Diabetes care in refugee camps: the experience of UNRWA

The epidemiology of gestational diabetes, gestation hypertension, and anemia in North Palestine from 2018 to 2020: A retrospective study

BACKGROUND

In Palestine, women face a challenging environment and a demanding lifestyle, which puts them at a higher risk of experiencing complications during pregnancy. This study aimed to examine the risk factors linked with abnormal hemoglobin (Hb) levels, gestational diabetes (GD), and gestational hypertension (GH) among pregnant women. The results was compared between women residing in cities or villages areas and those in refugee camps.

METHODS

Medical records (N = 7889) for pregnant women at primary healthcare centers in the North West Bank were reviewed for sociodemographic and medical data along with the reported fasting blood sugar, hemoglobin, and blood pressure in the first and second trimesters from July 2018 to July 2020. However, only 6640 were included in the analysis as 1249 were excluded for having multiple pregnancy or lost to follow up. Complications and risk factors were defined according to the available global guidelines. Then, descriptive analysis was used to show the percentages of different risk factors and complications among them. The correlation between the several characteristics and variables with these complications was assessed by calculating the odds ratios (OR) using logistic regression. P-values of <0.05 were considered significant.

RESULTS

The prevalence of adolescent pregnancy was the highest among women living in rural areas (9.8%) and grand multigravidity among refugee women (22%). The overall prevalence of anemia was higher in the second-trimester (16.2%) than in the first-trimester (11.2%), with anemic women in the first-trimester being more likely to be anemic in the second-trimester (OR = 8.223, P-value<0.001). Although anemia was less common in the first-trimester among refugees than among women living in urban areas (OR = 0.768, P-value = 0.006), it was more prevalent in the second-trimester (OR = 1.352, P-value<0.001). Moreover, refugee women were at lower risk than women living in urban areas of having GD (OR = 0.687, P-value<0.001) and diabetes mellitus (OR = 0.472, P-value<0.001) in the second-trimester. GH was associated with GD (OR = 1.401, P-value = 0.003) and DM (OR = 1.966, P-value<0.001).

CONCLUSION

The findings of this study provide evidence-based data on the considerable prevalence of pregnancy complications, anemia, GD, and GH among Palestinian pregnant women living in the north of the West Bank. Multi gravida, gestational age, Hb levels, and the type of settings were strong predictors of pregnancy complications. Therefore, a national plan is needed to ensure adequate maternal care for all, especially disadvantaged women, those in rural areas and refugee camps.

A systematic review of effective strategies for chronic disease management in humanitarian settings; opportunities and challenges

Large number of people with non-communicable diseases (NCDs) face barriers to adequate healthcare in humanitarian settings. We conducted a systematic literature review in MEDLINE/PubMed, Web of Science, EMBASE/DARE, Cochrane, and grey literature from 1990 to 2021 to evaluate effective strategies in addressing NCDs (diabetes, cardiovascular diseases, COPD, cancer) in humanitarian settings. From 2793 articles, 2652 were eliminated through title/abstract screening; 141 articles were reviewed in full; 93 were eliminated for not meeting full criteria. Remaining 48 articles were reviewed qualitatively to assess populations, settings, interventions, outcome, and efficacy and effectiveness; 38 studies addressed treatments, 9 prevention, and 7 epidemiology. Prevention studies broadly addressed capacity-building. Treatment and epidemiology studies largely addressed hypertension and diabetes. Interventions included web-based/mobile health strategies, pharmacy-level interventions, portable imaging, and capacity building including physical clinics, staff training, forging collaborations, guideline development, point-of-care labs, health promotion activities, EMR, and monitoring interventions. Collaboration between academia and implementing agencies was limited. Models of care were largely not well-described and varied between studies due to contextual constraints. Barriers to interventions included financial, logistical, organizational, sociocultural, and security. Cancer care is significantly understudied. Simplified care models adapted to contexts and program evaluations of implemented strategies could address gaps in applied research. Inherent challenges in humanitarian settings pose unavoidable perils to evidence generation which requires a shift in research mindset to match aspirations with practicality, research collaborations at the inception of projects, reworking of desired conventional level of research evidence considering resource-intense constraints (HR, time, cost), and adapted research tools, methods, and procedures.

Models of care for non-communicable diseases for displaced populations in Iraq: a scoping review

Non-communicable diseases (NCDs) are the leading cause of death and disability globally. Their importance in humanitarian settings is increasingly recognised, but evidence about how best to address NCDs in these setting is limited. This scoping review aimed to explore models of NCD care for displaced populations in Iraq, in order to build evidence to design context adapted models of care. A search of key databases (Medline, Embase, Scopus, EconLit, Global Health, Web of Science, and the Iraqi Academic Scientific Journals) was conducted and complemented with grey literature and snowballing searches. Documents were included if they referred to models of NCD care for displaced populations. We synthesised the data using a conceptual model of care framework. The findings were reported according to the PRISMA guidelines for scoping reviews. We identified 4036 documents of which 22 were eligible for inclusion. Only six documents were peer-reviewed studies with most being internal reports, commentaries, or press releases. Of the 14 documents that reported on their methods, most applied quantitative approaches (n = 7), followed by mixed-methods (n = 5) and qualitative approaches (n = 2). Only one document reported on outcome data and none applied longitudinal study designs. Documents generally described individual framework dimensions, mostly centring around medicines, facility-based services, and selected access dimensions. Most dimensions had few or no references. The most common model for displaced populations in Iraq was primary-level centred care that complemented or supported existing—mostly tertiary—public health system structures. Additionally, private facilities played an important role and were frequently accessed by displaced populations in most settings. Quality of care, particularly patient-perceived quality, emerged as a critical factor for designing context-adapted models of NCD care. This review also identified a strong regionality of NCD care, particularly in terms of access rates and barriers. We concluded that there is a scarcity of evidence on the effectiveness of models of NCD care for displaced populations in Iraq, calling for capacity building initiatives focused on implementation research and evaluation.

The Association Between High Hemoglobin Levels and Pregnancy Complications, Gestational Diabetes and Hypertension, Among Palestinian Women

INTRODUCTION

Gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP) are the principal causes of maternal morbidity and mortality. The maternal morbidity and mortality burden for Palestinian women is relatively high, suggesting a substandard quality of care. Therefore, an early diagnosis of GDM and gestational hypertension (GH) can improve prenatal care for pregnant women and improve pregnancy outcomes. Previous studies demonstrated that elevated Hb levels in the first trimester indicate possible pregnancy complications and should not only be considered as good iron status. However, ethnic differences could play a role in determining the magnitude of the association. We hypothesized that high Hb levels (≥12.5 g/dl) in the first trimester (6-13 gestational weeks, GW) are associated with increased risk of fasting blood sugar (FBS) ≥126 mg/dl, systolic blood pressure (SBP) ≥140 mmHg, and diastolic blood pressure (DBP) ≥90 mmHg among pregnant Palestinian women visiting prenatal clinics in Palestine.

METHODS

Medical records (N=5263) were reviewed for singleton pregnancies who had their first maternity care clinic visit (6-13 GW) at primary healthcare centers of the Palestinian Ministry of Health in the north of the West Bank in 2018 and 2019. Women were excluded if they had FBS ≥92 mg/dl, SBP ≥140 mmHg, DBP ≥90 mmHg, ultrasound-based gestational age >13 weeks, or who were previously diagnosed with diabetes mellites, GDM, hypertension, GH, taking drugs for these conditions, or were smoking during pregnancy. Hb levels in g/dl were divided to low (<11.0), normal (11-12.49), and high (≥12.5). The associations between high hemoglobin levels and pregnancy complications in pregnant women were assessed by calculating the odds ratios (OR) and their 95% confidence intervals (CIs) using logistic regression. P-values of <0.05 were considered significant.

RESULTS

The final number of eligible records was 2565. Pregnant women with high Hb levels in the first trimester were at higher risk of high FBS (≥126 mg/dl; OR=2.99, 95%CI, [1.675-5.368]) and high systolic blood pressure (≥140 mmHg; OR=3.048, 95%CI, [1.252-7.421]) at 24 GW. Gravidity was significantly associated with decreased risk of high FBS (OR=0.838, 95%CI [0.704-0.991]).

CONCLUSION

Our findings suggest that Hb level at registration could be utilized in predicting the risk of GDM and HP among Palestinian women who never had a previous history of these conditions. The results of this study could have important clinical implications for early screening, which could improve preventive and curative health services to promote the health of pregnant women and children.

Models of care for patients with hypertension and diabetes in humanitarian crises: a systematic review

Care for non-communicable diseases, including hypertension and diabetes (HTN/DM), is recognized as a growing challenge in humanitarian crises, particularly in low- and middle-income countries (LMICs) where most crises occur. There is little evidence to support humanitarian actors and governments in designing efficient, effective, and context-adapted models of care for HTN/DM in such settings. This article aimed to systematically review the evidence on models of care targeting people with HTN/DM affected by humanitarian crises in LMICs. A search of the MEDLINE, Embase, Global Health, Global Indexus Medicus, Web of Science, and EconLit bibliographic databases and grey literature sources was performed. Studies were selected that described models of care for HTN/DM in humanitarian crises in LMICs. We descriptively analysed and compared models of care using a conceptual framework and evaluated study quality using the Mixed Methods Appraisal Tool. We report our findings according to PRISMA guidelines. The search yielded 10 645 citations, of which 45 were eligible for this review. Quantitative methods were most commonly used (n = 34), with four qualitative, three mixed methods, and four descriptive reviews of specific care models were also included. Most studies detailed primary care facility-based services for HTN/DM, focusing on health system inputs. More limited references were made to community-based services. Health care workforce and treatment protocols were commonly described framework components, whereas few studies described patient centredness, quality of care, financing and governance, broader health policy, and sociocultural contexts. There were few programme evaluations or effectiveness studies, and only one study reported costs. Most studies were of low quality. We concluded that an increasing body of literature describing models of care for patients with HTN/DM in humanitarian crises demonstrated the development of context-adapted services but showed little evidence of impact. Our conceptual framework could be used for further research and development of NCD models of care.

Development and dissemination of clinical decision support across institutions: standardization and sharing of refugee health screening modules

OBJECTIVES

We developed and piloted a process for sharing guideline-based clinical decision support (CDS) across institutions, using health screening of newly arrived refugees as a case example.

MATERIALS AND METHODS

We developed CDS to support care of newly arrived refugees through a systematic process including a needs assessment, a 2-phase cognitive task analysis, structured preimplementation testing, local implementation, and staged dissemination. We sought consensus from prospective users on CDS scope, applicable content, basic supported workflows, and final structure. We documented processes and developed sharable artifacts from each phase of development. We publically shared CDS artifacts through online dissemination platforms. We collected feedback and implementation data from implementation sites.

RESULTS

Responses from 19 organizations demonstrated a need for improved CDS for newly arrived refugee patients. A guided multicenter workflow analysis identified 2 main workflows used by organizations that would need to be supported by shared CDS. We developed CDS through an iterative design process, which was successfully disseminated to other sites using online dissemination repositories. Implementation sites had a small-to-modest analyst time commitment but reported a good match between CDS and workflow.

CONCLUSION

Sharing of CDS requires overcoming technical and workflow barriers. We used a guided multicenter workflow analysis and online dissemination repositories to create flexible CDS that has been adapted at 3 sites. Organizations looking to develop sharable CDS should consider evaluating the workflows of multiple institutions and collecting feedback on scope, design, and content in order to make a more generalizable product.

Prevalence of Type 2 Diabetes and Its Association with Added Sugar Intake in Citizens and Refugees Aged 40 or Older in the Gaza Strip, Palestine

BACKGROUND

Little is known about the prevalence and risk factors of diabetes among Gaza Palestinians, 64% of whom are refugees with exceeded sugar intake. We aimed to estimate the prevalence of type 2 diabetes (T2D) and its association with added sugar intake among residents, with regular visits to primary healthcare centers (PHCs) across Gaza.

METHODS

From October to December of 2019, a cross-sectional survey was conducted among 1000 citizens and refugees in nine PHCs selected from the five governorates of the Gaza Strip. Information on dietary intake, medical history, and other risk factors was collected by trained health workers, using structured questionnaires. Anthropometry and biochemical data were extracted from the PHC medical record system.

RESULTS

Overall, the prevalence of diagnosed T2D and undiagnosed T2D were 45.2% and 16.8%, respectively, in adults aged 42 to 74 years, with the differences among citizens and refugees (diagnosed: 46.2% vs. 43.8%; undiagnosed: 15.7% vs. 18.2%). The uncontrolled glycaemic rate was 41.9% and 36.8% for diagnosed patients in citizens and refugees, respectively. Among those without a clinical diagnosis of T2D, after multivariable adjustment, daily added sugar intake was positively associated with fasting glucose and the risk of undiagnosed T2D (odds ratio, 95% CI, highest vs. lowest intake, was 2.71 (1.12-6.54) (pfor trend < 0.001). In stratified analysis, the associations between added sugar intake and the risk of undiagnosed T2D tend to be stronger among refugees or those with higher body mass index.

CONCLUSIONS

Among Palestinian adults, both citizens and refugees are affected by T2D. Added sugar intake is associated with the risk of undiagnosed T2D.

Anaemia prevalence in children newly registered at UNRWA schools: a cross-sectional study

OBJECTIVE

Children entering first grade at the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) schools in West Bank, Gaza, Lebanon, Jordan and Syria complete a comprehensive medical examination at UNRWA health centres (HCs) as a requirement for their acceptance. Our study aimed to assess anaemia prevalence and undernutrition indicators among new entrant school children during their preschool medical examination.

SETTINGS

In 2017, we conducted a cross-sectional study in 59 UNRWA HCs, targeting children entering first grade at UNRWA schools in four of UNRWA's countries of operation (known as fields), namely Gaza, West Bank, Syria and Lebanon.

PARTICIPANTS

2419 completed the study. Boys and girls living inside or outside Palestine refugee camps were included. Verbal consent was obtained from their parents.

PRIMARY AND SECONDARY OUTCOME MEASURES

Sociodemographic and anthropometric data on each child were collected. Underweight (weight-for-age z-score <-2 SD), stunting (height-for-age z-score <-2 SD), thinness (body mass index-for-age z-score <-2 SD) and obesity (body mass index-for-age z-score >+2 SD) were examined according to WHO growth indicators (5-10 years).

RESULTS

2419 students (1278 girls and 1141 boys) aged 6.1±0.4 years were examined. The prevalence of anaemia (haemoglobin (Hb) <11.5 g/L) was 25.0% (Gaza: 29.3%; West Bank: 22.0%; Syria: 30.0%; Lebanon: 18.3%). The mean Hb level was 12.0±0.9 g/L. The overall prevalence of stunting, thinness and underweight was 3.2%, 3.5% and 5.6%, respectively, with the highest levels found in Syria (4.3%, 6.3% and 10.1%, respectively). The highest prevalence of overweight was in Lebanon (8.6%), and the lowest was in Gaza (2.6%). Significant differences were found among fields with regard to undernutrition indicators (p=0.001). Also, children with anaemia had significantly higher prevalence of being underweight (5.2%) in comparison with those without anaemia (p=0.001).

CONCLUSIONS

The prevalence of anaemia among the surveyed children increased to 25.0%, compared with the previous study conducted by UNRWA in 2005 (19.5%). Thus, it is recommended that Hb testing be included in the medical examination of new entrant school children attending UNRWA schools.

A case study of government and civil societies’ collaboration and challenges in securing the rights of Congolese refugees living in Pietermaritzburg, KwaZulu-Natal, South Africa

Several South African focused studies have identified the numerous challenges faced by refugees in securing their legal rights to employment, education, health care, etc. There is a need therefore to investigate the extent to which such challenges are conterminous with bureaucratic institutions (such as government departments) limitations in fully implementing the refugee policy. In cognisance of the many shortcomings associated with state-assisted integration models, we examined how bureaucratic efficiency (in the provisioning of refugee rights) can be achieved, i.e. the feasibility of instituting dependency partnerships between the state and civil society. A case study based interpretive research design technique was adopted, drawing from one focus group discussion with Congolese refugees and face-to-face in-depth interviews with three purposively selected NGO representatives. We used two theoretical perspectives, namely the theory of monopolisation and Weber’s theory on bureaucracy, to analyse how bureaucratic arrangements can negatively impact on the implementation of the refugee policy and consequently on the refugees’ quality of life and standard of living in their host country. We identified that primary cultural factors, amongst others, unruly practices, social closure, and institutional biases widen the chasm between the formulation of a progressive refugee policy and its efficient implementation. The setting up of human rights education interventions and dependency partnerships is recommended as a means of improving bureaucratic efficiency in the transfer or implementation of refugee social protections.

Burden of eye disease and demand for care in the Bangladesh Rohingya displaced population and host community: A cohort study

BACKGROUND

There is a growing awareness that addressing chronic as well as acute health conditions may contribute importantly to the well-being of displaced populations, but eye care service has generally not been prioritized in crisis situations. We describe a replicable model of eye care provision as delivered by Orbis International and local partners to the Rohingya and host population in Cox's Bazar, Bangladesh, and characterize the burden of vision impairment and demand for sight-restoring services in this setting.

METHODS AND FINDINGS

Orbis International and local secondary facility Cox's Bazar Baitush Sharaf Hospital (CBBSH) provide eye care support to the Rohingya population and the host community of all ages in Cox's Bazar, Bangladesh, with fixed vision screening locations established in Camps 4 and 11 of the Kutupalong refugee settlement. Structured outreach targets these camps and four surrounding local subdistricts, with referrals made as needed for refraction (glasses measurement) and cataract surgery to CBBSH. Between February 2018 and March 2019, 48,105 displaced Rohingya (70.3%, among whom 71.6% were children and 46.5% women) and 20,357 local residents (29.7%, 88.5% children, 54.4% women) underwent vision screening. Displaced Rohingya sought services from a total of 12 surrounding camps, within which coverage was 17.3%, including 43.3% (27,027/62,424) of children aged 5-11 years and 60.0% (5,315/8,857) of adults ≥ 60 years old. The prevalence of blindness (presenting acuity < 3/60) among Rohingya patients exceeded that among local residents by 3- to 6-fold in each 10-year age group between 18 and 59 years (P < 0.001 comparing vision between the two groups in this age range), and the prevalence of cataract requiring surgery was also higher in Rohingya patients (18-29 years: 4.67% versus 1.80%, P = 0.0019; 30-39: 7.61% versus 2.39%, P < 0.001; and 40-49 years: 7.91% versus 3.77%, P = 0.0014). A limitation of the study is lack of data on population prevalence of eye disease.

CONCLUSIONS

The burden of untreated eye disease is very high among the Rohingya, particularly those in their peak working years who could contribute most to the resiliency of their community. Demand for eye care service is also great among children and adults in this population with many competing healthcare priorities. Research is needed, building on strong evidence of benefit in settled populations, to explore the specific impact of vision care on the well-being of displaced populations.

Health records for migrants and refugees: A systematic review

INTRODUCTION

One of the challenges facing migrants and refugees is access to medical records. The aim of this study was to identify Health Records (HRs) developed specifically for migrants and refugees, describe their characteristics, and discuss their reported strengths and weaknesses.

MATERIALS AND METHODS

A systematic review of articles focusing on HRs implemented exclusively for migrants and refugees was undertaken. Publications were identified by searching the scientific databases Embase, Medline, Scopus and Cochrane, the grey literature and by checking the reference lists of articles.

RESULTS

The literature search yielded an initial list of 1432 records, with 58 articles remaining after screening of title and abstract. Following full-text screening, 33 articles were retained. Among the 33 articles reviewed, 20 different HRs were identified.

DISCUSSION

Our findings suggest that HRs, especially electronic ones, might be efficient and effective tools for registering, monitoring and improving the health of migrants and refugees. However, some of the evidence base is narrative or institutional and needs to be backed up by scientific studies.

CONCLUSIONS

Health records, implemented specifically for migrants and refugees, seem to have the potential to address some of the challenges that they face in accessing health care, in particular in strategic hotspots, cross-border settings and for migrants on the move.

Estrogen receptor 1 gene polymorphisms (PvuII and XbaI) are associated with type 2 diabetes in Palestinian women

Background

Type 2 diabetes mellitus (T2DM) is a multifactorial disease where both genetic and environmental factors contribute to its pathogenesis. The PvuII and XbaI polymorphisms of the estrogen receptor 1 (ESR1) gene have been variably associated with T2DM in several populations. This association has not been studied in the Palestinian population. Therefore, the aim of this study was to investigate the association between the PvuII and XbaI variants in the ESR1 and T2DM and its related metabolic traits among Palestinian women.

Methods

This case-control study included 102 T2DM and 112 controls in which PvuII and XbaI variants of the ESR1 gene were genotyped using amplicon based next generation sequencing (NGS).

Results

Allele frequencies of both PvuII and XbaI variants were not significantly different between patients and control subjects (P > 0.05). In logestic regression analysis adjusted for age and BMI, the ESR1 PvuII variant was associated with risk of T2DM in three genotypic models (P < 0.025) but the strongest association was observed under over-dominant model (TT+CC vs. TC) (OR = 2.32, CI [1.18-4.55] adjusted P = 0.013). A similar but non-significant trend was also observed for the ESR1 XbaI variant under the over-dominant model (AA+GG vs. AG) (OR = 2.03, CI [1.05-3.95]; adjusted P = 0.035). The frequencies of the four haplotypes (TA, CG, CA, TG) were not significantly different in the T2DM patients compared with control group (P > 0.025). Among diabetic group, an inverse trend with risk of cardio vascular diseases was shown in carriers of CG haplotype compared to those with TA haplotype (OR = 0.28, CI [0.09-0.90]; adjusted P = 0.035). Further, stratified analyses based on ESR1 PvuII and XbaI genotypes revealed no evidence for association with lipid levels (TC, TG, HDL, LDL).

Conclusions

This is the first Palestinian study to conclude that ESR1 PuvII and XbaI variants may contribute to diabetes susceptibility in Palestinian women. Identification of genetic risk markers can be used in defining high risk subjects and in prevention trials.

Model to improve cardiometabolic risk factors in Palestine refugees with diabetes mellitus attending UNRWA health centers

Introduction The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) is the main primary healthcare provider and provides assistance and protection to around 5 million Palestine refugees in Jordan, Lebanon, Syria, West Bank and Gaza. Diabetes mellitus (DM) is a common problem among Palestine refugees, with a prevalence of 11.0%. In 2014, UNRWA embarked on a diabetes campaign to assist both patients with DM and staff in improving diabetes care management, by building the capacity of UNRWA's health staff and improving the knowledge and lifestyle behaviors among Palestine refugees with DM. Method Using a quasiexperimental study, we randomly selected 50 patients with diabetes from the 32 largest UNRWA health centers (HC); a total of 1600 participants were enrolled. Each HC conducted weekly group sessions for 6 months, including education, healthy cooking, and physical exercise. Body measurements, 2-hour postprandial glucose test, blood pressure and session attendance were collected on a weekly basis. Demographical data, pre/postquestionnaires and cholesterol levels were collected before and after the campaign. Paired t-test in SPSS V.21 was used. Results Out of 1600 patients, 1598 (1186 (74.0%) females and 412 (26.0%) males) completed the campaign; 576 (36.0%) patients had diabetes type 2 (DMII), 960 (60.0%) had DMII and hypertension and 62 (4.0%) had diabetes type 1 (DMI). After the campaign, the average weight loss was 2.6 kg (95% CI 2.4 to 2.7). In addition, 22% lost ≥5%, 25% lost 3%-5%, and 30% lost 1%-3% of their weight. Significant improvements were seen in blood glucose, cholesterol and waist circumference (WC) (p≤0.001 for all). The session attendance rate was 70.6% in total. Conclusions This campaign focused on raising healthy lifestyle awareness and practices among Palestine refugees with DM. It was associated with reduction cardiometabolic risk factors. Similar campaigns need to be sustained and expanded. Local community and non-governmental organization partnerships observed during the campaign should be strengthened and sustained.

Cancer Care for Refugees and Displaced Populations: Middle East Conflicts and Global Natural Disasters

Conflicts and natural disasters can cause major disruptions to people's lives. Media and news agencies usually focus on immediate consequences of these events, including loss of life and injuries, environmental and property destruction, and relief efforts. In this article, we will examine the effects of conflicts (focusing on in the Middle East) and global natural disasters on patients already diagnosed with cancer and on those who are diagnosed with cancer during and in the immediate aftermath of these events. We will review the limited literature, provide situational analysis, and discuss medical relief efforts, governmental readiness, and the role of United Nations agencies and international nongovernmental organizations. We will also discuss treatment of patients with cancer in the context of prolonged displacements and limited resources.

Reducing chronic disease through changes in food aid: A microsimulation of nutrition and cardiometabolic disease among Palestinian refugees in the Middle East

BACKGROUND

Type 2 diabetes mellitus and cardiovascular disease and have become leading causes of morbidity and mortality among Palestinian refugees in the Middle East, many of whom live in long-term settlements and receive grain-based food aid. The objective of this study was to estimate changes in type 2 diabetes and cardiovascular disease morbidity and mortality attributable to a transition from traditional food aid to either (i) a debit card restricted to food purchases, (ii) cash, or (iii) an alternative food parcel with less grain and more fruits and vegetables, each valued at $30/person/month.

METHODS AND FINDINGS

An individual-level microsimulation was created to estimate relationships between food aid delivery method, food consumption, type 2 diabetes, and cardiovascular disease morbidity and mortality using demographic data from the United Nations (UN; 2017) on 5,340,443 registered Palestinian refugees in Syria, Jordan, Lebanon, Gaza, and the West Bank, food consumption data (2011-2017) from households receiving traditional food parcel delivery of food aid (n = 1,507 households) and electronic debit card delivery of food aid (n = 1,047 households), and health data from a random 10% sample of refugees receiving medical care through the UN (2012-2015; n = 516,386). Outcome metrics included incidence per 1,000 person-years of hypertension, type 2 diabetes, atherosclerotic cardiovascular disease events, microvascular events (end-stage renal disease, diabetic neuropathy, and proliferative diabetic retinopathy), and all-cause mortality. The model estimated changes in total calories, sodium and potassium intake, fatty acid intake, and overall dietary quality (Mediterranean Dietary Score [MDS]) as mediators to each outcome metric. We did not observe that a change from food parcel to electronic debit card delivery of food aid or to cash aid led to a meaningful change in consumption, biomarkers, or disease outcomes. By contrast, a shift to an alternative food parcel with less grain and more fruits and vegetables was estimated to produce a 0.08 per 1,000 person-years decrease in the incidence of hypertension (95% confidence interval [CI] 0.05-0.11), 0.18 per 1,000 person-years decrease in the incidence of type 2 diabetes (95% CI 0.14-0.22), 0.18 per 1,000 person-years decrease in the incidence of atherosclerotic cardiovascular disease events (95% CI 0.17-0.19), and 0.02 decrease per 1,000 person-years all-cause mortality (95% CI 0.01 decrease to 0.04 increase) among those receiving aid. The benefits of this shift, however, could be neutralized by a small (2%) increase in compensatory (out-of-pocket) increases in consumption of refined grains, fats and oils, or confectionaries. A larger alternative parcel requiring an increase in total food aid expenditure by 27% would be more likely to have a clinically meaningful improvement on type 2 diabetes and cardiovascular disease incidence.

CONCLUSIONS

Contrary to the supposition in the literature, our findings do not robustly support the theory that transitioning from traditional food aid to either debit card or cash delivery alone would necessarily reduce chronic disease outcomes. Rather, an alternative food parcel would be more effective, even after matching current budget ceilings. But compensatory increases in consumption of less healthy foods may neutralize the improvements from an alternative food parcel unless total aid funding were increased substantially. Our analysis is limited by uncertainty in estimates of modeling long-term outcomes from shorter-term trials, focusing on diabetes and cardiovascular outcomes for which validated equations are available instead of all nutrition-associated health outcomes, and using data from food frequency questionnaires in the absence of 24-hour dietary recall data.

A Review on Emerging and Reemerging of Infectious Diseases in Jordan: The Aftermath of the Syrian Crises

The review aims to examine the emergence and reemergence of infectious diseases in Jordan, in parallel with the Syrian refugee crisis. Qualitative approach has been adopted for systematically examining the outcomes of the Syrian crisis, which resulted in emerging and reemerging infectious diseases. It has adhered that infectious diseases, including measles, tuberculosis, and cutaneous leishmaniasis, have hazardous effects on Syrian refugees along with the local population in Jordan. The threat of major infectious diseases is higher and alarming in Jordan. National health policies should be implemented to adhere the influence of infectious diseases as well as to reduce the extent of infectious diseases in Jordan. In the 21st century, Syrian conflict can be deliberated as one of the biggest humanitarian disasters. In this multifaceted emergency with devastating requirements and limitations, it has been found essential for dominant medical healthcare providers to develop medical strategies that are based on comprehensive understanding of the concerned context and the main medical requirements and susceptible groups.

Metabolic syndrome among overweight and obese adults in Palestinian refugee camps

BACKGROUND

Metabolic syndrome (MetS) is one of the main reasons for elevated cardiovascular morbidity and mortality worldwide. Obese and overweight individuals are at high risk of developing these chronic diseases. The aim of this study was to characterize and establish sex-adjusted prevalence of metabolic syndrome and its components.

METHODS

A cross-sectional study was conducted in 2015, 689 (329 men and 360 women) aged 18-65 years from three refugee camps in the West Bank. International Diabetes Federation and modified National Cholesterol Education Program-Third Adult Treatment Panel definitions were used to identify MetS.

RESULTS

The overall prevalence of obesity and overweight was high, 63.1%; Obesity (42 and 29.2% in women men; respectively and overweight 25.8 and 28.9% in women and men; respectively. The prevalence of MetS among obese and overweight was significantly higher (69.4%) according to IDF than NCEP definition (52%) (p < 0.002) with no significant differences between men and women using both definitions; (IDF; 71.8% men vs. 67.6% women, and (NCEP/ATP III; 51.9% men vs. 52.2% women). The prevalence of MetS increased significantly with increasing obesity and age when NCEP criterion is applied but not IDF. The prevalence of individual MetS components was: high waist circumference 81.3% according to IDF and 56.5% according to NCEP, elevated FBS 65.3% according to IDF and 56% according to NCEP, elevated blood pressure 48%, decreased HDL 65.8%, and elevated triglycerides 31.7%. Based on gender differences, waist circumferences were significantly higher in women according to both criteria and only elevated FBS was higher in women according to IDF criteria. Physical activity was inversely associated with MetS prevalence according to NCEP but not IDF. No significant associations were found with gender, smoking, TV watching, and family history of hypertension or diabetes mellitus.

CONCLUSION

In this study, irrespective of the definition used, metabolic syndrome is highly prevalent in obese and overweight Palestinian adults with no gender-based differences. The contribution of the metabolic components to the metabolic syndrome is different in men and women. With the increase of age and obesity, the clustering of metabolic syndrome components increased remarkably. More attention through health care providers should, therefore, be given to the adult population at risk to reduce adulthood obesity and subsequent cardiovascular diseases.

Cardiovascular disease in the Eastern Mediterranean region: epidemiology and risk factor burden

The Eastern Mediterranean region (EMR) comprises 22 countries or territories spanning from Morocco in the west to Pakistan in the east, and contains a population of almost 600 million people. Like many other developing regions, the burden of disease in the EMR has shifted in the past 30 years from primarily communicable diseases to noncommunicable diseases such as cardiovascular disease (CVD). Cardiovascular mortality in the EMR, mostly attributable to ischaemic heart disease, is expected to increase more dramatically in the next decade than in any other region except Africa. The most prominent CVD risk factors in this region include tobacco consumption, physical inactivity, depression, obesity, hypertension, and diabetes mellitus. Many individuals living in the EMR are unaware of their risk factor status, and even if treated, these risk factors are often poorly controlled. Furthermore, infrequent use of emergency medical services, delays in access to care, and lack of access to cardiac catheterization affects the timely diagnosis of CVD. Treatment of CVD is also suboptimal in this region, consisting primarily of thrombolysis, with insufficient provision of timely revascularization. In this Review, we summarize what is known about CVD burden, risk factors, and treatment strategies for individuals living in the EMR. This information will hopefully aid decision-makers when devising strategies on how to improve CVD prevention and management in this region.

Health service access and utilization among Syrian refugees in Jordan

Background

The influx of Syrian refugees into Jordan presents an immense burden to the Jordanian health system. Changing lifestyles and aging populations are shifting the global disease burden towards increased non-infectious diseases including chronic conditions, co-morbidities, and injuries which are more complicated and costly to manage. The strain placed on health systems threatens the ability to ensure the health needs of both refugees and host country populations are adequately addressed. In light of the increasing challenges facing host governments and humanitarian actors to meet health needs of Syrian refugees and affected host communities, this study was undertaken to assess utilization of health services among Syrian refugees in non-camp settings.

Methods

A survey of Syrian refugees in Jordan was undertaken in June 2014 to characterize health seeking behaviors and issues related to accessing care. A cluster design with probability proportional to size sampling was used to attain a nationally representative sample of 1550 non-camp Syrian refugee households. Differences in household characteristics by geographic region, facility type, and sector utilized were examined using chi-square and t-test methods.

Results

Care-seeking was high with 86.1 % of households reporting an adult sought medical care the last time it was needed. Approximately half (51.5 %) of services were sought from public sector facilities, 38.7 % in private facilities, and 9.8 % in charity/NGO facilities. Among adult care seekers, 87.4 % were prescribed medication during the most recent visit, 89.8 % of which obtained the medication. Overall, 51.8 % of households reported out-of-pocket expenditures for the consultation or medications at the most recent visit (mean US$39.9, median US$4.2).

Conclusions

Despite high levels of care-seeking, cost was an important barrier to health service access for Syrian refugees in Jordan. The cessation of free access to health care since the time of the survey is likely to have worsened health equity for refugees. Dependence of refugees on the public facilities for primary and specialist care has placed a great burden on the Jordanian health system. To improve accessibility and affordability of health services in an equitable manner for both refugees and Jordanian host communities, strategies that should be considered going forward include shifting resources for non-communicable diseases and other traditional hospital services to the primary level and creating strong health promotion programs emphasizing prevention and self-care are strategies.

Addressing chronic diseases in protracted emergencies: Lessons from HIV for a new health imperative

Forcible displacement has reached unprecedented levels, with more refugees and internally displaced people reported since comprehensive statistics have been collected. The rising numbers of refugees requiring health services, the protracted nature of modern displacement, and the changing demographics of refugee populations have created compelling new health needs and challenges. In addition to the risk of malnutrition, infectious diseases and exposure to the elements attendant upon conflict and the breakdown of public health systems, many displaced people now require continuity care for the prevention and treatment of cardiovascular disease, diabetes, asthma, cancer, and mental health, as well as maternal and child health services. In some regions, most refugee health services need to be provided in dispersed settings within host communities, rather than in traditional refugee camps, and the number of refugees suffering protracted displacement is growing rapidly. These realities highlight a significant disconnect between the health needs of twenty-first century refugees, and the global systems that have been established to address them. The global response to the HIV epidemic offers lessons about ways to support continuity care for chronic conditions during complex emergencies and may provide important blueprints as the global community struggles to redesign refugee health services.