The effect of explosive remnants of war on global public health: a systematic mixed-studies review using narrative synthesis.

Background: Explosive remnants of war (ERW)-landmines, unexploded ordnance (UXO), and abandoned explosive ordnance (AXO)-have been recognised as a threat to health since the 1990s. We aimed to study the effect of ERW on global public health.

Methods: In this systematic mixed-studies review, we searched the Web of Science, Scopus, PubMed, and ProQuest databases, and hand searched relevant websites, for articles published between Jan 1, 1990, and Aug 31, 2015. We used keywords and Medical Subject Headings related to ERW, landmines, UXO, and AXO to locate original peer-reviewed quantitative, qualitative, or mixed-methods studies in English of the direct physical or psychological effects of ERW on direct victims of the explosive device or reverberating social and economic effects on direct victims and indirect victims (their families and the wider at-risk community). We excluded studies if more than 20% of participants were military, if they were of deminers, if they were from high-income countries, or if they were of chemical weapons. We identified no peer-reviewed studies of AXO effects, so we extended the search to include grey literature. We critically appraised study quality using a mixed methods appraisal tool. We used a narrative synthesis approach to categorise and synthesise the literature. We extracted quantitative data and calculated means and percentages.

Findings: The initial search identified 10 226 studies, leaving 8378 (82%) after removal of duplicates, of which we reviewed 54 (26 [48%] were quantitative descriptive studies, 20 [37%] were quantitative non-randomised studies, four [7%] were mixed-methods studies, and four [7%] were grey literature). The direct psychological effects of landmines or UXO appear high. We identified comorbidity of anxiety and depression in landmine or UXO victims in four studies, more women presented with post-traumatic stress disorder than did men in two studies, and landmine or UXO victims reported a greater prevalence of post-traumatic stress disorder, anxiety, or depression than did control groups in two studies. Overall injury and mortality rates caused by landmines or UXO decreased over time across five studies and increased in one. More men were injured or killed by landmines or UXO than were women (0-30·6% of women), the mean ages of casualties ranged from 18·5 years to 38·1 years, and victims were likely to be doing an activity of economic necessity at the time of injury. The proportion of casualties of landmines or UXO younger than 18 years ranged from 22% to 55% across twelve studies. Landmine or UXO victims who had one or more limbs amputated ranged from 19·5% to 82·6%. Landmines and UXO had a negative effect on internally displaced populations and returning refugees, physical security, economic productivity, child health and educational attainment, food security, and agriculture in studies from seven countries. We could not establish the proportion of casualties caused by AXO from unplanned explosions at munitions sites, although the grey literature suggests that AXO is a substantial problem.

Interpretation: Individually, these landmine and UXO results are not new and substantiate findings from existing research. Taken together, however, these findings provide a picture of the effect of landmines and UXO that stretches far beyond injury and mortality prevalence, making landmine and UXO clearance a more favourable option for funders. AXO effects are understudied and warrant further research.

Funding: King's College London.