Baseline results of household participants are presented in Table 1. Though all respondents reported that the mother was still alive at the time of the survey, not all households had the mother provide survey responses. It is also customary in rural, conservative areas of the Middle East that patriarchal structures preclude women from representing the family to outside representatives. Only 77.1% of respondents were mothers of children that were selected from the sample. Differences between respondent type (mother, father, grandparents) were conducted to determine if a stratified analysis was necessary. There were no differences across the strata so pooled results are presented.
The sampling mechanism sought to capture individuals who had been lost to clinical follow-up from the immunization schedule. Several of the households were drawn from areas that had not been accessed by a healthcare professional for a prolonged time. Of the respondents, both the head-of-household and maternal education levels were lower than observed for Iraq, with nearly 29.6% of heads-of household and 39% of mothers reporting only completing primary education or less. This is reflective of the last two decades of trends of declining education completion among children and young adults, with 2020 estimates suggesting 47% of Iraqi children dropping out of school [25]. As of 2013, Iraq’s literacy rate is reported at 74%, a 26% drop from a 100% literacy rate in 1990 [26].
Table 1
Baseline Characteristics (n = 415)
Respondent to the Survey
|
|
Mother
|
320 (77.1%)
|
Father
|
88 (21.2%)
|
Grandparent
|
6 (1.5%)
|
Area
|
|
Rural
|
123 (29.6%)
|
Head of Household Education
|
|
Primary or less
|
123 (29.6%)
|
Some or All Secondary
|
191 (46.0%)
|
Beyond Secondary
|
101 (24.3%)
|
Number of Household Members
|
|
<=5
|
169 (40.7%)
|
More than 5
|
245 (59.3%)
|
Number of children less than 5 years of age in household
|
|
2 or fewer
|
145 (35%)
|
More than 2
|
269 (65%)
|
What type of home do you live in?
|
|
Apartment
|
22 (5.3%)
|
Multi Family home
|
77 (18.6%)
|
Single family home
|
316 (76.1%)
|
Internet at home
|
267 (64.3%)
|
Household Income Source
|
|
Laborer
|
35 (8.4%)
|
Farmer
|
75 (18.1%)
|
Business Owner
|
87 (21%)
|
Education
|
33 (8%)
|
Healthcare
|
23 (5%)
|
Engineer
|
28 (6%)
|
Administrative
|
36 (8%)
|
Relatives inside Iraq
|
17 (4%)
|
Maternal Education
|
|
Primary or less
|
162 (39%)
|
Some or All Secondary
|
212 (51.1%)
|
Beyond Secondary
|
41 (9.9%)
|
Maternal Marital Status
|
|
Married
|
379 (91.3%)
|
Divorced or Widowed
|
36 (8.7%)
|
Mother Children under five years of age
|
|
2 or fewer
|
367 (88.4%)
|
More than 2
|
48 (11.6%)
|
Maternal Age in Years
|
30 (4)
|
Number of household members
|
6 (2)
|
Number of household members < 5 yo
|
3 (2)
|
Childhood variables, including health status of the child, are presented in Table 2. Across developmental variables, the children achieved the developmental milestones of sitting up, speaking and walking within the normal range [27]. Overall reports of respiratory and diarrheal illnesses in the sample are consistent with UNICEF MICS Iraq reports and other studies across Iraq [18, 28]. UNICEF’s (United Nations Childrens Fund) MICS (Multiple Indicator Cluster Survey) 2018 reported 44% of children less than five years of age sought care for acute respiratory infections and 25% of children received care (oral rehudration solution) from a healthcare provider in the previous six months [19]. Among reported illnesses of the child, all were consistent with Iraq national statistics, including respiratory illnesses [29]. A primary drawback of this data is dependent on the respondent’s recall as the data was not cross-validated with health records.
Table 2
Description of Children in Cohort born and lived continuously in Hadeetha district, Anbar province between 2014–2021 (n = 415)
|
Mean (SD)
|
Range
|
Age in Months
|
33 (15)
|
(11, 72)
|
Months Breastfed
|
11.4 (4.2)
|
(2, 24)
|
Developmental Variables (Months)
|
|
|
Age first sit up
|
8 (1)
|
(5, 19)
|
Age first steps
|
14 (2)
|
(10, 19)
|
Age spoke first word
|
13 (3)
|
(7, 25)
|
Number of Illnesses in Past Six Months
|
|
|
Diarrheal Episodes
|
0.3 (0.99)
|
(0,14)
|
Respiratory Illnesses
|
0.45 (0.72)
|
(0, 8)
|
Fever Illnesses
|
0.83 (0.71)
|
(0, 4)
|
Other illnesses
|
1.1 (0.51)
|
(1, 6)
|
Immunization Completion
|
n (%)
|
(95% CI)
|
Fully Immunized by 12 Months
|
87 (21.4%)
|
(17.3%, 25.1%)
|
Any Illness Reported
|
|
|
Any diarrheal illness in last 6 months
|
87 (21%)
|
(17.1%, 24.9%)
|
Any respiratory illness in last 6 months
|
158 (38.1%)
|
(33.4%, 42.8%
|
Any fever related illness in last 6 months
|
285 (68.7%)
|
(64.2%, 73.2%)
|
Any other illness in last 6 months
|
115 (27.7%)
|
(23.4%, 32%)
|
Any illness in last six months
|
348 (83.9%)
|
(80.1%, 87.2%)
|
One illness
|
116 (28%)
|
(23.8%, 32.4%)
|
Two illnesses
|
170 (41%)
|
(36.3%, 45.7%)
|
Three illnesses
|
59 (14.2%)
|
(11.1%, 17.8%)
|
Four illnesses
|
3 (0.7%)
|
(0.2%, 1.9%)
|
Treatment seeking behaviors for the mother and child (by the caretaker) are presented in Fig. 1. There was a strong association between seeking treatment from a physician for the mother and for the child. Eighty-nine percent (291 of 327) of mothers who sought medical treatment from a physician for themselves also sought treatment from a physician for their child [OR = 22, 95% CI (12, 38.6)]. A similar association was observed for seeking medical treatment from a nurse. Sixty-seven percent of mothers who seek treatment from a nurse (70 of 104) for themselves also seek treatment from a nurse for their child [OR = 20, 95% (11.4, 35)]. Similarly, positive associations were seen for care seeking from a pharmacist, though not as strong as other provider categories [OR = 5.76, 95% CI (1.14, 29)]. Across paired comparisons of treatment seeking behaviors, there was no differences in health seeking behaviors between the caregiver for the mother versus care seeking for the child.
In order to understand obstacles to care during the ISIS occupation period, several questions focused on difficulty associated with healthcare access across provider type. The overall impact of conflict on the respondents was assessed across the domains of economic impact, damage to home and displacement. The majority of respondents indicated that seeking care for themselves, or their child, was difficult or very difficult during this period (Table 3). Sixteen percent of participants indicated their home was damaged during the conflict period, with 30% being displaced, all of whom moved to other areas in Anbar, mostly within Haditha. The results of the survey are consistent to wide scale assessments by the World Bank group which described Anbar bearing the greatest burden of infrastructure compromise and internally displaced persons [30].
Table 3
Conflict related experiences of respondents (n = 415)
|
n (%)
|
95% CI
|
Home was damaged
|
67 (16.1%)
|
(12.8%, 20%)
|
Living in same home as 2014–2018
|
277 (66.7%)
|
(62.1%, 71.2%)
|
Displaced from your home
|
125 (30.1%)
|
(25.9%, 34.7%)
|
Lost income 2014–2018
|
185 (44.6%)
|
(39.8%, 49.4%)
|
Answered Difficult or Very Difficult in Accessing the following during the 2014–2017 period
|
|
n (%)
|
95% CI
|
Healthcare for yourself
|
356 (85.5%)
|
(82.2%, 88.9%)
|
Healthcare for your child
|
333 (80.2%)
|
(76.2%, 83.9%)
|
Medication for yourself
|
367 (88.4%)
|
(85.1%, 91.2%)
|
Medication for your child
|
343 (82.7%)
|
(78.8%, 86.1%)
|
Vaccines for your child
|
339 (81.7%)
|
(77.8%, 85.2%)
|
Food
|
373 (89.9%)
|
(86.7%, 92.5%)
|
Conflict experiences provide a framework to understand health seeking behaviors during the conflict period and changes in the post-conflict period. Figure 2 describes absolute changes in treatment and medication seeking between the two time periods. From the conflict to post-conflict period, positive trends toward a reliance on physicians, and a decreased reliance on other healthcare professionals, was noted across categories. Identifying physicians as a source of treatment and medication increased the most compared to all provider types. Conversely, nurses as a source of treatment decreased by 23% and pharmacists as a source of medication decreased by 16%. An additional positive increase was noticed for technology to supplement treatment options, with 11% of respondents using the internet for treatment, medication, or medication information.
Additional analysis was performed to detect changes in care seeking at the individual level. Shifts in care seeking were from 2014–2017 and the follow-up period of 2021. Primarily, respondents indicated an increased reliance on physicians in the 2021 period. Forty-three percent of mothers who sought treatment from a nurse (85 of 200) during the conflict period continued to seek treatment from nurses during the post-conflict. Sixty-two percent of mothers (138 of 222) who did not utilize a physician during the conflict period began using a physician in the post-conflict period. Similar shifts were seen for medication seeking. Treatment and medication seeking shifted from nurses to physicians as well as pharmacists to physicians in the post-conflict period. Significant shifts were not seen from pharmacists to nurses or vice versa nor shifts away from using physicians.
Trusted sources of healthcare information saw similar trends as health seeking by provider type. Physicians were identified with the greatest frequency as trusted sources of information. Only a small portion of respondents indicated they used the internet to seek health information (13.1%) though 64% of respondents indicated they have internet in the home.
Table 4
Sources of healthcare Information for survey respondents as of 2021 (n = 415)
Seek healthcare information
|
Physician
|
288 (69.9%)
|
(65.3%, 74.2%)
|
Nurse
|
109 (26.5%)
|
(22.4%, 30.9%)
|
Pharmacist
|
13 (3.2%)
|
(1.8%, 5.2%)
|
Family Members
|
89 (21.6%)
|
(17.8%, 25.8%)
|
Internet
|
54 (13.1%)
|
(10.1%, 16.6%)
|
Traditional Healers
|
20 (4.9%)
|
(3.1%, 7.3%)
|
Focus Group and Key Informant Interview Results:
The qualitative arm of this study provided an opportunity to provide context for the respondents’ barriers to healthcare seeking during the period of conflict. The themes of the focus groups and key informant interviews are presented below around three themes: 1) Absorption and Adaption during the ISIS period and 2) Barriers to Recovery and Reconstruction in the post-conflict period.
Absorption and Adaptation: Provision of Health Services during Periods of Conflict
Differing from their counterparts in Ninewa, Salahuddin and Kirkuk, the Anbar healthcare managers expressed that the ISIS invasion and occupation was an extension of the previous two decades of conflict. The Anbar participants expressed exhausted adsorption capacity during ongoing aggression as the previous three decades did not provide an opportunity for rebound and recovery. Hadeetha was differentiated from other cities in Anbar as it was primarily surrounded, not occupied, by ISIS. The strangulation approach taken toward the city of Hadeetha, and surrounding tribes, left the area without electricity, food and medical services from 2014–2017. Furthermore, the isolation from ISIS control did not allow the formation of an alternate healthcare system under ISIS, which was largely a fee-for-service and referral system to other areas in Iraq, with ISIS permission. Instead, Hadeetha was reliant on continuation of services based upon what was available within the city itself. Medication and vaccine distribution was difficult, not only due to ISIS blockades, but lack of refrigeration systems, electricity and the sparsity of gasoline for vehicles.
Per the Pediatric District Health Manager, the number of healthcare professionals and employees within Hadeetha dropped from sixty to only six. Physicians, with opportunities outside of the region, were among the very first to leave. Remaining staff were mostly untrained or unseasoned professionals. Though the population of Hadeetha did not experience the large exodus patterns of the rest of Anbar, the health demands of the remaining population increased with few opportunities for health maintenance or emergency interventions. Interviewees indicated an increased reliance on traditional medicine, shifting of medical treatment to the few remaining nurses, a reappearance of vaccine preventable diseases and prolonged malnutrition.
Lack of security within Hadeetha impeded the health services of the remaining physicians. Without electricity or gasoline, both private and public clinics were closed. The Hadeetha main hospital was under construction at the time of the insurgency and was inoperable throughout the time period. Several times, desperate patients would seek the physician at home (ie, visit the district manager’s home) for emergent care. Physicians and other healthcare providers were execution targets by ISIS.
The central government attempted to mitigate disruptions in health services by delivering personnel, and supplies, by aircraft drops in a military airfield outside of Hadeetha. The healthcare professionals, pharmacists, doctors and nurses, would be required to run with supplies on their backs between the ISIS territory and Hadeetha to enter the city. Due to the two decades of insurgency, only Iraqi personnel with historic roots in Hadeetha would be deployed for three to six month stints in Anbar. These deliveries were intermittent and met with frequent disruption. Moments of lull would allow for continuation of mass vaccination campaigns. These services were often uncompensated. Routes for vaccination delivery were often redirected, requiring deliveries of vaccines from Baghdad’s Ministry of Health to be routed through Kerbala in the South of Iraq. Roads within Anbar were wrought with explosives as well as three decades of damage. The participants shared that steadfastness and patience, as well as an uncompromising commitment to their community, motivated their survival during this period. Another theme was a hopeful attitude that the next decade will bring a period of peace and opportunity for restoration and preparedness for the next crisis.
Recovery and Reconstruction: 2018 to Pre-Pandemic Hadeetha Health Services
Recovery themes focused on optimizing periods between unrest for health system capacity building and creating cohesive community networks. Intensive efforts were made to recruit healthcare professionals back to Anbar and Hadeetha. This process has been slow, as internally displaced persons continue to return to Anbar four years after cessation of conflict [31–35]. Ongoing national level disruptions in the form of political protests, limited educational and economic opportunities for the youth and regional interference are ongoing are slowing Anbar’s recovery.
Health problems within the districts persist, particularly malnutrition, violence related injuries, vaccine preventable diseases, cancer, and mental health problems. Recovery is ongoing. As of 2019, remote areas within the region were not under the control of the central government, making supervision of remote staff difficult and healthcare access focused on centralized locations in urban centers. The central government still struggled in compensating medical personnel who reported salary disruptions lasting a few months to an entire year in both 2019 and 2021.
Limited central government involvement and leadership had left Anbar and Hadeetha based recovery and resilience themes to focus on governorate and district efforts. A major theme was establishing community partnerships throughout Anbar to provide auxiliary support to healthcare personnel in times of conflict. An emphasis was placed on using traditional structures, not simply media platforms, to form community cohesion and response. Coordination across governorates for crisis training, occurring monthly, would provide specialized medical training of healthcare providers and community leaders. It was recommended to run simulation exercises during periods of political lull.
Recovery in the districts was prioritized around restoration of infrastructure. The Hadeetha hospital is now functional as are all of the primary healthcare centers. Sixty-percent of the subcenters (6 of 10) are fully functional as well. To mitigate the impact of healthcare sites as targets during insurgency and conflict, participants recommended identifying a series of alternate sites throughout the governorate for emergency stockpiles of supplies including vaccines, ambulances, and medications. This should be built into budget structures for the health districts. The need for central government recovery and attention was discussed across all districts and governorates in the seminar.