Measurement of attacks and interferences with health care in conflict: Validation of an incident reporting tool for attacks on and interferences with health care in eastern Burma

Rohini J. Haar, Katherine H.A. Footer, Sonal Singh, Susan G. Sherman, Casey Branchini, Joshua Sclar, Emily Clouse, Leonard S. Rubenstein

Research output: Contribution to journalArticlepeer-review

10 Scopus citations


Background: Attacks on health care in armed conflict and other civil disturbances, including those on health workers, health facilities, patients and health transports, represent a critical yet often overlooked violation of human rights and international humanitarian law. Reporting has been limited yet local health workers working on the frontline in conflict are often the victims of chronic abuse and interferences with their care-giving. This paper reports on the validation and revision of an instrument designed to capture incidents via a qualitative and quantitative evaluation method. Methods: Based on previous research and interviews with experts, investigators developed a 33-question instrument to report on attacks on healthcare. These items would provide information about who, what, where, when, and the impact of each incident of attack on or interference with health. The questions are grouped into 4 domains: health facilities, health workers, patients, and health transports. 38 health workers who work in eastern Burma participated in detailed discussion groups in August 2013 to review the face and content validity of the instrument and then tested the instrument based on two simulated scenarios. Completed forms were graded to test the inter-rater reliability of the instrument. Results: Face and content validity were confirmed with participants expressing that the instrument would assist in better reporting of attacks on health in the setting of eastern Burma where they work. Participants were able to give an accurate account of relevant incidents (86% and 82% on Scenarios 1 and 2 respectively). Item-by-item review of the instrument revealed that greater than 95% of participants completed the correct sections. Errors primarily occurred in quantifying the impact of the incident on patient care. Revisions to the translated instrument based on the results consisted primarily of design improvements and simplification of some numerical fields. Conclusion: This instrument was validated for use in eastern Burma and could be used as a model for reporting violence towards health care in other conflict settings.

Original languageEnglish (US)
Article number23
JournalConflict and Health
Issue number1
StatePublished - Nov 3 2014


  • Attacks on healthcare
  • Conflict
  • Health and human rights
  • Health protection
  • Health workers
  • Humanitarian law
  • Medicine
  • Safeguarding health
  • Violence
  • War

ASJC Scopus subject areas

  • Health(social science)
  • Public Health, Environmental and Occupational Health


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