Changes in Healthcare Seeking Behaviors Among Caretakers of Children in the Previously Occupied ISIS territory: Hadeetha, Anbar, Iraq: A Cross-Sectional Survey of 415 Households

Changes in Healthcare Seeking Behaviors Among Caretakers of Children in the Previously Occupied ISIS territory: Hadeetha, Anbar, Iraq: A Cross-Sectional Survey of 415 Households | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Changes in Healthcare Seeking Behaviors Among Caretakers of Children in the Previously Occupied ISIS territory: Hadeetha, Anbar, Iraq: A Cross-Sectional Survey of 415 Households Sara Al-Dahir, Tahseen Abdulateef Hasan, Alaa Khalil, William J Moss, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4124361/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Oct, 2024 Read the published version in Conflict and Health → Version 1 posted 10 You are reading this latest preprint version Abstract Background: The objective of this study was to describe changes in health seeking behaviors of caregivers of children ages 12-60 months of age in Hadeetha, Anbar, Iraq from the conflict period of ISIS (Islamic State of Syria and Iraq), 2014-2017, to the post-conflict period, 2021. The western province of Anbar, and the district of Hadeetha, have suffered direct impacts from the second United States led invasion (2003) through the ISIS invasion (2014-2017). With the primary health care centers being closed or inaccessible, the remaining population experienced changes in health seeking. The area of Anbar, Iraq remains largely remote from the discourse of health system recovery post-conflict. Methods: This was a mixed-methods study composed of a cross-sectional 415 household survey and focus groups in Hadeetha, Anbar, Iraq. Caretakers of children were interviewed from February to April 2021. Children were sampled from a list of children who missed at least one vaccination appointment without a return for follow-up from the birth cohorts of 2015-2020. Focus groups and key informant interviews occurred from 2019-2021. Results: In the post-conflict period, there were no differences in health seeking based upon provider type between respondents. Physicians were primary healthcare providers in the post-conflict period for 79% of respondents versus only 47% in the conflict period. Healthcare workers described major barriers to delivering services in Hadeetha during the ISIS occupation due to infrastructure damage, threats of violence, decreased medical personnel, lack of compensation and disruptions in medical supplies from 2014-2017. Conclusion: This study provides insight into health seeking challenges among the many individuals who remained in Hadeetha during the ISIS occupation. Health use patterns by provider type mirror the concerns the healthcare providers shared: limited availability, efflux of professional workers, limited resources and security challenges to providing care. Positive trends toward increased access to physicians during periods of peace are an encouraging marker for continued population resilience during the post-conflict period. Recovery efforts continue to be hampered by internal sectarian discord within Iraq as well as insufficient resources to maintain health services as well as provide catch-up health services, such as immunizations. Conflict health seeking Iraq ISIS (Islamic State of Iraq and Syria) child health maternal health Figures Figure 1 Figure 2 Background Iraq continues to adjust to displacement and return of families and children to the formerly ISIS occupied territories. As of 2022, migration reports suggest that nearly 4.1 million of Iraq’s original 6.7 million displaced returned to their original districts, but they are returning to largely unrecovered areas within the country [ 1 ]. Half of the total 4.1 million who require humanitarian aid lived in two governorates: Ninewa and Anbar [ 2 ]. Healthcare systems continue to adapt to providing for the remaining citizens as well as the influx of the returnees, while ongoing instability continues in the Anbar region. Iraq’s healthcare system and its attempts to rebound from four decades of war and ongoing stressors have been well documented since the First Gulf War [ 3 , 4 ]. Parallel to government funded primary healthcare clinics, the private fee-for-service system expanded throughout Iraq [ 5 , 6 ]. Preferential shifts of primary care providers to the private clinics created long lists of back-logged patients in the public sector, especially in areas that were inadequately staffed [ 6 ]. Though primary healthcare systems were prioritized for recovery after the second United States-led invasion, citizens still associated better services with the private sector [ 38 , 39 ]. The 2014–2017 ISIS (Islamic State of Iraq and Syria) invasion and occupation of Anbar, Ninewa, Salahideen and Kirkuk tested Iraq’s healthcare system even further. During the recovery period, Iraq’s Ministry of Health continued to suffer inequities in resource distribution in terms of trained human capital and equipment necessary for disease detection and treatment [ 7 ]. A strained healthcare system was coupled with a three-decade exodus of healthcare providers outside of Iraq [ 2 , 5 ]. Capacity building remains a significant challenge in Iraq, particularly in the primary health care arena [ 8 , 9 ]. Healthcare delivery is particularly interrupted in the immediate conflict period but the disruption continues for years post-conflict. Pre-conflict capacity of the health systems is one predictor of sustainability during the conflict if the system has the necessary absorptive capacity to continue under a violence stressor. Vaccination services are often disrupted or halted [ 10 , 11 ]. During periods of conflict, international organizations prioritize the needs of refugees and IDPs, with “remainees,” often inaccessible and remaining among the most vulnerable [ 12 ]. As of 2022, the United Nations identified one-hundred fifty-eight (158) activities in Anbar to reach the SDGs (Sustainable Development Goals), with only one focusing on reinforcing the primary healthcare system [ 13 ]. Even private-public partnerships that develop during the conflict period can hamper the redevelopment of the national healthcare system as humanitarian actors continue to express vested interest in the region, competing with needs identified by the native population [ 9 , 14 ]. Health-seeking behaviors of Iraqis under the ISIS occupation have been characterized for Mosul, in Northern Iraq. During ISIS control, a private fee-for-service system was established, with referral to approved affiliate governorates for specialty care. Vaccination services decreased and alternate health seeking among traditional providers filled gaps in the vacuum left by healthcare workers who left Iraq [ 15 , 2 , 16 , 5 ]. Healthcare workers who remained faced months, even years, of uncompensated labor [ 17 ]. Efforts to deliver care in the conflict and post-conflict period were fraught with violence, regional instability and lack of central government dedication to recovery. Infrastructure repair of hospitals took precedence over primary healthcare centers [ 17 ]. Whereas most of the studies that have emerged from Iraq have focused on urban centers that have been highlighted for their extent of infrastructure damage, no studies have emerged from the Anbar region [ 18 ]. Anbar is unique in that prior to the ISIS invasion, Anbar experienced years of sectarian violence under AlQaeda. United Nation data sets such as UNICEF MICS survey has limited ability to report on households in isolated, rural areas of former ISIS occupation [ 19 , 20 , 21 , 22 ]. The purpose of this study is to characterize health seeking behaviors of caretakers of children less than six years of age from the conflict to the post-conflict period in Hadeetha, Anbar, Iraq. It also provides narratives from the healthcare workers who attempted to provide care during the ISIS occupation of 2014–2017. Methods This study is comprised of two components: 1) a home-based, cross-sectional survey of children and their caretakers who had been lost to clinical follow-up for immunization completion in Hadeetha, Iraq and b) a qualitative component of focus groups and key informant interviews of health managers in the Anbar region. A home-based survey as well as a review of immunization records retrieved from the child’s immunization card was collected from household respondents between February and April 2021. The qualitative component included focus groups and key informant interviews of health care managers and professionals from Anbar, Iraq as part of a UNICEF sponsored Primary Health Care (PHC) and Extended Program on Immunizations (EPI) nationwide conference in Erbil, Iraq in November 2019. Additional follow-up interviews were conducted among medical professionals and the director of pediatric services of the Hadeetha district in December 2021 [ 17 , 23 ]. Household Surveys Study Setting Anbar is one of Iraq’s governorates which represents a large province bordering both of Iraq’s western neighbors: Syria and Jordan as well as Saudi Arabia to the south. The Hadeetha district is strategically located at the south of the Hadeetha dam, and straddles the Euphrates River. As of 2020, Hadeetha’s total population was estimated at 122,978, of which 15.75% are estimated to be younger than five years of age [ 24 ]. Unlike the rest of Anbar, central Hadeetha was surrounded, not occupied, by ISIS. This led to unique challenges within Hadeetha for the provision of health services. Study Population and Sampling Procedures: Random sampling occurred from a list of 3,953 children between 12 and 72 months of age who had been lost to clinical follow-up for immunization completion, with a greater than 95% response rate to the survey. The caregiver was contacted by the designated Hadeetha district EPI (Extended Program on Immunization) clinician. In order to be included in this analysis, the caregiver had to report that the Anbar province was a continuous place of residence from 2014–2021. A total of 415 household were randomly sampled and met criteria for inclusion in this analysis. The final sample represented 2,489 household members and 1,384 children under five years of age. Questionnaire: The survey design was based upon previously validated survey questions drawn from the Multiple Indicator Cluster Survey conducted in Iraq from 2000–2018. The caregiver survey included the following domains: 1) demographic information on the head of household, caretaker and child, b) household information, c) health history of the child, d) immunization record captured from vaccination records, and e) maternal demographic variables. An additional section was developed to assess the impact of conflict on healthcare access and attitudes. The conflict period was defined as the period of ISIS occupation until final liberation by Iraq: January 2014 to December 2017. Health seeking variables included treatment seeking, medication seeking and health care information seeking for the mother (caregiver) and the child. All data elements were designed and validated by the research teams in the United States and Iraq. Statistical Analysis: All baseline variables were analyzed using descriptive statistics, with number and percent as well as mean and standard deviation for continuous variables as needed. A total of 351 households were needed in order to reach 80% power at a 95% confidence level and 5% margin of error. Difference in health seeking by the mother versus the child (by the caretaker) are expressed as proportions and were analyzed with a Chi-square analysis ( Χ 2 ). Changes in health seeking from the conflict to the post-conflict period and differences in health seeking between the mother versus child are expressed as absolute changes by the respondents per type of health care provider (doctor, nurse or pharmacist) as well as non-health care professionals (religious leaders, family members, internet) and were assessed for statistical significance using Chi-square analysis ( Χ 2 ). Relative changes in health seeking from the conflict to the post-conflict period, such as shifts from healthcare provider type, were assessed using changes based on individual responses Bivariate data analysis was conducted using a series of contingency tables between care seeking based on health care provider type to produce a cross tabulation and Chi-square analysis ( Χ 2 ). Focus Groups and Key Informant Interviews: Healthcare Professional Participants: Health district managers from across Iraq were invited for a two-day conference in Erbil, Iraq as part of a PHC (primary healthcare center) health strengthening and EPI informational session in November 2019. Special break-out sessions to analyze health system’s resilience among the former ISIS occupied governorates of Anbar, Kirkuk, Ninewa and Salahiddeen occurred in parallel to the main sessions. Structured focus groups involved governorate-specific collaborative responses, a needs assessment and presentation of results. Focus group themes included adaptive strategies for provision of health services during the ISIS occupation and reconstruction and recovery efforts in the governorates. As severity of the conflict experience varied across governorates, structured questions permitted a formatted response in addition to open-ended opportunities to elaborate on the PHC and EPI specific failures within a governorate. Additional input was collected from the Hadeetha district Pediatric Health services manager in December 2021 as written key informant interviews. Data on reports of infrastructure damage, such as hospital and primary health care facilities, was cross-validated with a Ministry of Health/UNICEF health facilities national dataset. Analysis: Focus groups were conducted in Arabic and English. Themes were prioritized around three trends during the conflict and post-conflict period: emergent absorption during the immediate insurgency period, adaptation during the ongoing occupation and finally, reconstruction and recovery efforts. Coded terms using a discourse analysis approach was applied to the focus groups and key informant interviews This analysis focuses on the responses of the Anbar and Hadeetha participants. Results 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. Discussion The immediate period post-ISIS occupation in Anbar witnessed a slow recovery process in which infrastructure repair was prioritized over re-establishing decentralized patient services for remote and isolated communities. Attempts to meet the needs of the population were slowed with the continuing challenges of reincorporating into care the millions of returnees to the Anbar province. Health disparities that existed before occupation based upon wealth quintile were exacerbated by health literacy and overall literacy, which has dropped in Iraq since the second Gulf War. Unlike comparable countries based on Work Bank wealth indices, Iraq’s gross domestic product (GDP) spending on health care is lower, with only 4.2% of GDP spent on healthcare. Efforts by the Ministry of Health toward health financing and social insurance policies continue to be derailed by intermittent and prolonged period of conflict [ 10 ]. The effects on armed conflict on children can be considered acute and post-acute Though it is known that women and children bear the disproportionate burden by armed conflict, such metrics ae poorly quantified due to limitations in data gathering ability. Gaps in data are even wider for internally displaced persons and “remainees,” who are inaccessible during the conflict period or fall out of the reach of traditional aid and humanitarian agencies [ 36 , 37 ]. A systematic review of infectious disease interventions in conflict settings highlighted the disproportionate focus on polio and measles campaigns. This left other acute infectious conditions associated with early childhood mortality, such as acute respiratory infections and diarrheal disease, often not monitored at the level of vaccine preventable diseases [ 36 , 37 ]. In the one-year post-conflict period in Mosul, trends are noted in increases respiratory infections in Mosul [ 38 ]. The Hadeetha results also demonstrate childhood infections similar to national levels, but these are children who have not been retained in care and probably represent an underestimation. The post-conflict usage patterns indicate a desire by caregivers to seek medical treatment for their children from physicians. Anbar witnessed an exodus of healthcare providers during the ISIS occupations. The result was a reliance on alternate providers and paraprofessionals for treatment and medication during the conflict period and into the immediate post-conflict period. Similar trends were noted in Mosul, Iraq which investigated health utilization patterns in the recovery period in which pharmacists and alternative medicine were used by both residents who remained during ISIS and those who were returning [ 9 ]. Unlike studies in other parts of Iraq, this study investigates longitudinal, self-reported changes in healthcare use. The increase reliance on physicians correlates with the health workers reports of an increased return of physicians to the region after liberation. Decentralized approaches to healthcare, such as the use of nurses and pharmacists, particularly among the more rural residents, suggests that sub-centers and health houses more distant from Hadeetha central continue to depend on support staff such as nurses and pharmacists to work in the role of treatment and medication management. This can be a positive trend if it decreases the patient load burden for physicians as well as shores up additional health providers in a more decentralized approach, as long as sufficient training and supervision continues. This will also serve to provide continuity of services with a broader patient provider base in case of additional conflicts in the region. In non-conflict settings, recommendations to maximize health care utilization by patients can employ multiple strategies. Community engagement campaigns that increases patient decision-making strategies and a participator care model can be used to overcome care seeking challenges and provide equity of services across communities [53]. In conflict settings, recommendations revolve around prioritizing rural residents and returnees to conflict recovery zones. This recommendation does not address the continuing health gaps incurred by those who remained under occupation or in the midst of the conflict. In Iraq, health seeking was dictated by access. Under ISIS, a pay for service model was established. Dependence on the private sector exacerbated out of pocket health expenditures, driving a reliance on self-care and traditional healers. The quality of public sector care still paled in comparison to what was perceived as superior care in the private sector [ 39 ]. Shifting individuals back to the government sector for care remains a challenge throughout the recovery areas. Conclusion Iraq has four decades of experience with conflict and shock to the healthcare infrastructure. Recovery strategies have placed a strong emphasis on the need of the central government to develop and implement disaster-based strategies before, during and after a crisis. Among the disaster-based strategies required would be crisis support for healthcare professionals, cooperation across sectors and a community embedded approach to conflict resistance, endurance and recovery [ 17 ]. Crisis support would include stockpiles of necessary medical supplies, communication lines that would be preserved during times of violence and collateral networks of healthcare providers to provide support during conflict. Infrastructure repair for the returnees goes hand-in-hand with shoring up the healthcare infrastructure. Even post-conflict distribution of infrastructure recovery funds were inconsistent across and within the affected governorates [ 40 ]. In a country with great wealth disparities, exacerbated by the rural-urban divide and recent (even ongoing) conflict, the impact of out of pocket expenditure and health seeking behaviors outside of governmental clinics widens the divide in health outcomes for the poorest and most vulnerable. Ongoing United Nations efforts across Anbar do not focus on shoring up the primary health care centers, sub-centers and health houses in the recovery district. A concerted effort to reintegrate individuals into primary healthcare services and remedy the gaps in health care for those that were isolated for nearly half a decade must occur hand-in-hand with other community, government, social, and security campaigns. Reintegration into care pathways is the first step to health equity in the region and to ensure the most vulnerable do not remain vulnerable to the residual impact of conflict. Abbreviations EPI (Extended Program on Immunization) ISIS (Islamic State of Iraq and Syria) PHC (Primary healthcare center) UNICEF (United Nations Children’s Fund) MICS (Multiple Indicator Cluser Survey) USA (United States of America) Declarations Ethics approval and consent to participate: Institutional Review Board approval was received from Johns Hopkins University Bloomberg School of Public Health and the Hadeetha, Anbar, Iraq Ministry of Health Ethics Approval Board. Consent for Publication: No individually identifiable data is available. Availability of data and materials: The data that support the findings of this study are available from the authors and the district of health but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the Hadeetha district of health. Competing Interests: The researchers have no competing interests to declare. SA reports receiving funding from Pfizer and Roche-Genentech, though not related to this project. KT reports funding from Pfizer, AstraZeneca and Moderna, though not related to this project. Funding: Funding for this research was provided by Gulf Medical Relief Fund Inc, EIN 72-1197274, a United States based non-profit dedicated to delivering medical and food supplies to conflict areas and areas impacted by climate disruption. Authors’ Contributions: SA participated in the conception, design of the work, analysis, interpretation of data, drafted and revision. TH and AK contributed to the design of the work, the acquisition, interpretation of data; revision. WM, KT and GB participated in the conception, design of the work, interpretation of data, revision. MK participated in the conception, design of the work, analysis, interpretation of data, revision of manuscript. All authors read and approved the final manuscript. Acknowledgments: Special acknowledgement goes to Johns Hopkins Bloomberg School of Public Health for support and guidance during this research process. Additional acknowledgement’s for Dr. Klaus Heyer for assistance with approach to the qualitative analysis and support during the project. Finally, thanks is provided to Xavier University of Louisiana for providing the necessary leave time to complete the research, specifically Dr. Kathleen Kennedy and Dr. Anne McCall. Finally, this work was supported with the guidance of Dr. SM Moazzem Hossain and the Iraq UNICEF Team. References UNIOM. Organización Internacional para las Migraciones. 2018 December 12 [cited 2020 April 24]. Avalable from: https://www.iom.int/es/countries/iraq. Reliefweb. Iraq Humanitarian Needs Overview 2020. 2019 November [2020 April 24]. [EN/AR/KU] - Iraq. ReliefWeb. 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Lafta R, Cetorelli V, Burnham G. Health and Health Seeking in Mosul During ISIS Control and Liberation: Results From a 40-Cluster Household Survey. Disaster Med Public Health Prep . 2019;13(4):758–766. doi:10.1017/dmp.2019.11. UNICEF MICS. Multiple Indicator Cluster Surveys Iraq 2018. Surveys - UNICEF MICS; 2019 February. Accessed: April 24, 2020. Available from: https://mics.unicef.org/surveys. UNICEF. Multiple Indicator Cluster Surveys Iraq 2000. Surveys - UNICEF MICS. 2021 December. Accessed: April 24, 2020. Available from: https://mics.unicef.org/surveys. UNICEF. Multiple Indicator Cluster Surveys Iraq 2006. Surveys - UNICEF MICS. 2007 October. Accessed: April 24, 2020. Available from: https://mics.unicef.org/surveys. UNICEF. Multiple Indicator Cluster Surveys Iraq 2011. Surveys - UNICEF MICS. https://mics.unicef.org/surveys. Published September 2012. Accessed April 24, 2020. Khalil A. Interview with Dr. Tahseen AbdulLatif Hassan, Pediatric Director, Hadeetha District Iraq. Conducted January 15, 2022. Khalil A. Abdul Latif, T. (Interview) Hadeetha District Health Director. 2020 February 15. UNICEF. Iraq Educational Fact Sheets. 2020-UNICEF Data. UNICDEF; 2019 July 1 [cited 2020 July 1]. Available from: https://data.unicef.org/wp-content/uploads/2019/07/2020-IRAQ-Education-Factsheets_UNICEF_final.pdf. IRFAD. Iraq Education. IRFAD. 2014 [cited 202 February 2022]. Available from http://www.irfad.org/iraq-education/. Center for Disease Control and Prevention. CDC Developmental Milestones. 2022 March [cited 2022 April]. Available from https://www.cdc.gov/ncbddd/actearly/milestones/index.html. Harb A, Abraham S, O'Dea M, Hantosh HA, Jordan D, Habib I. Sociodemographic Determinants of Healthcare-Seeking Options and Alternative Management Practices of Childhood Diarrheal Illness: A Household Survey among Mothers in Iraq. Am J Trop Med Hyg. 2020 Dec 7;104(2):748-755. doi: 10.4269/ajtmh.20-0529. PMID: 33289474; PMCID: PMC7866356. Al-Thamiri D, Al-Kubaisy W, Ali SH. Asthma prevalence and severity among primary-school children in Baghdad. East Mediterr Health J. 2005 Jan-Mar;11(1-2):79-86. PMID: 16532675. World Bank Group. Iraq Reconstruction & Investment. Part 2. World Bank; January 2018 [cited 2020 April 24]. Available from from: https://openknowledge.worldbank.org/bitstream/handle/10986/29438/123631.pdf?sequence=4. World Bank. Iraq. World Bank; 2020 [cited 2020 March 1]. Available from: https://data.worldbank.org/country/iraq. World Bank. Classification of Fragile and Conflict-Affected Situations. World Bank; 2021 July 1 [cited 2022 March 24]. Available from: https://www.worldbank.org/en/topic/fragilityconflictviolence/brief/harmonized-list-of-fragile-situations. Iraq Humanitarian Situation Report -2019. UNICEF Iraq; 2019 [cited 2020 April 24]. Available from: https://www.unicef.org/iraq/reports/iraq-humanitarian-situation-report-2019. Ala’din Alawan MOH. Health in Iraq – The Current Situation: Our Vision for the Future and Areas of Work. Al-Adib Press (2004). WHO. Iraq Humanitarian Emergencies. World Health Organization; 2019 December [2020 March 1]. Available from: http://applications.emro.who.int/docs/IRQ/IRQ-SitRep-Sep-Nov-2019-eng.pdf?ua=1. Akseer N, Wright J, Tasic H, Everett K, Scudder E, Amsalu R, Boerma T, Bendavid E, Kamali M, Barros AJD, da Silva ICM, Bhutta ZA. Women, children and adolescents in conflict countries: an assessment of inequalities in intervention coverage and survival. BMJ Glob Health. 2020 Jan 26;5(1):e002214. doi: 10.1136/bmjgh-2019-002214. PMID: 32133179; PMCID: PMC7042600. Bendavid E, Boerma T, Akseer N, Langer A, Malembaka EB, Okiro EA, Wise PH, Heft-Neal S, Black RE, Bhutta ZA; BRANCH Consortium Steering Committee. The effects of armed conflict on the health of women and children. Lancet. 2021 Feb 6;397(10273):522-532. doi: 10.1016/S0140-6736(21)00131-8. Epub 2021 Jan 24. PMID: 33503456; PMCID: PMC7612212. Lafta R, Al-Nuaimib MA, Sultan LR, Rihawa H, Burnham G. Health Care and Care-Seeking in Mosul 1 Year After Defeat of ISIS. Disaster Med Public Health Prep. 2021 Jul 21:1-8. doi: 10.1017/dmp.2021.112. Epub ahead of print. PMID: 34284845. Shabila NP, Al-Tawil NG, Al-Hadithi TS, Sondorp E. Using Q-methodology to explore people's health seeking behavior and perception of the quality of primary care services. BMC Public Health. 2014 Jan 6;14:2. doi: 10.1186/1471-2458-14-2. PMID: 24387106; PMCID: PMC3882479. Iraqi Governorate Profiles [cited 2019 December 1]. Available from: https://www.ncciraq.org/en/about/about-iraq/ iraqi-governorate-profiles. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 21 Oct, 2024 Read the published version in Conflict and Health → Version 1 posted Editorial decision: Revision requested 14 Aug, 2024 Reviews received at journal 14 Aug, 2024 Reviewers agreed at journal 01 Jun, 2024 Reviews received at journal 03 May, 2024 Reviewers agreed at journal 24 Apr, 2024 Reviewers agreed at journal 24 Mar, 2024 Reviewers invited by journal 19 Mar, 2024 Submission checks completed at journal 19 Mar, 2024 Editor assigned by journal 19 Mar, 2024 First submitted to journal 18 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4124361","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":281436237,"identity":"df1ca271-695a-4939-86a5-41147b1c3a70","order_by":0,"name":"Sara 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University","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Deloria","lastName":"Knoll","suffix":""},{"id":281436243,"identity":"dc59b867-e875-482a-b923-97250534eab0","order_by":6,"name":"Gilbert Burnham","email":"","orcid":"","institution":"Johns Hopkins University","correspondingAuthor":false,"prefix":"","firstName":"Gilbert","middleName":"","lastName":"Burnham","suffix":""}],"badges":[],"createdAt":"2024-03-18 15:20:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4124361/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4124361/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13031-024-00622-4","type":"published","date":"2024-10-21T15:57:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":53196046,"identity":"e0fdad38-0de5-4064-9d5a-a1843bbfc7b6","added_by":"auto","created_at":"2024-03-21 18:28:24","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":54155,"visible":true,"origin":"","legend":"\u003cp\u003eDifference in Treatment Seeking Behaviors Between Caregiver and Child (by Caregiver) (n=415)\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4124361/v1/7b25037092db3d28201a0972.jpg"},{"id":53196045,"identity":"2e4fc210-fd61-4c75-93cc-abe215a67072","added_by":"auto","created_at":"2024-03-21 18:28:24","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":73489,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in Healthseeking Behaviors of Caretakers from the Conflict to the Post-Conflict Period (n=415)\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4124361/v1/2c39f46e9e3109b2b1a70b49.jpg"},{"id":67681831,"identity":"4ee5f3fa-2eba-4b5c-b14c-9d605ab393b4","added_by":"auto","created_at":"2024-10-28 16:10:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":918367,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4124361/v1/014b2cbd-466e-4e16-bcde-432f565d8fd7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Changes in Healthcare Seeking Behaviors Among Caretakers of Children in the Previously Occupied ISIS territory: Hadeetha, Anbar, Iraq: A Cross-Sectional Survey of 415 Households","fulltext":[{"header":"Background","content":"\u003cp\u003eIraq continues to adjust to displacement and return of families and children to the formerly ISIS occupied territories. As of 2022, migration reports suggest that nearly 4.1\u0026nbsp;million of Iraq\u0026rsquo;s original 6.7\u0026nbsp;million displaced returned to their original districts, but they are returning to largely unrecovered areas within the country [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Half of the total 4.1\u0026nbsp;million who require humanitarian aid lived in two governorates: Ninewa and Anbar [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Healthcare systems continue to adapt to providing for the remaining citizens as well as the influx of the returnees, while ongoing instability continues in the Anbar region.\u003c/p\u003e \u003cp\u003eIraq\u0026rsquo;s healthcare system and its attempts to rebound from four decades of war and ongoing stressors have been well documented since the First Gulf War [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Parallel to government funded primary healthcare clinics, the private fee-for-service system expanded throughout Iraq [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Preferential shifts of primary care providers to the private clinics created long lists of back-logged patients in the public sector, especially in areas that were inadequately staffed [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThough primary healthcare systems were prioritized for recovery after the second United States-led invasion, citizens still associated better services with the private sector [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The 2014\u0026ndash;2017 ISIS (Islamic State of Iraq and Syria) invasion and occupation of Anbar, Ninewa, Salahideen and Kirkuk tested Iraq\u0026rsquo;s healthcare system even further. During the recovery period, Iraq\u0026rsquo;s Ministry of Health continued to suffer inequities in resource distribution in terms of trained human capital and equipment necessary for disease detection and treatment [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A strained healthcare system was coupled with a three-decade exodus of healthcare providers outside of Iraq [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Capacity building remains a significant challenge in Iraq, particularly in the primary health care arena [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHealthcare delivery is particularly interrupted in the immediate conflict period but the disruption continues for years post-conflict. Pre-conflict capacity of the health systems is one predictor of sustainability during the conflict if the system has the necessary absorptive capacity to continue under a violence stressor. Vaccination services are often disrupted or halted [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. During periods of conflict, international organizations prioritize the needs of refugees and IDPs, with \u0026ldquo;remainees,\u0026rdquo; often inaccessible and remaining among the most vulnerable [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. As of 2022, the United Nations identified one-hundred fifty-eight (158) activities in Anbar to reach the SDGs (Sustainable Development Goals), with only one focusing on reinforcing the primary healthcare system [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Even private-public partnerships that develop during the conflict period can hamper the redevelopment of the national healthcare system as humanitarian actors continue to express vested interest in the region, competing with needs identified by the native population [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHealth-seeking behaviors of Iraqis under the ISIS occupation have been characterized for Mosul, in Northern Iraq. During ISIS control, a private fee-for-service system was established, with referral to approved affiliate governorates for specialty care. Vaccination services decreased and alternate health seeking among traditional providers filled gaps in the vacuum left by healthcare workers who left Iraq [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Healthcare workers who remained faced months, even years, of uncompensated labor [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Efforts to deliver care in the conflict and post-conflict period were fraught with violence, regional instability and lack of central government dedication to recovery. Infrastructure repair of hospitals took precedence over primary healthcare centers [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhereas most of the studies that have emerged from Iraq have focused on urban centers that have been highlighted for their extent of infrastructure damage, no studies have emerged from the Anbar region [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Anbar is unique in that prior to the ISIS invasion, Anbar experienced years of sectarian violence under AlQaeda. United Nation data sets such as UNICEF MICS survey has limited ability to report on households in isolated, rural areas of former ISIS occupation [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The purpose of this study is to characterize health seeking behaviors of caretakers of children less than six years of age from the conflict to the post-conflict period in Hadeetha, Anbar, Iraq. It also provides narratives from the healthcare workers who attempted to provide care during the ISIS occupation of 2014\u0026ndash;2017.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study is comprised of two components: 1) a home-based, cross-sectional survey of children and their caretakers who had been lost to clinical follow-up for immunization completion in Hadeetha, Iraq and b) a qualitative component of focus groups and key informant interviews of health managers in the Anbar region. A home-based survey as well as a review of immunization records retrieved from the child\u0026rsquo;s immunization card was collected from household respondents between February and April 2021. The qualitative component included focus groups and key informant interviews of health care managers and professionals from Anbar, Iraq as part of a UNICEF sponsored Primary Health Care (PHC) and Extended Program on Immunizations (EPI) nationwide conference in Erbil, Iraq in November 2019. Additional follow-up interviews were conducted among medical professionals and the director of pediatric services of the Hadeetha district in December 2021 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eHousehold Surveys\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eStudy Setting\u003c/h2\u003e \u003cp\u003eAnbar is one of Iraq\u0026rsquo;s governorates which represents a large province bordering both of Iraq\u0026rsquo;s western neighbors: Syria and Jordan as well as Saudi Arabia to the south. The Hadeetha district is strategically located at the south of the Hadeetha dam, and straddles the Euphrates River. As of 2020, Hadeetha\u0026rsquo;s total population was estimated at 122,978, of which 15.75% are estimated to be younger than five years of age [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Unlike the rest of Anbar, central Hadeetha was surrounded, not occupied, by ISIS. This led to unique challenges within Hadeetha for the provision of health services.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population and Sampling Procedures:\u003c/h2\u003e \u003cp\u003eRandom sampling occurred from a list of 3,953 children between 12 and 72 months of age who had been lost to clinical follow-up for immunization completion, with a greater than 95% response rate to the survey. The caregiver was contacted by the designated Hadeetha district EPI (Extended Program on Immunization) clinician. In order to be included in this analysis, the caregiver had to report that the Anbar province was a continuous place of residence from 2014\u0026ndash;2021. A total of 415 household were randomly sampled and met criteria for inclusion in this analysis. The final sample represented 2,489 household members and 1,384 children under five years of age.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eQuestionnaire:\u003c/h2\u003e \u003cp\u003eThe survey design was based upon previously validated survey questions drawn from the Multiple Indicator Cluster Survey conducted in Iraq from 2000\u0026ndash;2018. The caregiver survey included the following domains: 1) demographic information on the head of household, caretaker and child, b) household information, c) health history of the child, d) immunization record captured from vaccination records, and e) maternal demographic variables. An additional section was developed to assess the impact of conflict on healthcare access and attitudes. The conflict period was defined as the period of ISIS occupation until final liberation by Iraq: January 2014 to December 2017. Health seeking variables included treatment seeking, medication seeking and health care information seeking for the mother (caregiver) and the child. All data elements were designed and validated by the research teams in the United States and Iraq.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis:\u003c/h2\u003e \u003cp\u003eAll baseline variables were analyzed using descriptive statistics, with number and percent as well as mean and standard deviation for continuous variables as needed. A total of 351 households were needed in order to reach 80% power at a 95% confidence level and 5% margin of error. Difference in health seeking by the mother versus the child (by the caretaker) are expressed as proportions and were analyzed with a Chi-square analysis (\u003cem\u003eΧ\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e). Changes in health seeking from the conflict to the post-conflict period and differences in health seeking between the mother versus child are expressed as absolute changes by the respondents per type of health care provider (doctor, nurse or pharmacist) as well as non-health care professionals (religious leaders, family members, internet) and were assessed for statistical significance using Chi-square analysis (\u003cem\u003eΧ\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e). Relative changes in health seeking from the conflict to the post-conflict period, such as shifts from healthcare provider type, were assessed using changes based on individual responses Bivariate data analysis was conducted using a series of contingency tables between care seeking based on health care provider type to produce a cross tabulation and Chi-square analysis (\u003cem\u003eΧ\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFocus Groups and Key Informant Interviews:\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eHealthcare Professional Participants:\u003c/h2\u003e \u003cp\u003eHealth district managers from across Iraq were invited for a two-day conference in Erbil, Iraq as part of a PHC (primary healthcare center) health strengthening and EPI informational session in November 2019. Special break-out sessions to analyze health system\u0026rsquo;s resilience among the former ISIS occupied governorates of Anbar, Kirkuk, Ninewa and Salahiddeen occurred in parallel to the main sessions. Structured focus groups involved governorate-specific collaborative responses, a needs assessment and presentation of results. Focus group themes included adaptive strategies for provision of health services during the ISIS occupation and reconstruction and recovery efforts in the governorates. As severity of the conflict experience varied across governorates, structured questions permitted a formatted response in addition to open-ended opportunities to elaborate on the PHC and EPI specific failures within a governorate. Additional input was collected from the Hadeetha district Pediatric Health services manager in December 2021 as written key informant interviews. Data on reports of infrastructure damage, such as hospital and primary health care facilities, was cross-validated with a Ministry of Health/UNICEF health facilities national dataset.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis:\u003c/h2\u003e \u003cp\u003eFocus groups were conducted in Arabic and English. Themes were prioritized around three trends during the conflict and post-conflict period: emergent absorption during the immediate insurgency period, adaptation during the ongoing occupation and finally, reconstruction and recovery efforts. Coded terms using a discourse analysis approach was applied to the focus groups and key informant interviews This analysis focuses on the responses of the Anbar and Hadeetha participants.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBaseline results of household participants are presented in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. 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.\u003c/p\u003e\n\u003cp\u003eThe 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 [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]. As of 2013, Iraq\u0026rsquo;s literacy rate is reported at 74%, a 26% drop from a 100% literacy rate in 1990 [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBaseline Characteristics (n\u0026thinsp;=\u0026thinsp;415)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRespondent to the Survey\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e320 (77.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFather\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88 (21.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrandparent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (1.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eArea\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e123 (29.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHead of Household Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e123 (29.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSome or All Secondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e191 (46.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBeyond Secondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e101 (24.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Household Members\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;=5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e169 (40.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMore than 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e245 (59.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of children less than 5 years of age in household\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 or fewer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e145 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMore than 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e269 (65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat type of home do you live in?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eApartment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (5.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMulti Family home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77 (18.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSingle family home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e316 (76.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eInternet at home\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e267 (64.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousehold Income Source\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLaborer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (8.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFarmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75 (18.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBusiness Owner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87 (21%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealthcare\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEngineer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdministrative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelatives inside Iraq\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e162 (39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSome or All Secondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e212 (51.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBeyond Secondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41 (9.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal Marital Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e379 (91.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDivorced or Widowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (8.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMother Children under five years of age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 or fewer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e367 (88.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMore than 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48 (11.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal Age in Years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of household members\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of household members\u0026thinsp;\u0026lt;\u0026thinsp;5 yo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eChildhood variables, including health status of the child, are presented in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Across developmental variables, the children achieved the developmental milestones of sitting up, speaking and walking within the normal range [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]. Overall reports of respiratory and diarrheal illnesses in the sample are consistent with UNICEF MICS Iraq reports and other studies across Iraq [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]. UNICEF\u0026rsquo;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 [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. Among reported illnesses of the child, all were consistent with Iraq national statistics, including respiratory illnesses [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. A primary drawback of this data is dependent on the respondent\u0026rsquo;s recall as the data was not cross-validated with health records.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDescription of Children in Cohort born and lived continuously in Hadeetha district, Anbar province between 2014\u0026ndash;2021 (n\u0026thinsp;=\u0026thinsp;415)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge in Months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(11, 72)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonths Breastfed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.4 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(2, 24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDevelopmental Variables (Months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge first sit up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(5, 19)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge first steps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(10, 19)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge spoke first word\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(7, 25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Illnesses in Past Six Months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiarrheal Episodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.3 (0.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0,14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRespiratory Illnesses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.45 (0.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0, 8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFever Illnesses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.83 (0.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0, 4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther illnesses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.1 (0.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(1, 6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eImmunization Completion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFully Immunized by 12 Months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87 (21.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(17.3%, 25.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAny Illness Reported\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAny diarrheal illness in last 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87 (21%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(17.1%, 24.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAny respiratory illness in last 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e158 (38.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(33.4%, 42.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAny fever related illness in last 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e285 (68.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(64.2%, 73.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAny other illness in last 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e115 (27.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(23.4%, 32%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAny illness in last six months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e348 (83.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(80.1%, 87.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eOne illness\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e116 (28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(23.8%, 32.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eTwo illnesses\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e170 (41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(36.3%, 45.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eThree illnesses\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59 (14.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(11.1%, 17.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eFour illnesses\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (0.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.2%, 1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTreatment 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\u0026thinsp;=\u0026thinsp;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\u0026thinsp;=\u0026thinsp;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\u0026thinsp;=\u0026thinsp;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.\u003c/p\u003e\n\u003cp\u003eIn 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 \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). 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 [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eConflict related experiences of respondents (n\u0026thinsp;=\u0026thinsp;415)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHome was damaged\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67 (16.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(12.8%, 20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLiving in same home as 2014\u0026ndash;2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e277 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(62.1%, 71.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDisplaced from your home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e125 (30.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(25.9%, 34.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLost income 2014\u0026ndash;2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e185 (44.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(39.8%, 49.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnswered Difficult or Very Difficult in Accessing the following during the 2014\u0026ndash;2017 period\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealthcare for yourself\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e356 (85.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(82.2%, 88.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealthcare for your child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e333 (80.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(76.2%, 83.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedication for yourself\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e367 (88.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(85.1%, 91.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedication for your child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e343 (82.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(78.8%, 86.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVaccines for your child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e339 (81.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(77.8%, 85.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e373 (89.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(86.7%, 92.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eConflict 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.\u003c/p\u003e\n\u003cp\u003eAdditional analysis was performed to detect changes in care seeking at the individual level. Shifts in care seeking were from 2014\u0026ndash;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.\u003c/p\u003e\n\u003cp\u003eTrusted 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.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSources of healthcare Information for survey respondents as of 2021 (n\u0026thinsp;=\u0026thinsp;415)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eSeek healthcare information\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e288 (69.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(65.3%, 74.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e109 (26.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(22.4%, 30.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePharmacist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13 (3.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(1.8%, 5.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFamily Members\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e89 (21.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(17.8%, 25.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInternet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e54 (13.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(10.1%, 16.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraditional Healers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(3.1%, 7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eFocus Group and Key Informant Interview Results:\u003c/h2\u003e\n \u003cp\u003eThe qualitative arm of this study provided an opportunity to provide context for the respondents\u0026rsquo; 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.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eAbsorption and Adaptation: Provision of Health Services during Periods of Conflict\u003c/h2\u003e\n \u003cp\u003eDiffering 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\u0026ndash;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.\u003c/p\u003e\n \u003cp\u003ePer 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.\u003c/p\u003e\n \u003cp\u003eLack 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\u0026rsquo;s home) for emergent care. Physicians and other healthcare providers were execution targets by ISIS.\u003c/p\u003e\n \u003cp\u003eThe 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\u0026rsquo;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.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eRecovery and Reconstruction: 2018 to Pre-Pandemic Hadeetha Health Services\u003c/h2\u003e\n \u003cp\u003eRecovery 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 [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e]. 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\u0026rsquo;s recovery.\u003c/p\u003e\n \u003cp\u003eHealth 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.\u003c/p\u003e\n \u003cp\u003eLimited 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.\u003c/p\u003e\n \u003cp\u003eRecovery 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.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe immediate period post-ISIS occupation in Anbar witnessed a slow recovery process in which infrastructure repair was prioritized over re-establishing decentralized patient services for remote and isolated communities. Attempts to meet the needs of the population were slowed with the continuing challenges of reincorporating into care the millions of returnees to the Anbar province. Health disparities that existed before occupation based upon wealth quintile were exacerbated by health literacy and overall literacy, which has dropped in Iraq since the second Gulf War. Unlike comparable countries based on Work Bank wealth indices, Iraq\u0026rsquo;s gross domestic product (GDP) spending on health care is lower, with only 4.2% of GDP spent on healthcare. Efforts by the Ministry of Health toward health financing and social insurance policies continue to be derailed by intermittent and prolonged period of conflict [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe effects on armed conflict on children can be considered acute and post-acute Though it is known that women and children bear the disproportionate burden by armed conflict, such metrics ae poorly quantified due to limitations in data gathering ability. Gaps in data are even wider for internally displaced persons and \u0026ldquo;remainees,\u0026rdquo; who are inaccessible during the conflict period or fall out of the reach of traditional aid and humanitarian agencies [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. A systematic review of infectious disease interventions in conflict settings highlighted the disproportionate focus on polio and measles campaigns. This left other acute infectious conditions associated with early childhood mortality, such as acute respiratory infections and diarrheal disease, often not monitored at the level of vaccine preventable diseases [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In the one-year post-conflict period in Mosul, trends are noted in increases respiratory infections in Mosul [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The Hadeetha results also demonstrate childhood infections similar to national levels, but these are children who have not been retained in care and probably represent an underestimation.\u003c/p\u003e \u003cp\u003eThe post-conflict usage patterns indicate a desire by caregivers to seek medical treatment for their children from physicians. Anbar witnessed an exodus of healthcare providers during the ISIS occupations. The result was a reliance on alternate providers and paraprofessionals for treatment and medication during the conflict period and into the immediate post-conflict period. Similar trends were noted in Mosul, Iraq which investigated health utilization patterns in the recovery period in which pharmacists and alternative medicine were used by both residents who remained during ISIS and those who were returning [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUnlike studies in other parts of Iraq, this study investigates longitudinal, self-reported changes in healthcare use. The increase reliance on physicians correlates with the health workers reports of an increased return of physicians to the region after liberation. Decentralized approaches to healthcare, such as the use of nurses and pharmacists, particularly among the more rural residents, suggests that sub-centers and health houses more distant from Hadeetha central continue to depend on support staff such as nurses and pharmacists to work in the role of treatment and medication management. This can be a positive trend if it decreases the patient load burden for physicians as well as shores up additional health providers in a more decentralized approach, as long as sufficient training and supervision continues. This will also serve to provide continuity of services with a broader patient provider base in case of additional conflicts in the region.\u003c/p\u003e \u003cp\u003eIn non-conflict settings, recommendations to maximize health care utilization by patients can employ multiple strategies. Community engagement campaigns that increases patient decision-making strategies and a participator care model can be used to overcome care seeking challenges and provide equity of services across communities [53]. In conflict settings, recommendations revolve around prioritizing rural residents and returnees to conflict recovery zones. This recommendation does not address the continuing health gaps incurred by those who remained under occupation or in the midst of the conflict.\u003c/p\u003e \u003cp\u003eIn Iraq, health seeking was dictated by access. Under ISIS, a pay for service model was established. Dependence on the private sector exacerbated out of pocket health expenditures, driving a reliance on self-care and traditional healers. The quality of public sector care still paled in comparison to what was perceived as superior care in the private sector [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Shifting individuals back to the government sector for care remains a challenge throughout the recovery areas.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIraq has four decades of experience with conflict and shock to the healthcare infrastructure. Recovery strategies have placed a strong emphasis on the need of the central government to develop and implement disaster-based strategies before, during and after a crisis. Among the disaster-based strategies required would be crisis support for healthcare professionals, cooperation across sectors and a community embedded approach to conflict resistance, endurance and recovery [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Crisis support would include stockpiles of necessary medical supplies, communication lines that would be preserved during times of violence and collateral networks of healthcare providers to provide support during conflict. Infrastructure repair for the returnees goes hand-in-hand with shoring up the healthcare infrastructure. Even post-conflict distribution of infrastructure recovery funds were inconsistent across and within the affected governorates [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In a country with great wealth disparities, exacerbated by the rural-urban divide and recent (even ongoing) conflict, the impact of out of pocket expenditure and health seeking behaviors outside of governmental clinics widens the divide in health outcomes for the poorest and most vulnerable. Ongoing United Nations efforts across Anbar do not focus on shoring up the primary health care centers, sub-centers and health houses in the recovery district. A concerted effort to reintegrate individuals into primary healthcare services and remedy the gaps in health care for those that were isolated for nearly half a decade must occur hand-in-hand with other community, government, social, and security campaigns. Reintegration into care pathways is the first step to health equity in the region and to ensure the most vulnerable do not remain vulnerable to the residual impact of conflict.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEPI (Extended Program on Immunization)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eISIS (Islamic State of Iraq and Syria)\u003c/p\u003e\n\u003cp\u003ePHC (Primary healthcare center)\u003c/p\u003e\n\u003cp\u003eUNICEF (United Nations Children\u0026rsquo;s Fund)\u003c/p\u003e\n\u003cp\u003eMICS (Multiple Indicator Cluser Survey)\u003c/p\u003e\n\u003cp\u003eUSA (United States of America)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eInstitutional Review Board approval was received from Johns Hopkins University Bloomberg School of Public Health and the Hadeetha, Anbar, Iraq Ministry of Health Ethics Approval Board.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for Publication:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eNo individually identifiable data is available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe data that support the findings of this study are available from the authors and the district of health but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the Hadeetha district of health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting Interests:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe researchers have no competing interests to declare. SA reports receiving funding from Pfizer and Roche-Genentech, though not related to this project. KT reports funding from Pfizer, AstraZeneca and Moderna, though not related to this project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eFunding for this research was provided by Gulf Medical Relief Fund Inc, EIN\u0026nbsp;72-1197274, a United States based non-profit dedicated to delivering medical and food supplies to conflict areas and areas impacted by climate disruption.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; Contributions:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eSA participated in the\u0026nbsp;conception, design of the work, analysis,\u0026nbsp;interpretation of data,\u0026nbsp;drafted and revision. TH and AK contributed to the design of the work, the acquisition, interpretation of data;\u0026nbsp;revision. WM, KT and GB participated in the \u0026nbsp;conception, design of the work, interpretation of data, revision. MK participated in the\u0026nbsp;conception, design of the work, analysis, interpretation of data, revision of manuscript.\u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgments:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpecial acknowledgement goes to Johns Hopkins Bloomberg School of Public Health for support and guidance during this research process. Additional acknowledgement\u0026rsquo;s for Dr. Klaus Heyer for assistance with approach to the qualitative analysis and support during the project. Finally, thanks is provided to Xavier University of Louisiana for providing the necessary leave time to complete the research, specifically Dr. Kathleen Kennedy and Dr. Anne McCall. Finally, this work was supported with the guidance of Dr. SM Moazzem Hossain and the Iraq UNICEF Team.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUNIOM. 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Accessed April 24, 2020.\u003c/li\u003e\n\u003cli\u003eKhalil A. Interview with Dr. Tahseen AbdulLatif Hassan, Pediatric Director, Hadeetha District Iraq. Conducted January 15, 2022.\u003c/li\u003e\n\u003cli\u003eKhalil A. Abdul Latif, T. (Interview) Hadeetha District Health Director. 2020 February 15.\u003c/li\u003e\n\u003cli\u003eUNICEF. Iraq Educational Fact Sheets. 2020-UNICEF Data. UNICDEF; 2019 July 1 [cited 2020 July 1]. Available from: https://data.unicef.org/wp-content/uploads/2019/07/2020-IRAQ-Education-Factsheets_UNICEF_final.pdf.\u003c/li\u003e\n\u003cli\u003eIRFAD. Iraq Education. IRFAD. 2014 [cited 202 February 2022]. Available from http://www.irfad.org/iraq-education/.\u003c/li\u003e\n\u003cli\u003eCenter for Disease Control and Prevention. CDC Developmental Milestones. 2022 March [cited 2022 April]. Available from https://www.cdc.gov/ncbddd/actearly/milestones/index.html.\u003c/li\u003e\n\u003cli\u003eHarb A, Abraham S, O\u0026apos;Dea M, Hantosh HA, Jordan D, Habib I. Sociodemographic Determinants of Healthcare-Seeking Options and Alternative Management Practices of Childhood Diarrheal Illness: A Household Survey among Mothers in Iraq. Am J Trop Med Hyg. 2020 Dec 7;104(2):748-755. doi: 10.4269/ajtmh.20-0529. PMID: 33289474; PMCID: PMC7866356.\u003c/li\u003e\n\u003cli\u003eAl-Thamiri D, Al-Kubaisy W, Ali SH. Asthma prevalence and severity among primary-school children in Baghdad. East Mediterr Health J. 2005 Jan-Mar;11(1-2):79-86. PMID: 16532675.\u003c/li\u003e\n\u003cli\u003eWorld Bank Group. Iraq Reconstruction \u0026amp; Investment. Part 2. World Bank; January 2018 [cited 2020 April 24]. Available from from: https://openknowledge.worldbank.org/bitstream/handle/10986/29438/123631.pdf?sequence=4.\u003c/li\u003e\n\u003cli\u003eWorld Bank. Iraq. World Bank; 2020 [cited 2020 March 1]. Available from: https://data.worldbank.org/country/iraq.\u003c/li\u003e\n\u003cli\u003eWorld Bank. Classification of Fragile and Conflict-Affected Situations. World Bank; 2021 July 1 [cited 2022 March 24]. Available from: https://www.worldbank.org/en/topic/fragilityconflictviolence/brief/harmonized-list-of-fragile-situations.\u003c/li\u003e\n\u003cli\u003eIraq Humanitarian Situation Report -2019. UNICEF Iraq; 2019 [cited 2020 April 24]. Available from: https://www.unicef.org/iraq/reports/iraq-humanitarian-situation-report-2019.\u003c/li\u003e\n\u003cli\u003eAla\u0026rsquo;din Alawan MOH. Health in Iraq \u0026ndash; The Current Situation: Our Vision for the Future and Areas of Work. Al-Adib Press (2004).\u003c/li\u003e\n\u003cli\u003eWHO. Iraq Humanitarian Emergencies. World Health Organization; 2019 December [2020 March 1]. Available from: http://applications.emro.who.int/docs/IRQ/IRQ-SitRep-Sep-Nov-2019-eng.pdf?ua=1.\u003c/li\u003e\n\u003cli\u003eAkseer N, Wright J, Tasic H, Everett K, Scudder E, Amsalu R, Boerma T, Bendavid E, Kamali M, Barros AJD, da Silva ICM, Bhutta ZA. Women, children and adolescents in conflict countries: an assessment of inequalities in intervention coverage and survival. BMJ Glob Health. 2020 Jan 26;5(1):e002214. doi: 10.1136/bmjgh-2019-002214. PMID: 32133179; PMCID: PMC7042600.\u003c/li\u003e\n\u003cli\u003eBendavid E, Boerma T, Akseer N, Langer A, Malembaka EB, Okiro EA, Wise PH, Heft-Neal S, Black RE, Bhutta ZA; BRANCH Consortium Steering Committee. The effects of armed conflict on the health of women and children. Lancet. 2021 Feb 6;397(10273):522-532. doi: 10.1016/S0140-6736(21)00131-8. Epub 2021 Jan 24. PMID: 33503456; PMCID: PMC7612212.\u003c/li\u003e\n\u003cli\u003eLafta R, Al-Nuaimib MA, Sultan LR, Rihawa H, Burnham G. Health Care and Care-Seeking in Mosul 1 Year After Defeat of ISIS. Disaster Med Public Health Prep. 2021 Jul 21:1-8. doi: 10.1017/dmp.2021.112. Epub ahead of print. PMID: 34284845.\u003c/li\u003e\n\u003cli\u003eShabila NP, Al-Tawil NG, Al-Hadithi TS, Sondorp E. Using Q-methodology to explore people\u0026apos;s health seeking behavior and perception of the quality of primary care services. BMC Public Health. 2014 Jan 6;14:2. doi: 10.1186/1471-2458-14-2. PMID: 24387106; PMCID: PMC3882479.\u003c/li\u003e\n\u003cli\u003eIraqi Governorate Profiles [cited 2019 December 1]. Available from: https://www.ncciraq.org/en/about/about-iraq/ iraqi-governorate-profiles.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"conflict-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"conf","sideBox":"Learn more about [Conflict and Health](http://conflictandhealth.biomedcentral.com/)","snPcode":"13031","submissionUrl":"https://submission.nature.com/new-submission/13031/3","title":"Conflict and Health","twitterHandle":"@Conflict_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Conflict, health seeking, Iraq, ISIS (Islamic State of Iraq and Syria), child health, maternal health","lastPublishedDoi":"10.21203/rs.3.rs-4124361/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4124361/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u0026nbsp;\u003c/strong\u003eThe objective of this study was to describe changes in health seeking behaviors of caregivers of children ages 12-60 months of age in Hadeetha, Anbar, Iraq from the conflict period of ISIS (Islamic State of Syria and Iraq), 2014-2017, to the post-conflict period, 2021. The western province of Anbar, and the district of Hadeetha, have suffered direct impacts from the second United States led invasion (2003) through the ISIS invasion (2014-2017). With the primary health care centers being closed or inaccessible, the remaining population experienced changes in health seeking. The area of Anbar, Iraq remains largely remote from the discourse of health system recovery post-conflict.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u0026nbsp;\u003c/strong\u003eThis was a mixed-methods study composed of a cross-sectional 415 household survey and focus groups in Hadeetha, Anbar, Iraq. Caretakers of children were interviewed from February to April 2021. Children were sampled from a list of children who missed at least one vaccination appointment without a return for follow-up from the birth cohorts of 2015-2020. Focus groups and key informant interviews occurred from 2019-2021.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e In the post-conflict period, there were no differences in health seeking based upon provider type between respondents. Physicians were primary healthcare providers in the post-conflict period for 79% of respondents versus only 47% in the conflict period. Healthcare workers described major barriers to delivering services in Hadeetha during the ISIS occupation due to infrastructure damage, threats of violence, decreased medical personnel, lack of compensation and disruptions in medical supplies from 2014-2017.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e This study provides insight into health seeking challenges among the many individuals who remained in Hadeetha during the ISIS occupation. Health use patterns by provider type mirror the concerns the healthcare providers shared: limited availability, efflux of professional workers, limited resources and security challenges to providing care. Positive trends toward increased access to physicians during periods of peace are an encouraging marker for continued population resilience during the post-conflict period. Recovery efforts continue to be hampered by internal sectarian discord within Iraq as well as insufficient resources to maintain health services as well as provide catch-up health services, such as immunizations.\u003c/p\u003e","manuscriptTitle":"Changes in Healthcare Seeking Behaviors Among Caretakers of Children in the Previously Occupied ISIS territory: Hadeetha, Anbar, Iraq: A Cross-Sectional Survey of 415 Households","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-21 18:28:19","doi":"10.21203/rs.3.rs-4124361/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-14T15:18:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-14T15:16:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"154959630560068724939437645619499030451","date":"2024-06-01T16:44:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-03T16:14:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"c4a8ea4c-35ce-48cb-a407-32c3f61ccc29","date":"2024-04-24T16:17:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"34fb3a16-0092-40f4-aed5-1aefee2bf39d","date":"2024-03-24T13:19:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-19T15:05:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-19T07:05:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-19T07:05:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"Conflict and Health","date":"2024-03-18T15:19:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"conflict-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"conf","sideBox":"Learn more about [Conflict and Health](http://conflictandhealth.biomedcentral.com/)","snPcode":"13031","submissionUrl":"https://submission.nature.com/new-submission/13031/3","title":"Conflict and Health","twitterHandle":"@Conflict_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"993da546-806c-4ecf-b931-17dc8bbd6e66","owner":[],"postedDate":"March 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-28T16:00:35+00:00","versionOfRecord":{"articleIdentity":"rs-4124361","link":"https://doi.org/10.1186/s13031-024-00622-4","journal":{"identity":"conflict-and-health","isVorOnly":false,"title":"Conflict and Health"},"publishedOn":"2024-10-21 15:57:00","publishedOnDateReadable":"October 21st, 2024"},"versionCreatedAt":"2024-03-21 18:28:19","video":"","vorDoi":"10.1186/s13031-024-00622-4","vorDoiUrl":"https://doi.org/10.1186/s13031-024-00622-4","workflowStages":[]},"version":"v1","identity":"rs-4124361","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4124361","identity":"rs-4124361","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}