International Federation of Red Cross and Red Crescent Societies

This paper describes an action framework for countries with low tuberculosis (TB) incidence (<100 TB cases per million population) that are striving for TB elimination. The framework sets out priority interventions required for these countries to progress first towards "pre-elimination" (<10 cases per million) and eventually the elimination of TB as a public health problem (less than one case per million). TB epidemiology in most low-incidence countries is characterised by a low rate of transmission in the general population, occasional outbreaks, a majority of TB cases generated from progression of latent TB infection (LTBI) rather than local transmission, concentration to certain vulnerable and hard-to-reach risk groups, and challenges posed by cross-border migration. Common health system challenges are that political commitment, funding, clinical expertise and general awareness of TB diminishes as TB incidence falls. The framework presents a tailored response to these challenges, grouped into eight priority action areas: 1) ensure political commitment, funding and stewardship for planning and essential services; 2) address the most vulnerable and hard-to-reach groups; 3) address special needs of migrants and cross-border issues; 4) undertake screening for active TB and LTBI in TB contacts and selected high-risk groups, and provide appropriate treatment; 5) optimise the prevention and care of drug-resistant TB; 6) ensure continued surveillance, programme monitoring and evaluation and case-based data management; 7) invest in research and new tools; and 8) support global TB prevention, care and control. The overall approach needs to be multisectorial, focusing on equitable access to high-quality diagnosis and care, and on addressing the social determinants of TB. Because of increasing globalisation and population mobility, the response needs to have both national and global dimensions.

Cash transfers have become an increasingly important component of social protection policies in both developed and developing countries. While such programs are often implemented electronically in developed countries, in many developing countries with weak financial infrastructure, such transfers are distributed manually, resulting in significant costs to program recipients and the public sector alike. The introduction of mobile money systems in many developing countries offers new opportunities for distributing cash transfers. Using data from a randomized experiment of a mobile money cash transfer program in Niger, we find evidence of benefits of this new system: household diet diversity was 9%–16% higher among households who received mobile transfers, and children ate an additional one-third of a meal per day. These results can be partially attributed to time savings associated with mobile transfers, as program recipients spent less time traveling to and waiting for their transfer. They are also associated with shifts in intrahousehold bargaining power for women. These results suggest that electronic transfers may address key logistical challenges in implementing cash transfer programs in developing countries but that sufficient investment in the payments infrastructure is needed.

In December 1997, 170 hemorrhagic fever-associated deaths were reported in Garissa District, Kenya. Laboratory testing identified evidence of acute Rift Valley fever virus (RVFV). Of the 171 persons enrolled in a cross-sectional study, 31(18%) were anti-RVFV immunoglobulin (Ig) M positive. An age-adjusted IgM antibody prevalence of 14% was estimated for the district. We estimate approximately 27,500 infections occurred in Garissa District, making this the largest recorded outbreak of RVFV in East Africa. In multivariable analysis, contact with sheep body fluids and sheltering livestock in one s home were significantly associated with infection. Direct contact with animals, particularly contact with sheep body fluids, was the most important modifiable risk factor for RVFV infection. Public education during epizootics may reduce human illness and deaths associated with future outbreaks.

Decolonising global health was a hot topic in 2020. It was the subject of more than 50 academic articles between January and December 2020, appeared as a new area covered in numerous conferences, and featured in public statements by leaders of global health organisations. Although its aims have not been formally defined, we see ‘decolonising global health’ as a movement that fights against ingrained systems of dominance and power in the work to improve the health of populations, whether this occurs between countries, including between previously colonising and plundered nations, and within countries, for example the privileging of what Connell calls research-based knowledge formation over the lived experience of people themselves.1 2 It is well documented—although often overlooked—that global health has evolved from colonial and tropical medicine, which were ‘designed to control colonised populations and make political and economic exploitation by European and North American powers easier’.3 The operations of many organisations active in global health thus perpetuate the very power imbalances they claim to rectify, through colonial and extractive attitudes, and policies and practices that concentrate resources, expertise, data and branding within high-income country (HIC) institutions.4 5 As a group of global health practitioners from different backgrounds, we reflect on our personal and professional experiences of systems and processes that institutionalise power imbalances. In this article, we propose a roadmap for global health practitioners, like us, who want to see rhetoric turn into reforms, focusing on systemic changes needed in organisations led from HICs. This is important now, because the flurry of statements and virtue signalling in 2020, could, in …

Abstract Drought is a slow‐onset, creeping natural hazard and a recurrent phenomenon in the arid and semi‐arid regions of Gujarat (India). In Asia, the standardized precipitation index (SPI) has gained wider acceptance in the detection and the estimation of the intensity, magnitude and spatial extent of droughts. The main advantage of the SPI, in comparison with other indices, is that the SPI enables both determination of drought conditions at different time scales and monitoring of different drought types. This index captures the accumulated deficit (SPI < 0) or surplus (SPI > 0) of precipitation over a specified period, and provides a normalized measure (i.e. spatially invariant Z score) of relative precipitation anomalies at multiple time scales. In the present study, monthly time series of rainfall data (1981–2003) from 160 stations were used to derive SPI, particularly at 3‐month time scales. This 3‐month SPI was interpolated to depict spatial patterns of meteorological drought and its severity during typical drought and wet years. Correlation analysis was also done to evaluate usefulness of SPI to quantify effects of drought on food grain productivity. Further, time series of SPI were exploited to assess the drought risk in Gujarat. Copyright © 2007 Royal Meteorological Society

AimsIn the past few years, there has been an unprecedented increase in the number of forcibly displaced migrants worldwide, of which a substantial proportion is refugees and asylum seekers. Refugees and asylum seekers may experience high levels of psychological distress, and show high rates of mental health conditions. It is therefore timely and particularly relevant to assess whether current evidence supports the provision of psychosocial interventions for this population. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the efficacy and acceptability of psychosocial interventions compared with control conditions (treatment as usual/no treatment, waiting list, psychological placebo) aimed at reducing mental health problems in distressed refugees and asylum seekers. METHODS: We used Cochrane procedures for conducting a systematic review and meta-analysis of RCTs. We searched for published and unpublished RCTs assessing the efficacy and acceptability of psychosocial interventions in adults and children asylum seekers and refugees with psychological distress. Post-traumatic stress disorder (PTSD), depressive and anxiety symptoms at post-intervention were the primary outcomes. Secondary outcomes include: PTSD, depressive and anxiety symptoms at follow-up, functioning, quality of life and dropouts due to any reason. RESULTS: We included 26 studies with 1959 participants. Meta-analysis of RCTs revealed that psychosocial interventions have a clinically significant beneficial effect on PTSD (standardised mean difference [SMD] = -0.71; 95% confidence interval [CI] -1.01 to -0.41; I2 = 83%; 95% CI 78-88; 20 studies, 1370 participants; moderate quality evidence), depression (SMD = -1.02; 95% CI -1.52 to -0.51; I2 = 89%; 95% CI 82-93; 12 studies, 844 participants; moderate quality evidence) and anxiety outcomes (SMD = -1.05; 95% CI -1.55 to -0.56; I2 = 87%; 95% CI 79-92; 11 studies, 815 participants; moderate quality evidence). This beneficial effect was maintained at 1 month or longer follow-up, which is extremely important for populations exposed to ongoing post-migration stressors. For the other secondary outcomes, we identified a non-significant trend in favour of psychosocial interventions. Most evidence supported interventions based on cognitive behavioural therapies with a trauma-focused component. Limitations of this review include the limited number of studies collected, with a relatively low total number of participants, and the limited available data for positive outcomes like functioning and quality of life. CONCLUSIONS: Considering the epidemiological relevance of psychological distress and mental health conditions in refugees and asylum seekers, and in view of the existing data on the effectiveness of psychosocial interventions, these interventions should be routinely made available as part of the health care of distressed refugees and asylum seekers. Evidence-based guidelines and implementation packages should be developed accordingly.

BACKGROUND: Cholera remains a persistent health problem in sub-Saharan Africa and worldwide. Cholera can be controlled through appropriate water and sanitation, or by oral cholera vaccination, which provides transient (∼3 years) protection, although vaccine supplies remain scarce. We aimed to map cholera burden in sub-Saharan Africa and assess how geographical targeting could lead to more efficient interventions. METHODS: We combined information on cholera incidence in sub-Saharan Africa (excluding Djibouti and Eritrea) from 2010 to 2016 from datasets from WHO, Médecins Sans Frontières, ProMED, ReliefWeb, ministries of health, and the scientific literature. We divided the study region into 20 km × 20 km grid cells and modelled annual cholera incidence in each grid cell assuming a Poisson process adjusted for covariates and spatially correlated random effects. We combined these findings with data on population distribution to estimate the number of people living in areas of high cholera incidence (>1 case per 1000 people per year). We further estimated the reduction in cholera incidence that could be achieved by targeting cholera prevention and control interventions at areas of high cholera incidence. FINDINGS: We included 279 datasets covering 2283 locations in our analyses. In sub-Saharan Africa (excluding Djibouti and Eritrea), a mean of 141 918 cholera cases (95% credible interval [CrI] 141 538-146 505) were reported per year. 4·0% (95% CrI 1·7-16·8) of districts, home to 87·2 million people (95% CrI 60·3 million to 118·9 million), have high cholera incidence. By focusing on the highest incidence districts first, effective targeted interventions could eliminate 50% of the region's cholera by covering 35·3 million people (95% CrI 26·3 million to 62·0 million), which is less than 4% of the total population. INTERPRETATION: Although cholera occurs throughout sub-Saharan Africa, its highest incidence is concentrated in a small proportion of the continent. Prioritising high-risk areas could substantially increase the efficiency of cholera control programmes. FUNDING: The Bill & Melinda Gates Foundation.

The unprecedented scale of the Ebola outbreak in Western Africa (2014-2015) has prompted an explosion of efforts to understand the transmission dynamics of the virus and to analyze the performance of possible containment strategies. Models have focused primarily on the reproductive numbers of the disease that represent the average number of secondary infections produced by a random infectious individual. However, these population-level estimates may conflate important systematic variation in the number of cases generated by infected individuals, particularly found in spatially localized transmission and superspreading events. Although superspreading features prominently in first-hand narratives of Ebola transmission, its dynamics have not been systematically characterized, hindering refinements of future epidemic predictions and explorations of targeted interventions. We used Bayesian model inference to integrate individual-level spatial information with other epidemiological data of community-based (undetected within clinical-care systems) cases and to explicitly infer distribution of the cases generated by each infected individual. Our results show that superspreaders play a key role in sustaining onward transmission of the epidemic, and they are responsible for a significant proportion ([Formula: see text]61%) of the infections. Our results also suggest age as a key demographic predictor for superspreading. We also show that community-based cases may have progressed more rapidly than those notified within clinical-care systems, and most transmission events occurred in a relatively short distance (with median value of 2.51 km). Our results stress the importance of characterizing superspreading of Ebola, enhance our current understanding of its spatiotemporal dynamics, and highlight the potential importance of targeted control measures.

OBJECTIVES/HYPOTHESIS: To develop and validate the Reflux Symptom Score (RSS), a self-administered patient-reported outcome questionnaire for patients with laryngopharyngeal reflux (LPR). STUDY DESIGN: Prospective controlled study. METHODS: A total of 113 patients with LPR were enrolled and treated with diet and 3 months of pantoprazole, alginate, and/or magaldrate depending on the LPR characteristics (acid, nonacid, or mixed). Eighty asymptomatic individuals completed the study. Patients and controls completed the RSS twice within a 7-day period to assess test-retest reliability. Internal consistency was measured using Cronbach's α for the RSS items in patients and controls. Validity was assessed by comparing the baseline RSS with the Reflux Symptom Index (RSI) and Voice Handicap Index (VHI). Seventy-seven patients completed the RSS at baseline and after 6 and 12 weeks of treatment to assess responsiveness to change. The RSS cutoff for determining the presence and absence of LPR was examined by receiver operating characteristic analysis. RESULTS: = 0.831). Internal validity was excellent based on the higher RSS in patients compared with controls (P = .001). RSS, RSI, and VHI scores significantly improved from pre- to posttreatment, indicating a high responsiveness to change. RSS >13 can be considered suggestive of LPR-related symptoms. RSS was not influenced by the occurrence of gastroesophageal reflux disease, LPR subtypes, or patient characteristics. CONCLUSIONS: RSS is a self-administered patient-reported outcome questionnaire that demonstrates high reliability and excellent criterion-based validity. RSS can be used in diagnosing and monitoring LPR disease. LEVEL OF EVIDENCE: 3b Laryngoscope, 130:E98-E107, 2020.

Epidemic diphtheria reemerged in the Russian Federation in 1990 and spread to all Newly Independent States (NIS) and Baltic States by the end of 1994. Factors contributing to the epidemic included increased susceptibility of both children and adults, socioeconomic instability, population movement, deteriorating health infrastructure, initial shortages of vaccine, and delays in implementing control measures. In 1995, aggressive control strategies were implemented, and since then, all affected countries have reported decreases of diphtheria; however, continued efforts by national health authorities and international assistance are still needed. The legacy of this epidemic includes a reexamination of the global diphtheria control strategy, new laboratory techniques for diphtheria diagnosis and analysis, and a model for future public health emergencies in the successful collaboration of multiple international partners. The reemergence of diphtheria warns of an immediate threat of other epidemics in the NIS and Baltic States and a longer-term potential for the reemergence of vaccine-preventable diseases elsewhere. Continued investment in improved vaccines, control strategies, training, and laboratory techniques is needed.

Abstract. Given the increased attention on resilience strengthening in international humanitarian and development work, there is a growing need to invest in its measurement and the overall accountability of resilience strengthening initiatives. The purpose of this article is to present our framework and tool for measuring community-level resilience to flooding and generating empirical evidence and to share our experience in the application of the resilience concept. At the time of writing the tool is being tested in 75 communities across eight countries. Currently 88 potential sources of resilience are measured at the baseline (initial state) and end line (final state) approximately 2 years later. If a flood occurs in the community during the study period, resilience outcome measures are recorded. By comparing pre-flood characteristics to post-flood outcomes, we aim to empirically verify sources of resilience, something which has never been done in this field. There is an urgent need for the continued development of theoretically anchored, empirically verified, and practically applicable disaster resilience measurement frameworks and tools so that the field may (a) deepen understanding of the key components of disaster resilience in order to better target resilience-enhancing initiatives, and (b) enhance our ability to benchmark and measure disaster resilience over time, and (c) compare how resilience changes as a result of different capacities, actions and hazards.

Bangladesh is one of the poorest and most disaster-prone countries in the world. To address both problems simultaneously, sustainable livelihoods (SL) could be better connected with disaster risk reduction (DRR). For this purpose, one initiative implemented in Bangladesh is called the Vulnerability to Resilience (V2R) programme which ran from 2013 to 2016. This programme was primarily initiated and funded by the British Red Cross in a consortium with the Swedish Red Cross and the German Red Cross. This article presents the first evaluation of the V2R programme with three objectives. The first objective was to measure whether the selected communities have achieved community resilience characteristics as defined by the programme. The second objective was to conduct a cost-benefit analysis for the intervention. The third objective was to analyse V2R’s impact on the communities in terms of DRR and SL. Community-based focus group discussions and household-based surveys were conducted before and after the intervention (2013–2016) in two coastal communities in Patuakhali district, Nowapara and Pashurbunia. The analysis found that community members are now engaged with many hazard-resilient and vulnerability-reducing livelihood activities, using SL to implement DRR, yet these approaches were almost absent prior to V2R. Consequently, the communities have achieved resilience characteristics, being more well-organized and better connected; having better access to infrastructure, services, and economic opportunities; are more knowledgeable and healthier; and are better managing their available resources. Critiques of the concepts are discussed, although in this case, DRR based on SL has shown positive results, exactly as development theory suggests.

Population coverage of insecticide-treated nets (ITNs) in Africa falls well below the Abuja target of 60% while coverage levels achieved during vaccination campaigns in the same populations typically exceed 90%. Household (HH) cost of ITNs is an important barrier to their uptake. We investigated the coverage, equity and cost of linking distribution of free ITNs to a measles vaccination campaign. During a national measles vaccination campaign in Zambia, children in four rural districts were given a free ITN when they received their measles vaccination. In one urban district, children were given a voucher, which could be redeemed for a net at a commercial distribution site. About 1700 HHs were asked whether they received vaccination and an ITN during a measles campaign, as well as questions on assets (e.g. type roofing material or bicycle ownership) to assess HH wealth. Net ownership was calculated for children in each wealth quintile. In the rural areas, ITN coverage among children rose from 16.7% to 81.1% and the equity ratio from 0.32 to 0.88 and in the urban area from 50.7% to 76.2% (equity ratio: 0.66-1.19). The operational cost per ITN delivered was dollar 0.35 in the rural area with direct distribution and $1.89 in the urban areas with voucher distribution. Mass distribution of ITNs through vaccination campaigns achieves rapid, high and equitable coverage at low cost.

OBJECTIVES: To investigate the role of laryngopharyngeal reflux (LPR) in the development of benign lesions of the vocal folds (BLVF). METHODS: PubMed, Cochrane Library, and Scopus were searched by three independent investigators for articles published between January 1990 and November 2018 providing substantial information about the role of LPR in the development of nodules, polyps, cysts, Reinke's edema, and sulcus vocalis. Inclusion, exclusion, diagnostic criteria and clinical outcome evaluation of included studies were analyzed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. RESULTS: Of the 155 relevant publications, 42 studies were included. Thirty-five were clinical studies and seven were experimental research studying the impact of reflux on vocal fold tissue. Only seven clinical studies utilized objective LPR diagnoses (pH monitoring), suggesting an association between LPR and the development of nodules, polyps, and Reinke's edema. These studies were characterized by a substantial heterogeneity due to discrepancies in inclusion/exclusion criteria, diagnostic methods, and clinical outcome evaluation. The few basic science studies on this topic support that LPR creates an environment that may predispose to BLVF through changes in defense mechanisms of the vocal folds, cell-to-cell dehiscence, inflammatory reaction of the vocal folds, and reaction to phonotrauma. CONCLUSIONS: Caustic mucosal injury from LPR could cause increased susceptibility of the vocal fold mucosa to injury and subsequent formation of nodules, polyps, or Reinke's edema. However, the heterogeneity and the low number of high-quality studies limit the ability to draw definitive conclusions. Future clinical and experimental studies are needed to better identify the role of reflux in development of BLVF. Laryngoscope, 129:E329-E341, 2019.

OBJECTIVE: To assess the cost-effectiveness (CE) of annual targeted larviciding campaigns from 2001 to 2005 against the dengue vector Aedes aegypti in two urban areas of Cambodia with a population of 2.9 million people. METHODS: The intervention under analysis consisted of annual larviciding campaigns targeting medium to large water storage containers in households and other premises. The CE compared the intervention against the hypothetical alternative of no intervention. The CE was calculated as the ratio of disability adjusted life years (DALYs) saved to the net cost of the intervention (in 2005 US dollars) by year. A sensitivity analysis explored the range of study parameters. RESULTS: The intervention reduced the number of dengue cases and deaths by 53%. It averted an annual average of 2980 dengue hospitalizations, 11,921 dengue ambulatory cases and 23 dengue deaths, resulting in a saving of 997 DALYs per year. The gross cost of the intervention was US $567,800 per year, or US $0.20 per person covered. As the intervention averted considerable medical care, the annual net cost of the intervention was US $312,214 (US $0.11 per person covered) from a public sector perspective and US $37,137 (US $0.01 per person covered) from a societal perspective. The resulting CE ratios were: US $313/DALY gained from the public perspective and US $37/DALY gained from the societal perspective. Even under the most conservative assumption, the intervention remained cost effective from both perspectives. CONCLUSIONS: Annual, targeted larviciding campaigns appear to have been effective and cost-effective medium-term interventions to reduce the epidemiologic and economic burden of dengue in urban areas of Cambodia.

BACKGROUND/METHODS: Insecticide-treated nets (ITNs) are the primary tool for malaria vector control in sub-Saharan Africa, and have been responsible for an estimated two-thirds of the reduction in the global burden of malaria in recent years. While the ultimate goal is high levels of ITN use to confer protection against infected mosquitoes, it is widely accepted that ITN use must be understood in the context of ITN availability. However, despite nearly a decade of universal coverage campaigns, no country has achieved a measured level of 80% of households owning 1 ITN for 2 people in a national survey. Eighty-six public datasets from 33 countries in sub-Saharan Africa (2005-2017) were used to explore the causes of failure to achieve universal coverage at the household level, understand the relationships between the various ITN indicators, and further define their respective programmatic utility. RESULTS: = 0.92), because individuals in households with some but not enough ITNs are captured as having access, but the household does not qualify as having 1 ITN for 2 people. Among households with 7-9 people, mean population ITN access was 41.0% (95% CI 36.5-45.6), whereas only 6.2% (95% CI 4.0-8.3) of these same households owned at least 1 ITN for 2 people. On average, 60% of the individual protection measured by the population access indicator is obscured when focus is put on the household "universal coverage" indicator. The practice of limiting households to a maximum number of ITNs in mass campaigns severely restricts the ability of large households to obtain enough ITNs for their entire family. CONCLUSIONS: The two household-level indicators-one representing minimal coverage, the other only 'universal' coverage-provide an incomplete and potentially misleading picture of personal protection and the success of an ITN distribution programme. Under current ITN distribution strategies, the global malaria community cannot expect countries to reach 80% of households owning 1 ITN for 2 people at a national level. When programmes assess the success of ITN distribution activities, population access to ITNs should be considered as the better indicator of "universal coverage," because it is based on people as the unit of analysis.

Background The mental health burden among refugees in high-income countries (HICs) is high, whereas access to mental healthcare can be limited. Objective To examine the effectiveness of a peer-provided psychological intervention (Problem Management Plus; PM+) in reducing symptoms of common mental disorders (CMDs) among Syrian refugees in the Netherlands. Methods We conducted a single-blind, randomised controlled trial among adult Syrian refugees recruited in March 2019–December 2021 (No. NTR7552). Individuals with psychological distress (Kessler Psychological Distress Scale (K10) >15) and functional impairment (WHO Disability Assessment Schedule (WHODAS 2.0) >16) were allocated to PM+ in addition to care as usual (PM+/CAU) or CAU only. Participants were reassessed at 1-week and 3-month follow-up. Primary outcome was depression/anxiety combined (Hopkins Symptom Checklist; HSCL-25) at 3-month follow-up. Secondary outcomes included depression (HSCL-25), anxiety (HSCL-25), post-traumatic stress disorder (PTSD) symptoms (PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; PCL-5), impairment (WHODAS 2.0) and self-identified problems (PSYCHLOPS; Psychological Outcomes Profiles). Primary analysis was intention-to-treat. Findings Participants (n=206; mean age=37 years, 62% men) were randomised into PM+/CAU (n=103) or CAU (n=103). At 3-month follow-up, PM+/CAU had greater reductions on depression/anxiety relative to CAU (mean difference −0.25; 95% CI −0.385 to −0.122; p=0.0001, Cohen’s d =0.41). PM+/CAU also showed greater reductions on depression (p=0.0002, Cohen’s d =0.42), anxiety (p=0.001, Cohen’s d =0.27), PTSD symptoms (p=0.0005, Cohen’s d =0.39) and self-identified problems (p=0.03, Cohen’s d =0.26), but not on impairment (p=0.084, Cohen’s d =0.21). Conclusions PM+ effectively reduces symptoms of CMDs among Syrian refugees. A strength was high retention at follow-up. Generalisability is limited by predominantly including refugees with a resident permit. Clinical implications Peer-provided psychological interventions should be considered for scale-up in HICs.

BACKGROUND: The recruitment of community health volunteers (CHVs) to support the delivery of health programmes is an established approach in underserved areas and in particular where there are health inequalities due to the scarcity of trained human resources. However, there is a dearth of evidence about what works to improve CHVs' performance. This review aimed to synthesise existing literature to explain why, how and under which circumstances intervention approaches to improve the performance of CHVs are more likely to be successful. METHODS: We performed a realist synthesis. We identified candidate theories related to our review questions, which then guided the selection, appraisal and analysis of primary studies. Publications of interest dating from 2008 to 2012 were identified by a systematic search in PubMed and IDEAS databases. We considered all study designs that examined the various aspects of CHV performance in the context of formal organisational settings to be eligible and excluded the studies that did not provide explanation about the performance of CHVs neither in the findings nor in the discussion part. Data were arranged according to their reference to context, interventions, outcomes and mechanisms in order to identify the interaction between them. The synthesis of data allowed us to determine explanatory patterns within or across the studies. RESULTS: We identified broad intervention approaches within the 23 papers included in the review: positioning of the CHV within the community, establishment of clear roles, provision of skill-based and ongoing training, incentives, supervision and logistical support for task distribution and implementation. The findings provided information regarding which mechanisms (self-esteem, sense of duty, self-efficacy, sense of being fairly treated) to target when implementing such approaches, and which contextual factors (stable and supportive cultural, political and social context and intervention closely linked to local health services) create the most favourable conditions for these mechanisms to occur, ultimately contributing to CHVs' better performance. Four main explanatory patterns around these mechanisms emerged as being fundamental to better performance. CONCLUSIONS: The patterns identified, combined with the designers' and other stakeholders' assumptions on how such interventions are expected to work, can be tested by empirical studies in order to provide useful information to be used by programme implementers, policymakers, donors and the community.

With special reference to the First Optional Protocol of the International Covenant on Civil and Political Rights, the Convention Against Torture and the European Convention on Human Rights and Fundamental Freedoms, the author examines the underlying concepts and gaps in refugee protection. Taking account of relevant UN and Council of Europe human tights mechanisms and the existing case law which protects an individual from refoulement, the author attempts to show that international redress mechanisms can, when applied correctly, serve to counter-balance politically expedient decisions of national asylum authorities. He argues that existing procedures deserve the attention of practitioners and that those concerned with maintaining access to international protection should familiarize themselves with the admissibility criteria and acquire the skills necessary to petition international human rights bodies.

We describe an effort to develop a consensus-based research agenda for mental health and psychosocial support (MHPSS) interventions in humanitarian settings for 2021-30. By engaging a broad group of stakeholders, we generated research questions through a qualitative study (in Indonesia, Lebanon, and Uganda; n=101), consultations led by humanitarian agencies (n=259), and an expert panel (n=227; 51% female participants and 49% male participants; 84% of participants based in low-income and middle-income countries). The expert panel selected and rated a final list of 20 research questions. After rating, the MHPSS research agenda favoured applied research questions (eg, regarding workforce strengthening and monitoring and evaluation practices). Compared with research priorities for the previous decade, there is a shift towards systems-oriented implementation research (eg, multisectoral integration and ensuring sustainability) rather than efficacy research. Answering these research questions selected and rated by the expert panel will require improved partnerships between researchers, practitioners, policy makers, and communities affected by humanitarian crises, and improved equity in funding for MHPSS research in low-income and middle-income countries.