Challenges and opportunities for implementation of substance misuse interventions in conflict-affected populations

Abstract

Alcohol and other drug misuse are significant but neglected public health issues in conflict-affected populations. In this article, we review the literature on the challenges and strategies for implementing substance misuse treatment and prevention services in conflict and post-conflict settings in low- and middle-income countries. We identified nine studies describing interventions in conflict-affected populations residing in Afghanistan, Croatia, India, Kenya, Kosovo, Pakistan, and Thailand. Six of these nine studies focused on refugee populations. Reports revealed challenges to intervention implementation, as well as promising practices and recommendations for future implementation that we characterized as existing in the inner and outer contexts of an implementing organization. Challenges existing in the outer context included low political prioritization, lack of coordination and integration, and limited advocacy for access to substance misuse services. Challenges within the inner context related to competing priorities and a shortage of providers. Resource limitations existed in both the inner and outer contexts. Stigma was a challenge that threatened implementation and utilization of substance use services in situations when substance use interventions were not congruent with the roles, structure, values, and authority of the system or implementing organization. Future research should focus on developing, applying, and evaluating strategies for overcoming these challenges in order to make progress toward meeting the need for substance misuse services in conflict-affected populations.

Male and LGBT survivors of sexual violence in conflict situations: a realist review of health interventions in low-and middle-income countries

“…These services can integrate screening and brief interventions to identify and refer survivors to specialised services, prevent mental disorders for those with subthreshold symptoms, increase awareness about mental health and reduce barriers to care. Access may be facilitated because there seem to be less stigma associated with seeking care in primary health facilities as opposed to services solely serving sexual violence cases [113,147]. Primary health services can also be an effective entry point into the system, especially if local explanatory models and help seeking behaviour are in line with what these type of services' discourse on health and what they have to offer [147].…”

“…There are challenges, however, to the implementation of integrated care. The allocation of resources is usually siloed in humanitarian emergencies, and overcoming coordination challenges requires engagement from all sectors involved [113].…”

“…Mental health is unlikely to be prioritised by survivors who are struggling to feed themselves or find shelter [63]. At the same time, mental health can deteriorate if these needs are not met [113]. Factors such as poverty and armed conflict may act as daily stressors in the lives of CRSV survivors, and can further hinder access to basic health services, compromising positive health outcomes [114].…”

Public health imperatives in countering drug related health threats and vulnerabilities in contemporary Palestinian refugee camps

“…Guidelines for humanitarian assistance refer to actions to address substance in refugee settings, but practice remains limited by the lack of evidence on effectiveness and limited implementation of substance use interventions ( Greene et al., 2019 ). Operational research on navigating implementation barriers such as stigma and service provider capacity, and devising effective models for service integration and delivery and generating robust evidence to inform policy and resource allocation is in its infancy ( Greene et al., 2018 ; Greene et al., 2019 ). Recommendations therefore centre on the need to standard measurement and reporting of substance related outcomes, and utilise existing guidance and adapt interventions implemented in refugee populations in other countries ( Ezard et al., 2011 ; Greene et al., 2018 ; Greene et al., 2019 ; Kane & Greene, 2018 ), train UNRWA social and health workers (for example mhGAP substance-use training) in brief and family interventions, community behaviour change and harm reduction, and design and evaluate prevention and treatment interventions for substance misuse specific to outcomes relevant to displaced Palestinian communities.…”

“…These include, the UNODC and WHO International Standards for Treatment of Drug Use Disorders ( UNODC/WHO, 2020 ) and the International Standards on Drug Use Prevention ( UNODC, 2018 ). Intervention-orientated qualitative rapid assessment and response methods are warranted ( Ezard et al., 2011 ; Greene et al., 2018 ; UNHCR/WHO, 2008 ; Greene et al., 2019 ) to inform a culturally and contextually relevant response. Such responses should focus on preventive measures including promoting parental and family skills, youth social and emotional skills, enforcing environmental policies including the loose regulations around pharmacy dispensing of habit forming drugs in the camps; and preventing the exploitation of youth by criminal networks and for radicalisation.…”