Luissa Vahedi

Since the 1990s, fragility has emerged as a concept that describes the nation states of low- and middle-income countries. The assumptions about people living in so-called fragile countries have influenced health promotion research and practice in terms of the topic areas studied and the way interventions are designed and implemented. In critiquing the assumptions underlying fragility, we apply and extend the harms of damage-centered research to the concept of state fragility. We argue that fragility labeling and classification systems are not neutral representations of the world. Rather, these approaches are underscored by the power hierarchies that further engender fragility. In this spirit, we critique ‘state fragility’ as a concept applied to people living in so-called ‘fragile countries’. Further, by amplifying expressions of self-governance as forms of everyday resistance and survival among people living in fragile countries, we highlight what global health promotion researchers and practitioners might overlook when adopting the fragility labeling and classification system. In drawing on Haiti as a case study of collective citizen resistance to state fragility, we illustrate the less measured expressions of everyday strength that can inform a new global health promotion agenda that is imagined and scaled from the bottom up.

Since the 1990s, fragility has been used to describe low‐ and middle‐income countries (LMICs) with limited ability to respond to external threats in ways that ensure citizen safety, security, and welfare. Fragility challenges us to engage with governance, including why and how many institutions (including those in high‐income countries) fail to protect citizens during climate change. We ask the question: how can state fragility be applied, critiqued, and expanded when considering climate change, including anthropogenic drivers, extreme weather events, mitigation, and adaptation? We present a globally applicable framework of governance fragility and emphasise the role of institutional‐level gaps in motivation/willingness to act, evidence uptake, and implementation in creating fragilities that inhibit climate resilience. Using the United States as a case study, we apply the framework to identify the political ideologies that inform institutional‐level motivations, shape evidence uptake, and moderate implementation capacity. This expanded notion of governance fragility (beyond conflict‐affected LMICs) offers a globally‐relevant lens to imagine possible solutions, including a research‐to‐practice agenda that contends both with ideology/willingness to act and decentralised forms of climate governance in the face of national‐level fragilities.

Social roles shape differential exposure to climate hazards and access to sexual and reproductive health (SRH) services and supports, posing distinct mental and emotional challenges. Yet, the gendered mental health consequences of these intersections remain largely unknown. We conducted a scoping review of empirical studies examining mental health experiences in low- and middle-income countries (LMICs) where climate-related events are related to SRH outcomes. Using a comprehensive search strategy across four databases (Medline, Embase, Web of Science, Scopus), we screened 40,503 qualitative, quantitative, and mixed methods records to include 50 peer-reviewed studies across 43 countries. Studies were analyzed using thematic meta-synthesis to identify patterns in gendered mental health responses to climate change and SRH stressors. Climate change is a structural determinant of mental health and SRH, with gender and age mediating exposure and vulnerability. The social identities of motherhood, fatherhood, and adolescence intersect in distinct ways with climate change hazards and unmet SRH needs to shape mental health experiences. Three thematic domains emerged: (1) motherhood under intensified domestic burdens, (2) fatherhood and coping under resource scarcity, (3) adolescent girls’ mental and menstrual distress under water and sanitation inequities. Climate-induced psychological distress, manifesting as anxiety, depression, trauma, and social withdrawal, are linked to disrupted care giving, increased gender-based violence, and compromised menstrual dignity. Mental health burdens at the intersection of climate change and SRH are deeply gendered and shaped by the ways climate change impacts social determinants of health. Despite growing evidence, integrated responses remain scarce. Addressing these challenges requires multi-sectoral collaboration, gender-sensitive mental health frameworks, and inclusive SRH policies that reflect the lived realities of LMIC populations.

Emerging studies from low-and-middle-income countries (LMIC) have applied mixed methods to investigate gender-based violence (GBV) syndemics. There is currently no guidance on how to appropriately combine qualitative and quantitative methods when testing syndemic theory. This research introduces a mixed methods framework for testing GBV syndemics in LMIC. A multi-step approach was used for framework development. The framework centers on the distinct strengths of the population perspective (quantitative) and locally grounded perspective (qualitative) and informs the development of (i) measurement tools, (ii) causal models, and (iii) contextual interventions. This article contributes an application of mixed methods to inform the design of studies that robustly test theoretical constructs. Further, this article demonstrates how a sensitive/hidden exposure like GBV contributes to the patterning of chronic and infectious diseases, leading to population health disparities.

Parenting while experiencing intimate partner violence (IPV), depression, and poor diet quality can contribute to child health inequities. Syndemic theory offers a framework to understand how maternal conditions can lead to inequitable child health outcomes, such as diarrheal disease: a risk factor for childhood mortality and stunting. This study uses the 2022 Nepal Demographic and Health Survey to test an intergenerational syndemic model addressing three key questions: (1) Do IPV, depression, and absent dietary iron intake co-occur among mothers? (2) Does the probability of child diarrhea increase with concurrent maternal exposures to these three factors? (3) Are these relationships stronger in disadvantaged households? The analysis included 2,019 mother-child dyads. Interaction models on additive and multiplicative scales were constructed to predict child diarrhea as a function of maternal syndemic exposures, accounting for complex survey design. The prevalence of single exposure to IPV, depression, and absent dietary iron intake was higher among mothers in poorer households. In disadvantaged households (two lowest household wealth quintiles), children’s odds of diarrhea were higher when mothers experienced syndemic vulnerability (IPV, depression, and absent iron intake) on multiplicative (aOR=1.321, 95%CI:1.000, 1.745) and additive scales (B = 0.027, 95%CI:-0.002, 0.055). Household disadvantage may exacerbate the synergistic effects of IPV, depression, and iron deficiency, increasing the likelihood of child diarrhea. Interventions targeting these maternal health adversities in disadvantaged households may reduce the impact on child health.

Objective: This research provides the first population-based investigation of intimate partner violence (IPV) and women’s dietary intake of iron and Vitamin A-rich foods using representative data from eight low- and middle-income countries. Design: Using multivariable logistic regression, we estimated the relationship between various forms of past year IPV (physical, emotional and sexual) and consumption of Vitamin A and iron-rich foods. Setting: We conducted secondary data analysis of cross-sectional demographic and health surveys from Cambodia (2021, n 5640), Nepal (2022, n 4179), Sierra Leone (2019, n 3812), Nigeria (2018, n 8313), Tajikistan (2017, n 4800), Cote D’Ivoire (2021, n 3656), Kenya (2022, n 10 758) and the Philippines (2022, n 12 278). Participants: Women of reproductive age (15–49 years) comprised the analytical sample. Results: Results revealed distinct relationship patterns between various IPV forms and women’s dietary consumption of micronutrient-rich foods. The most consistent relationships being that past year (i) sexual IPV (adjusted OR (aOR): 0·72, 95 % CI: 0·53, 0·98), (ii) physical IPV (aOR: 0·86, 95 % CI: 0·73, 1·01) and (iii) emotional IPV (aOR: 0·81, 95 % CI: 0·70, 0·94) significantly reduced the odds of consuming iron-rich foods in the pooled analyses. Due to between-country heterogeneity concerning the relationship between IPV and Vitamin A, pooled estimates for dietary vitamin A consumption were non-significant. However, in the Philippines, IPV was associated with reduced dietary Vitamin A intake. Conclusions: IPV is associated with altered dietary intake patterns and between-country differences could be due to different food environments. Mechanisms explaining our findings may involve consequences of IPV that impact diet and dietary practices: depression, control of resources and physical trauma.

Gender-based violence (GBV) is disproportionately perpetrated against women and girls, due to harmful gender and social norms, structural gender-based power inequalities and pervasive discrimination against women and girls globally. In settings of fragility (eg, weak governance and humanitarian emergencies), risk factors for GBV are exacerbated while protective factors are eroded. Adequate nutrition is critical for mental and physical health and ensuring adequate nutrition for children in fragile settings is particularly critical. Fragile settings include heightened risk for GBV and malnutrition, but the combined impact of these two health contributors has rarely been examined together. Based on a rapid evidence assessment, we present evidence for associations between GBV against women and girls and child nutrition outcomes, identifying gaps in the evidence base and discussing key conceptual and methodological issues concerning research on this intersection. Improved understanding of the intersections between GBV and nutrition outcomes can help further highlight the linkages between these two public health issues and help inform programming and policy in both sectors.