin Coughlin, Muslih Irwani, Waad Ibrahim Khalil, Phuong Pham, and Patrick Vinck. 6/2020. “English Version: "Never Forget: Views on Peace and Justice Within Conflict-Affected Communities in Northern Iraq"”.Abstract

    This survey offers a snapshot of the perceptions and attitudes about peace and justice within communities affected by the conflict with the Islamic State (IS). It is based on 5,213 interviews conducted in 2019 among a representative sample of internally displaced persons in northern Iraq and residents of the city of Mosul and surrounding areas.The research documents a severe lack of trust in official institutions, particularly in the Government of Iraq itself, stemming in large part from the belief that these institutions do not act in the best interest of the population. Few respondents had confidence in the Government of Iraq’s ability to investigate the crimes committed by the Islamic State fairly and accurately and to provide justice to survivors of the conflict.Despite the mistrust, respondents favor local justice and truth-seeking mechanisms. They view these efforts as necessary to build a durable peace, alongside measures to address the root causes of the rise of IS and longstanding divisions between the people of Iraq. However, rather than the challenge being diversity itself, the challenge is the Government of Iraq’s ability to promote and facilitate reconciliation and unity.Without an accountable government that is perceived to be legitimate and is trusted by all Iraqis, calls for justice and accountability may go unanswered, and the country risks slipping back into another conflict.

    The research was conducted by the Harvard Humanitarian Initiative in partnership with Mosul University and the Iraq-based Public Policy Institute. It was supported by the Ministry of Foreign Affairs of the Netherlands, which played no role in the design, analysis or publication of the research.

    Abdulrazzaq Al-Saiedi, Kevin Coughlin, Muslih Irwani, Waad Ibrahim Khalil, Phuong Pham, and Patrick Vinck. 6/2020. “الترجمة العربية (Arabic Version): "Never Forget: Views on Peace and Justice Within Conflict-Affected Communities in Northern Iraq"”.Abstract

    This survey offers a snapshot of the perceptions and attitudes about peace and justice within communities affected by the conflict with the Islamic State (IS). It is based on 5,213 interviews conducted in 2019 among a representative sample of internally displaced persons in northern Iraq and residents of the city of Mosul and surrounding areas.The research documents a severe lack of trust in official institutions, particularly in the Government of Iraq itself, stemming in large part from the belief that these institutions do not act in the best interest of the population. Few respondents had confidence in the Government of Iraq’s ability to investigate the crimes committed by the Islamic State fairly and accurately and to provide justice to survivors of the conflict.Despite the mistrust, respondents favor local justice and truth-seeking mechanisms. They view these efforts as necessary to build a durable peace, alongside measures to address the root causes of the rise of IS and longstanding divisions between the people of Iraq. However, rather than the challenge being diversity itself, the challenge is the Government of Iraq’s ability to promote and facilitate reconciliation and unity.Without an accountable government that is perceived to be legitimate and is trusted by all Iraqis, calls for justice and accountability may go unanswered, and the country risks slipping back into another conflict.

    The research was conducted by the Harvard Humanitarian Initiative in partnership with Mosul University and the Iraq-based Public Policy Institute. It was supported by the Ministry of Foreign Affairs of the Netherlands, which played no role in the design, analysis or publication of the research.

    Sarah Ferguson, Vincenzo Bollettino, Phuong Pham, Patrick Vinck, Rachel Dickinson, Alexis Smart, and Evan Bloom. 5/2020. “Bangladesh Network Analysis Report”.Abstract
    Coordination among actors during an emergency is crucial for effective, efficient action. The existence of pre-disaster relationships between actors can strengthen the speed with which coordination occurs in a disaster setting, making relationshipbuilding before a disaster an important element of preparedness. As such, understanding the relationships between stakeholders working to advance disaster resilience and response is a crucial first step to support institutional strengthening and capacity building. The Harvard Humanitarian Initiative (HHI), Concern Worldwide, and Jagrata Juba Shangha (JJS) are jointly implementing programs to enhance climate change adaptation and disaster resilience among coastal communities in Bagerhat District, Bangladesh. This district is located in Bangladesh’s low-elevation coastal zones, which are especially vulnerable to natural disasters and have already begun to see the effects of climate change. Bagerhat has high levels of food and water insecurity and poverty, and is highly vulnerable to natural disasters and climate change impacts (5). The district has been heavily impacted by recent cyclones, and is experiencing sea level rise and saltwater intrusion. This network analysis was undertaken to support strengthening coordination and collaboration among actors working on climate change adaptation and disaster resilience in Bagerhat.
    Vincenzo Bollettino and Sarah Ferguson. 5/2020. “Case Study: Academic/NGO Collaboration to Understand Climate Change and Disaster Resilience Implementation in Bagerhat District, Bangladesh”.Abstract
    This case study describes a research collaboration between an academic institution and non-governmental organizations (NGOs) designed to inform programs to strengthen coordination in Bangladesh. The case describes the rationale for conducting the study, the research process, and outcomes of the research. The objective of the case study is to support local or municipal governments, NGOs, students, or other program managers to consider how collaboration with academic institutions could enhance their programs, as well as how research such as a network analysis could be useful to inform their work. For those interested in conducting a network analysis, the case also provides resources and tools to support researchers and organizations to replicate the study in their program context.
    Sylvia Kehlenbrink, James Smith, Eimhin Ansbro, Daniela C Fuhr, Anson Cheung, and Ruwan Ratnayake. 8/1/2019. “The burden of diabetes and use of diabetes care in humanitarian crises in low-income and middle-income countries.” The Lancet, 7, 8, Pp. 638-647.Abstract
    Human suffering as a result of natural disasters or conflict includes death and disability from non-communicable diseases, including diabetes, which have largely been neglected in humanitarian crises. The objectives of this Series paper were to examine the evidence on the burden of diabetes, use of health services, and access to care for people with diabetes among populations affected by humanitarian crises in low-income and middle-income countries, and to identify research gaps for future studies. We reviewed the scientific literature on this topic published between 1992 and 2018. The results emphasise that the burden of diabetes in humanitarian settings is not being captured, clinical guidance is insufficient, and diabetes is not being adequately addressed. Crisis-affected populations with diabetes face enormous constraints accessing care, mainly because of high medical costs. Further research is needed to characterise the epidemiology of diabetes in humanitarian settings and to develop simplified, cost-effective models of care to improve the delivery of diabetes care during humanitarian crises.

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