Cancer in refugees in Jordan and Syria between 2009 and 2012: challenges and the way forward in humanitarian emergencies

The emergence and regression of political priority for refugee integration into the Jordanian health system: an analysis using the Kingdon's multiple streams model

BACKGROUND

The prolonged presence of Syrian refugees in Jordan has highlighted the need for sustainable health service delivery models for refugees. In 2012, the Jordanian government adopted a policy that granted Syrian refugees access, free of charge, to the national health system. However since 2012, successive policy revisions have limited refugee access. This paper seeks to understand factors that initially put refugee integration into the health system on the policy agenda, as well as how these same factors later affected commitment to sustain the policy.

METHODS

This paper draws on data from a document review of 197 peer-reviewed and grey literature publications, a media analysis of newspaper articles retrieved from four officially recognized newspapers in Jordan, and 33 semi-structured key informant interviews. We used Kingdon's Multiple Streams Model - a well-established tool for analyzing policy adoption - to understand how political priority developed for integration of refugees into the health system.

RESULTS

We find that several factors helped bring attention to the issue, namely concerns over infectious disease transmission to host communities, high rates of chronic conditions among the refugee population and the increasingly urban and dispersed nature of refugees. At the outset of the conflict, the national mood was receptive to refugees. Politicians and government officials quickly recognized the crisis as an opportunity to secure material and technical support from the international humanitarian community. At the same time, global pressures for integrating refugees into national health systems helped move the integration agenda forward in Jordan and the region more broadly. Since 2012, there were several modifications to the policy that signal profound changes in national views around the continued presence of Syrian refugees in the country, as well as reduced external financial support which has undermined the sustainability of the policy.

CONCLUSION

This case study underscores the dynamic nature of policymaking and the challenge of sustaining government commitment to the right to health among refugees. Our analysis has important implications for advocates seeking to advance and maintain momentum for the integration of refugees into national health systems.

Systemic Treatment of Patients With Metastatic Breast Cancer: ASCO Resource-Stratified Guideline

PURPOSE

To guide clinicians and policymakers in three global resource-constrained settings on treating patients with metastatic breast cancer (MBC) when Maximal setting-guideline recommended treatment is unavailable.

METHODS

A multidisciplinary, multinational panel reviewed existing ASCO guidelines and conducted modified ADAPTE and formal consensus processes.

RESULTS

Four published resource-agnostic guidelines were adapted for resource-constrained settings; informing two rounds of formal consensus; recommendations received ≥75% agreement.

RECOMMENDATIONS

Clinicians should recommend treatment according to menopausal status, pathological and biomarker features when quality results are available. In first-line, for hormone receptor (HR)-positive MBC, when a non-steroidal aromatase inhibitor and CDK 4/6 inhibitor combination is unavailable, use hormonal therapy alone. For life-threatening disease, use single-agent chemotherapy or surgery for local control. For premenopausal patients, use ovarian suppression or ablation plus hormone therapy in Basic settings. For human epidermal growth factor receptor 2 (HER2)-positive MBC, if trastuzumab, pertuzumab, and chemotherapy are unavailable, use trastuzumab and chemotherapy; if unavailable, use chemotherapy. For HER2-positive, HR-positive MBC, use standard first-line therapy, or endocrine therapy if contraindications. For triple-negative MBC with unknown PD-L1 status, or if PD-L1-positive and immunotherapy unavailable, use single-agent chemotherapy. For germline BRCA1/2 mutation-positive MBC, if poly(ADP-ribose) polymerase inhibitor is unavailable, use hormonal therapy (HR-positive MBC) and chemotherapy (HR-negative MBC). In second-line, for HR-positive MBC, Enhanced setting recommendations depend on prior treatment; for Limited, use tamoxifen or chemotherapy. For HER2-positive MBC, if trastuzumab deruxtecan is unavailable, use trastuzumab emtansine; if unavailable, capecitabine and lapatinib; if unavailable, trastuzumab and/or chemotherapy (hormonal therapy alone for HR-positive MBC).Additional information is available at www.asco.org/resource-stratified-guidelines. It is ASCO's view that healthcare providers and system decision-makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

Leveraging e-health for enhanced cancer care service models in middle-income contexts: Qualitative insights from oncology care providers

Background

Global cancer research has predominantly favoured high-income countries (HICs). The unique challenges in low- and middle-income countries (LMICs) demand tailored research approaches, accentuated further by the disparities highlighted during the COVID-19 pandemic.

Aim and objectives

This research endeavoured to dissect the intricacies of cancer care in LMICs, with Jordan serving as a case study. Specifically, the study aimed to conduct an in-depth analysis of the prevailing cancer care model and assess the transformative potential of eHealth technologies in bolstering cancer care delivery.

Methods

Utilising a qualitative methodology, in-depth semi-structured interviews with oncology healthcare professionals were executed. Data underwent inductive thematic analysis as per Braun and Clarke's guidelines.

Results

From the analysed data, two dominant themes surfaced. Firstly, "The current state of cancer care delivery" was subdivided into three distinct subthemes. Secondly, "Opportunities for enhanced care delivery via e-health" underscored the urgency of digital health reforms.

Conclusion

The need to restrategise cancer care in LMICs is highlighted by this study, using the Jordanian healthcare context as a reference. The transformative potential of e-health initiatives has been illustrated. However, the relevance of this study might be limited by its region-specific approach. Future research is deemed essential for deeper exploration into the integration of digital health within traditional oncology settings across diverse LMICs, emphasising the significance of telemedicine in digital-assisted care delivery reforms.

"It's my life, not theirs!" Therapeutic itineraries and refugee reflections on referral health care in western Tanzania

Globally, refugees number over 25 million. Yet, little attention has been paid to how refugees access referral health care in host countries. By referral, I mean the process by which a patient deemed too sick to be managed at a lower-level health facility is transferred to a higher-level facility with more resources to provide care. In this article, I provide reflections on referral health care from the perspective of refugees living in exile in Tanzania. Through qualitative methods of interviews, participant observation, and clinical record review, I trace how global refugee policy on referral health care manifests itself in the lives of refugees locally in a country like Tanzania that has strict policies and limitations on freedom of movement. In this space, refugees experience complex medical problems, many of which began prior to or during their flight to Tanzania. Many refugees indeed are approved to be referred to a Tanzanian hospital for further treatment. Others are denied care or pursue other therapeutic itineraries outside the formal system. But, all are subject to policies of Tanzania that restrict freedom of movement and almost all experience delays on several levels (e.g., waiting for a referral, waiting at the referral hospital, waiting for follow-up appointments). In the end, refugees in this context emerge not simply as passive beings upon which biopower is enacted, but also as active agents, sometimes circumventing a system of power in their pursuit of their right to health, all in the context of strict policy that seeks to enforce state security over one's right to health. In the process, refugee experiences with referral health care become a window into the larger politics of refugee hosting in Tanzania in the present day.

Impact of Disasters on Older Adult Cancer Outcomes: A Scoping Review

PURPOSE

There is an urgent need to address the growing global cancer burden in the context of complex disaster events, which both disrupt access to oncology care and facilitate carcinogenic exposures. Older adults (65 years and older) are a growing population with multifaceted care needs, making them especially vulnerable to disasters. The objective of this scoping review is to characterize the state of the literature concerning older adult cancer-related outcomes and oncologic care after a disaster event.

METHODS

A search was conducted in PubMed and Web of Science. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews, articles were extracted and screened for inclusion. Eligible articles were summarized using descriptive and thematic analyses.

RESULTS

Thirty-five studies met all criteria for full-text review. The majority focused on technological disasters (60%, n = 21), followed by climate-amplified disasters (28.6%, n = 10) and geophysical disasters (11.4%, n = 4). Thematic analysis classified the current evidence into three major categories: (1) studies concerned with carcinogenic exposure and cancer incidence related to the disaster event, (2) studies examining changes in access to cancer care and cancer treatment disruptions as a result of the disaster event, and (3) studies exploring the psychosocial experiences of patients with cancer affected by a disaster event. Few studies focused on older adults specifically, and most of the current evidence focuses on disasters in the United States or Japan.

CONCLUSION

Older adult cancer outcomes after a disaster event are understudied. Current evidence suggests that disasters worsen cancer-related outcomes among older adults by disrupting continuity of care and access to timely treatment. There is a need for prospective longitudinal studies following older adult populations postdisaster and studies focused on disasters in low- and middle-income country contexts.

Radiation therapy for prostate cancer in Syrian refugees: facing the need for change

Purpose

To report the utilization of radiation therapy in Syrian refugee patients with prostate cancer residing in Turkey.

Methods and materials

A multi-institutional retrospective review including 14 cancer centers in Turkey was conducted to include 137 Syrian refugee patients with prostate cancer treated with radiation therapy (RT). Toxicity data was scored using the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0. Noncompliance was defined as a patient missing two or more scheduled RT appointments.

Results

Advanced disease, defined as stage III or IV, was reported in 64.2% of patients while androgen deprivation therapy (ADT) was only administrated to 20% of patients. Conventionally fractionated RT with a median number of 44 fractions was delivered to all patients with curative intent (n = 61) while palliative RT (n = 76) was delivered with a median number of 10 fractions. The acute grade 3-4 toxicity rate for the entire cohort was 16%. Noncompliance rate was 42%.

Conclusion

Most Syrian refugee prostate cancer patients presented with advanced disease however ADT was seldom used. Despite the low treatment compliance rate, conventional fractionation was used in all patients. Interventions are critically needed to improve screening and increase the use of standard-of-care treatment paradigms, including hypofractionated RT and ADT.

War and oncology: cancer care in five Iraqi provinces impacted by the ISIL conflict

War and cancer have been intertwined in Iraq for over three decades, a country where the legacies and ongoing impacts of conflict have been commonly associated with both increased cancer rates as well as the deterioration of cancer care. Most recently, the Islamic State of Iraq and the Levant (ISIL) violently occupied large portions of the country's central and northern provinces between 2014 and 2017, causing devastating impacts on public cancer centers across central and northern Iraq. Focusing on the five Iraqi provinces previously under full or partial ISIL occupation, this article examines the immediate and long-term impacts of war on cancer care across three periods (before, during, and after the ISIL conflict). As there is little published data on oncology in these local contexts, the paper relies primarily upon the qualitative interviews and lived experience of oncologists serving in the five provinces studied. A political economy lens is applied to interpret the results, particularly the data related to progress in oncology reconstruction. It is argued that conflict generates immediate and long-term shifts in political and economic conditions that, in turn, shape the rebuilding of oncology infrastructure. The documentation of the destruction and reconstruction of local oncology systems is intended to benefit the next generation of cancer care practitioners in the Middle East and other conflict-affected regions areas in their efforts to adapt to conflict and rebuild from the legacies of war.

Investigating the impact of COVID-19 on patients with cancer from areas of conflict within the MENA region treated at King Hussein Cancer Center

Background

There is a paucity of evidence regarding the impact of COVID-19 on cancer care among refugees or patients from areas of conflict. Cancer care for these populations remains fragmented due to resource scarcity and limited infrastructure.

Aims

To explore the effect of COVID-19 on cancer care among patients from areas of conflict treated at King Hussein Cancer Center (KHCC).

Methodology

We performed a retrospective chart review of all patients from areas of conflict, treated at KHCC from 2018 to 2021. Patients' demographics and clinical characteristics are presented in the form of descriptive statistics. Interrupted Time Series (ITS) analysis was utilized to investigate the impact of COVID-19 on the number of admissions throughout the study's period.

Results

A total of 3317 patients from areas of conflict were included in the study. Among these, 1546 were males (46.6%) while 1771 (53.4%) were female. Libyans (34.6%), Palestinians (24.8%), Iraqis (24.5%), Syrians (15.3%), and Sudanese patients (0.9%) constituted our study sample. ITS analysis demonstrated that the start of the COVID-19 lockdown significantly decreased admissions by 44.0% (p = 0.020), while the end of the COVID-19 restriction significantly improved admissions by 43.0% (p = 0.023). Among those with available SEER stages, more than a quarter of patients had distant metastasis (n = 935, 28.2%) irrespective of age and biological sex. Advanced presentations during 2020 had approximately a 16% and 6% increase compared to 2018 and 2019, respectively. Breast cancer (21.4%), hematolymphoid cancers (18.1%), and cancers of the digestive system (16.5%) were the most common cancers among our cohort.

Conclusion

Restrictions associated with COVID-19 had a significant effect on the number of admissions of patients from areas of conflict. In the long term, this effect may impact the survival outcomes of affected patients.

Reasons for referral and referral compliance among Congolese and Burundian refugees living in Tanzania: a community-based, cross-sectional survey

OBJECTIVES

In order to prevent overburdening of higher levels of care, national healthcare systems rely on processes of referral, including for refugee populations which number 26 million globally. The goal of this study is to use data from a population-based household survey to describe patterns of referral services among a population of Congolese and Burundian refugees living in Tanzania.

DESIGN

Cross-sectional survey using cluster randomised sampling.

SETTING

Nyarugusu refugee camp, Kigoma, Tanzania.

PARTICIPANTS

153 refugees.

PRIMARY OUTCOME

Referral compliance.

SECONDARY OUTCOMES

Proportion of referrals that were surgical; proportion of referrals requiring diagnostic imaging.

RESULTS

Out of 153 individuals who had been told they needed a referral, 96 (62.7%) had gone to the referral hospital. Of the 57 who had not gone, 36 (63%) reported they were still waiting to go and had waited over a month. Of the participants who had been referred (n=96), almost half of the participants reported they were referred for a surgical problem (n=43, 45%) and the majority received radiological testing at an outside hospital (n=72, 75%). Congolese refugees more frequently had physically completed their referral compared with Burundians (Congolese: n=68, 76.4% vs Burundian: n=28, 43.8%, p<0.001). In terms of intracamp referral networks, most refugees reported being referred to the hospital or clinic by a community health worker (n=133, 86.9%).

CONCLUSION

To our knowledge, this is the first community-based study on patterns of referral healthcare among refugees in Tanzania and sub-Saharan Africa. Our findings suggest patients were referred for surgical problems and for imaging, however not all referrals were completed in a timely fashion. Future research should attempt to build prospective referral registries that allow for better tracking of patients and examination of waiting times.

The Global Incidence, Mortality, and Burden of Breast Cancer in 2019: Correlation With Smoking, Drinking, and Drug Use

Background

Female breast cancer (FBC) is the most common type of cancer and is associated with a considerable disease burden as well as significant mortality rates. The present study aimed to provide an update on the incidence, mortality, and burden of FBC in 2019, based on the Global Burden of Disease (GBD) Study.

Materials

The incidence, death rate, disability-adjusted life years (DALYs), years of life lost (YLLs), years lived with disability (YLDs), the age-standardized rates (ASR) of FBC in 204 countries, and a variety of classifications, were retrieved from the Global Burden of Disease Study. Data on tobacco use, alcohol consumption, and drug use were collected. The incidence, mortality, and burden of FBC were registered and compared between regions. Associations between age-standardized incidence rates and age-standardized mortality rates of FBC with smoking, drinking, and drug use were determined.

Results

The highest incidence of FBC was observed in countries with a high socioeconomic status such as those of the European continent. Despite the lower incidence of FBC in countries with a low socio-demographic index (SDI), mortality rates secondary to FBC are higher in these countries than in high-income countries. The highest age-standardized mortality rate has been reported in the Eastern Mediterranean Region (EMRO), followed by the African Region (AFRO). The highest age-standardized rates of DALY and YLL per 100,000 population in 2019 were observed in lower-income countries, while the highest ASR of YLD per 100,000 population was reported in high-income countries.

Conclusion

The present GBD-based study provides a comprehensive review of the incidence, mortality, and burden of FBC in 2019. The incidence of FBC is higher in regions with a higher socioeconomic status, whereas mortality rates and DALYs are higher in poorly developed regions. We suggest better screening measures and early detection programs for the latter regions.

Utilization of radiation therapy and predictors of noncompliance among Syrian refugees in Turkey

Background

Access to cancer care is a problem that continues to plague refugees displaced from their home countries. The turbulent political crisis in Syria, which has led to millions of refugees seeking asylum in Turkey, merits further attention. We aimed to study the rate of utilization of radiation therapy among Syrian refugees with cancer living in Turkey in an attempt to identify the contributing factors predictive of non-compliance with prescribed RT.

Methods

In this retrospective review of 14 institutional databases, Syrian refugee patients in Turkey with a cancer diagnosis from January 2015 to December 2019 who were treated with RT were identified. The demographic data, treatment compliance rates, and toxicity outcomes in these patients were surveyed. Variable predictors of noncompliance such as age, sex, diagnosis, treatment length, and toxicity were studied. The association between these variables and patient noncompliance was determined.

Results

We identified 10,537 patients who were diagnosed with cancer during the study period, of whom 1010 (9.6%) patients were treated with RT. Breast cancer (30%) and lung cancer (14%) were the most common diagnoses with up to 68% of patients diagnosed at an advanced stage (Stage III, IV). 20% of the patients were deemed noncompliant. Treatment with concurrent chemoradiotherapy (OR 1.61, 95% CI 1.06–2.46, p = 0.023) and living in a refugee camp (OR 3.62, 95% CI 2.43–5.19, p < 0.001) were associated with noncompliance. Age, sex and treatment length were not significantly associated with noncompliance.

Conclusions

Noncompliance with radiotherapy among Syrian refugees in Turkey remains an area of concern with a multitude of factors contributing to these alarming numbers. Further studies to better ascertain the finer nuances of this intricately complex problem and a global combination of efforts can pave the way to providing a solution.

'Vulnerable' but not 'Valuable': Older refugees and perceptions of deservingness in medical humanitarianism

In a crisis, there is widespread recognition and acceptance that not all lives can be saved. But whose lives can legitimately be saved and who decides? Recent scholarship has begun to examine how refugees perceived as 'vulnerable', such as women and children, are frequently prioritized over other groups in humanitarian responses. Such analyses, however, fail to adequately explain why some groups - such as older persons - are considered vulnerable and yet are largely neglected. Based on the case of older Syrian refugees in Jordan, this article critically examines the ways in which humanitarian health actors make sense of the humanitarian principle of 'impartiality' in the face of limited resources. Based on 61 interviews and observational data collected in Jordan between 2017 and 2019, my results show that humanitarians routinely classify older refugees as 'vulnerable' and in need of medical assistance. Yet I find that three neoliberal considerations - including perceptions of the reduced lifespan, disproportionate disease burden, and limited contributions to the economy of older refugees - make this demographic low 'value for money'. This article expands our understanding of how medical humanitarian understandings of 'deservingness' are increasingly shaped by market-driven logics, and how these (re)create ageist, gendered and racialized hierarchies within refugee health.

Analysis of health overseas development aid for internally displaced persons in low- and middle-income countries

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First detailed analysis of overseas development aid (ODA) for the health of IDPs.

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Reports low and declining health ODA for IDPs.

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Indicates major inequity in health ODA for IDPs compared to refugees.

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Negligible ODA for IDPs was for non-communicable diseases and mental health.

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Health ODA for IDPs did not appear to be related to IDP health needs.

Background

There are an estimated 55 million internally displaced persons (IDPs) globally. IDPs commonly have worse health outcomes than host populations and other forcibly displaced populations such as refugees. Official development assistance (ODA) is a major source of the global financial response for health in low- and middle-income countries (LMICs), including for populations affected by armed conflict and forced displacement. Analysis of ODA supports efforts to improve donor accountability, transparency and the equitable use of ODA. The aim of this study is to examine international donor support and responsiveness to IDP health needs through analysis of ODA disbursements to LMICs between 2010 and 2019.

Methods

ODA disbursement data to LMICs from 2010 to 2019 were extracted from the Creditor Reporting System (CRS) database and analysed with Stata software using a combination of: (i) text searching for IDP and refugee related terms; and (ii) relevant health and humanitarian CRS purpose codes. Descriptive analysis was used to examine patterns of ODA disbursement, and nonlinear least squared regression analysis was used to examine responsiveness of ODA disbursement to recipient country IDP population size and health system capacity and health characteristics.

Findings

The study highlighted declining per IDP capita health ODA from USD 5.34 in 2010 to USD 3.72 in 2019 (with annual average decline of -38% from the 2010 baseline). In contrast, health ODA for refugees in LMICs increased from USD 18.55 in 2010 to USD 23.31 in 2019 (with an annual average increase of +14%). Certain health topics for IDPs received very low ODA, with only 0.44% of IDP health ODA disbursed for non-communicable diseases (including mental health). There was also weak evidence of IDP health ODA being related to recipient country IDP population size, and health system capacity and health characteristics. The paper highlights the need for increased investment by donors in IDP health ODA and to ensure that it is responsive to their health needs.

Cancer among syrian refugees living in Konya Province, Turkey

BACKGROUND

With more than 3.6 million Syrian refugees Turkey hosts the world's largest number of Syrians. Considering the morbidity, mortality, and healthcare spending, cancer is one of the leading health and economic burden for patients and healthcare systems. However, very limited information available in the scientific literature to understand the burden and characteristics of cancer in countries hosting Syrian refugees. The aim of the present study is to evaluate the demographic and clinical characteristics, treatment outcome of Syrian cancer patients living in Konya, Turkey.

METHODS

We retrospectively reviewed medical records of Syrian cancer patients at three major institutions from 2005 to 2020. The information regarding demographic and clinical characteristics of patients were identified. The number of days between the first symptom and diagnosis was considered as the "diagnostic interval". Patients who failed to attend clinics within four weeks of appointment were assumed abandoned treatment. Survival curves were estimated using the Kaplan-Meier method.

RESULTS

We identified 230 adult and 38 children refugee diagnosed with cancer during the study period. With regards to adult patients, there were 114 (49.6%) male and 116 (50.4%) female. The median age at diagnosis was 52.4, 47.3 years for male, female respectively. The five most common cancer by site among all were; breast (24.8%), colorectal (10.9%), lung (7.4%), central nervous system (CNS) (7.0%), and stomach (5.2%). 93 (40.4%) had metastatic disease at diagnosis. The overall survival probability was 37.5% at five years for the adult population. Data were extracted for 20 boys and 18 girls with childhood cancer. Their median age at diagnosis was 5.8 and 6.0 years respectively. The three most common childhood cancer were; leukemias (21.1%), lymphomas (21.1%), and CNS (13.2%). Excluding leukemia, 13 (43.3%) of childhood cancer cases had the advanced disease at diagnosis. Three year survival probality was 69.5%. The median diagnostic interval for adult and childhood cancer was 96.5 (IQR = 53-165) and 23 (IQR = 13.5-59) days respectively. Twenty-one adults and four children had treatment abandonment.

CONCLUSION

This study contributes to understanding the burden of cancer among Syrian refugees living in Konya, growing health issue for refugees. Larger and prospective studies will help to measure the real burden and compare the difference in cancer risk factors, care, and outcomes among the refugee and host populations.

Incidence of Cancer in Adolescents and Young Adults in Jordan, 2000-2017

The epidemiology of cancer in adolescents and young adults (AYAs) is distinct and underinvestigated. Therefore, we investigated the incidence of cancer in AYAs in Jordan.

Delivering a primary-level non-communicable disease programme for Syrian refugees and the host population in Jordan: a descriptive costing study

The Syrian conflict has caused enormous displacement of a population with a high non-communicable disease (NCD) burden into surrounding countries, overwhelming health systems’ NCD care capacity. Médecins sans Frontières (MSF) developed a primary-level NCD programme, serving Syrian refugees and the host population in Irbid, Jordan, to assist the response. Cost data, which are currently lacking, may support programme adaptation and system scale up of such NCD services. This descriptive costing study from the provider perspective explored financial costs of the MSF NCD programme. We estimated annual total, per patient and per consultation costs for 2015–17 using a combined ingredients-based and step-down allocation approach. Data were collected via programme budgets, facility records, direct observation and informal interviews. Scenario analyses explored the impact of varying procurement processes, consultation frequency and task sharing. Total annual programme cost ranged from 4 to 6 million International Dollars (INT$), increasing annually from INT$4 206 481 (2015) to INT$6 739 438 (2017), with costs driven mainly by human resources and drugs. Per patient per year cost increased 23% from INT$1424 (2015) to 1751 (2016), and by 9% to 1904 (2017), while cost per consultation increased from INT$209 to 253 (2015–17). Annual cost increases reflected growing patient load and increasing service complexity throughout 2015–17. A scenario importing all medications cut total costs by 31%, while negotiating importation of high-cost items offered 13% savings. Leveraging pooled procurement for local purchasing could save 20%. Staff costs were more sensitive to reducing clinical review frequency than to task sharing review to nurses. Over 1000 extra patients could be enrolled without additional staffing cost if care delivery was restructured. Total costs significantly exceeded costs reported for NCD care in low-income humanitarian contexts. Efficiencies gained by revising procurement and/or restructuring consultation models could confer cost savings or facilitate cohort expansion. Cost effectiveness studies of adapted models are recommended.

Lessons learned in the provision NCD primary care to Syrian refugee and host communities in Lebanon: the need to 'act locally and think globally'

BACKGROUND

Prevention and control of non-communicable diseases (NCDs) remain inadequate in resource-scarce countries, particularly in conflict situations. This paper describes a multicomponent intervention for management of hypertension and diabetes among older adult Syrian refugees and the Lebanese host community and reflects on challenges for scaling up NCD integration into primary care in humanitarian situations.

METHODS

Using a mixed method approach, the study focused on monitoring and evaluation of the three components of the intervention: healthcare physical facilities and documentation processes, provider knowledge and guideline-concordant performance, and refugee and host community awareness.

RESULTS

Findings revealed overall high compliance of healthcare workers with completing data collection forms. Their knowledge of basic aspects of hypertension/diabetes management was adequate, but diagnosis knowledge was low. Patients and healthcare providers voiced satisfaction with the program. Yet, interruptions in medicines' supplies and lapses in care were perceived by all study groups alike as the most problematic aspect of the program.

CONCLUSIONS

Our intervention program was aligned with internationally agreed-upon practices, yet, our experiences in the field point to the need for more 'local testing' of modified interventions within such contexts. This can then inform 'thinking globally' on guidelines for the delivery of NCD care in crisis settings.

Late presentation and suboptimal treatment of breast cancer among Syrian refugees: a retrospective study

Objectives

The crisis in Syria has had a profound impact on the entire region. In this study, we report the patterns of presentation and management of Syrian patients with breast cancer treated at our institution.

Methods

We retrospectively collected data on Syrian refugees treated for breast cancer over the past 10 years at our center. Management was compared against our approved clinical practice guidelines.

Results

A total of 113 patients were eligible and included. The median age (range) at diagnosis was 47 (21–84) years and most women presented with locally advanced or metastatic disease (n = 74, 65.5%). Breast-conserving surgery and breast reconstruction were performed in 27 (33.8%) and 11 (35.4%) patients, respectively. Only a few patients received targeted (35.5%) or advanced endocrine therapy (30.0%). In total, 37 (32.7%) patients had considerable deviations from our institutional treatment guidelines and had worse outcomes.

Conclusions

Syrian refugees with breast cancer present late, have more advanced-stage disease, and are more likely to receive delayed and suboptimal therapy. An international systematic approach for cancer care among such vulnerable populations is urgently needed.

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.

MSF experiences of providing multidisciplinary primary level NCD care for Syrian refugees and the host population in Jordan: an implementation study guided by the RE-AIM framework

BACKGROUND

In response to the rising global NCD burden, humanitarian actors have rapidly scaled-up NCD services in crisis-affected low-and-middle income countries. Using the RE-AIM implementation framework, we evaluated a multidisciplinary, primary level model of NCD care for Syrian refugees and vulnerable Jordanians delivered by MSF in Irbid, Jordan. We examined the programme's Reach, Effectiveness, Adoption and acceptance, Implementation and Maintenance over time.

METHODS

This mixed methods retrospective evaluation, undertaken in 2017, comprised secondary analysis of pre-existing cross-sectional household survey data; analysis of routine cohort data from 2014 to 2017; descriptive costing analysis of total annual, per-patient and per-consultation costs for 2015-2017 from the provider-perspective; a clinical audit; a medication adherence survey; and qualitative research involving thematic analysis of individual interviews and focus group discussions.

RESULTS

The programme enrolled 23% of Syrian adult refugees with NCDs in Irbid governorate. The cohort mean age was 54.7 years; 71% had multi-morbidity and 9.9% self-reported a disability. The programme was acceptable to patients, staff and stakeholders. Blood pressure and glycaemic control improved as the programme matured and by 6.6 mmHg and 1.12 mmol/l respectively within 6 months of patient enrolment. Per patient per year cost increased 23% from INT$ 1424 (2015) to 1751 (2016), and by 9% to 1904 (2017). Cost per consultation increased from INT$ 209 to 253 (2015-2017). Staff reported that clinical guidelines were usable and patients' self-reported medication adherence was high. Individual, programmatic and organisational challenges to programme implementation and maintenance included the impact of war and the refugee experience on Syrian refugees' ability to engage; inadequate low-cost referral options; and challenges for MSF to rapidly adapt to operating in a highly regulated and complex health system. Essential programme adaptations included refinement of health education, development of mental health and psychosocial services and addition of essential referral pathways, home visit, physiotherapy and social worker services.

CONCLUSION

RE-AIM proved a valuable tool in evaluating a complex intervention in a protracted humanitarian crisis setting. This multidisciplinary programme was largely acceptable, achieving good clinical outcomes, but for a limited number of patients and at relatively high cost. We propose that model simplification, adapted procurement practices and use of technology could improve cost effectiveness without reducing acceptability, and may facilitate replication.

Operational considerations for the management of non-communicable diseases in humanitarian emergencies

Non-communicable diseases (NCD) represent an increasing global challenge with the majority of mortality occurring in low- and middle-income countries (LMICs). Concurrently, many humanitarian crises occur in these countries and the number of displaced persons, either refugees or internally displaced, has reached the highest level in history. Until recently NCDs in humanitarian contexts were a neglected issue, but this is changing. Humanitarian actors are now increasingly integrating NCD care in their activities and recognizing the need to harmonize and enhance NCD management in humanitarian crises. However, there is a lack of a standardized response during operations as well as a lack of evidence-based NCD management guidelines in humanitarian settings. An informal working group on NCDs in humanitarian settings, formed by members of the World Health Organization, Médecins Sans Frontières, the International Committee of the Red Cross, the International Federation of the Red Cross and others, and led by the United Nations High Commissioner for Refugees, teamed up with the University of Geneva and Geneva University Hospitals to develop operational considerations for NCDs in humanitarian settings. This paper presents these considerations, aiming at ensuring appropriate planning, management and care for NCD-affected persons during the different stages of humanitarian emergencies. Key components include access to treatment, continuity of care including referral pathways, therapeutic patient education/patient self-management, community engagement and health promotion. In order to implement these components, a standardized approach will support a consistent response, and should be based on an ethical foundation to ensure that the "do no harm" principle is upheld. Advocacy supported by evidence is important to generate visibility and resource allocation for NCDs. Only a collaborative approach of all actors involved in NCD management will allow the spectrum of needs and continuum of care for persons affected by NCDs to be properly addressed in humanitarian programmes.

Strengthening capacity for cancer research in conflict settings: key informant insights from the Middle East

Background

Management of cancer in the Middle East and North Africa (MENA) region is accompanied by multiple challenges including heterogeneous access to early detection and treatment options and limited implementation of national cancer control plans. Furthermore, protracted armed conflicts across the region have had dramatic effects, including disruption of healthcare systems and the migration of healthcare professionals. Strengthening capacity for cancer research has been identified as a key intervention to correct data poverty, inform policy, manage limited resources and improve health outcomes.

Objective

The main objective of this study is to gain insights into the landscape, barriers and enablers of cancer training, research and care in the MENA region.

Method

We utilised purposive sampling to interview 16 key informants from a diverse academic, medical and research background originating from countries affected by conflicts, such as Lebanon, and from active conflict zones including Iraq and Syria.

Results

The themes that emerged from the interviews focused on the barriers to cancer care, barriers to cancer research and training, strengths and importance of cancer research and training recommendations. The detrimental effect of conflict on cancer provision and research was a cross-cutting sub-theme disrupting cancer care provision and research due to unsafe environments, fragmented facilities, absence of drugs and migration of personnel. When asked about perceived optimal training format for cancer research, most informants recommended a post-graduate, face-to-face training focusing on cancer research methods and concepts.

Conclusion

This study offers a unique insight into the barriers affecting cancer research and capacity-strengthening priorities from oncologists and researchers working in conflict-affected areas of the MENA region. These data will form the base for future capacity-strengthening initiatives addressing specific regional challenges.

Non-communicable diseases in disasters: a protocol for a systematic review

Background:

NCDs require an ongoing management for optimal outcomes, which is challenging in emergency settings, because natural disasters increase the risk of acute NCD exacerbations and lead to health systems’ inability to respond. This study aims to develop a protocol for a systematic review on non-communicable diseases in natural disaster settings.

Methods:

This systematic review protocol is submitted to the International Prospective Register of Systematic Reviews (Registration No. CRD42020164032). The electronic databases to be used in this study include: Medline, Scopus, Web of Science, Clinical Key, CINAHL, EBSCO, Ovid, EMBASE, ProQuest, Google Scholar, Cochrane Library (Cochrane database of systematic reviews; Cochrane central Register of controlled Trials). Records from 1997 to 2019 are subject to this investigation. Three independent researchers will review the titles, abstracts, and full texts of articles eligible for inclusion, and if not matched, they will be reviewed by a final fourth reviewer. The proposed systematic review will be reported in accordance with the reporting guideline provided in the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) statement. We select studies based on: PICOs (Participants, Interventions, Comparators, and Outcomes).

Results:

This systematic review identifies any impacts of natural disasters on patients with NCDs in three stages i.e. before, during and in the aftermath of natural disasters.

Conclusions:

A comprehensive response to NCD management in natural disasters is an important but neglected aspect of non-communicable disease control and humanitarian response, which can significantly reduce the potential risk of morbidity and mortality associated with natural disasters.

Bat-Borne Coronaviruses in Jordan and Saudi Arabia: A Threat to Public Health?

Emerging infectious diseases are of great concern to public health, as highlighted by the ongoing coronavirus disease 2019 (COVID-19) pandemic. Such diseases are of particular danger during mass gathering and mass influx events, as large crowds of people in close proximity to each other creates optimal opportunities for disease transmission. The Hashemite Kingdom of Jordan and the Kingdom of Saudi Arabia are two countries that have witnessed mass gatherings due to the arrival of Syrian refugees and the annual Hajj season. The mass migration of people not only brings exotic diseases to these regions but also brings new diseases back to their own countries, e.g., the outbreak of MERS in South Korea. Many emerging pathogens originate in bats, and more than 30 bat species have been identified in these two countries. Some of those bat species are known to carry viruses that cause deadly diseases in other parts of the world, such as the rabies virus and coronaviruses. However, little is known about bats and the pathogens they carry in Jordan and Saudi Arabia. Here, the importance of enhanced surveillance of bat-borne infections in Jordan and Saudi Arabia is emphasized, promoting the awareness of bat-borne diseases among the general public and building up infrastructure and capability to fill the gaps in public health preparedness to prevent future pandemics.

Knowledge of cervical cancer risk factors and symptoms among women in a refugee settlement: a cross-sectional study in northern Uganda

BACKGROUND

There are limited data on awareness of cervical cancer risk factors and symptoms among refugee populations living in Uganda. In this study, we sought to determine the awareness and knowledge of cervical cancer risk factors and symptoms among women in Palabek refugee settlement, northern Uganda.

METHODS

We conducted a cross-sectional study. 815 women (aged 18-60 years) were randomly selected using multistage sampling in Palabek refugee settlement. Data were collected using pre-tested, structured questionnaires. Logistic regression models were used to determine magnitudes of association between socio-demographic and health system factors, and knowledge on cervical cancer risk factors and symptoms.

RESULTS

The majority of participants (53%, n = 433) were young (18-29 years), married (68%, n = 553), and did not have formal employment (93%, n = 759). Less than half (40%, n = 325) had heard of cervical cancer. Of those who had heard, most recognized multiple male sexual partners, early onset of sexual intercourse and HPV infections as risk factors for cervical cancer (93%, n = 295; 89%, n = 283; and 86%, n = 271 respectively). Median knowledge score for risk factor recognition = 7 (IQR: 3-9). Median knowledge score for symptoms recognition = 7 (IQR: 1-10). Half of women (50%, n = 409) correctly recognized 7 to 11 symptoms of cervical cancer, with vaginal bleeding between menstrual periods, pelvic pain, and vaginal bleeding during/after sexual intercourse recognized by 58, 52 and 54% respectively. Single women (OR = 0.59 (95%CI: 0.38-0.94), and women that lived farther than 1 kilo meter from nearest health facility in South Sudan (OR = 0.36-0.49 (95%CI: 0.26-0.84) were less likely to be knowledgeable of symptoms of cervical cancer.

CONCLUSION

A significant proportion of women in Palabek refugee settlement had not heard about cervical cancer. Refugee health services providers could increase awareness of cervical cancer risk factors and symptoms through health education in order to promote risk reduction behaviours and guide women during symptoms appraisal. Single women and those who lived more than one kilo metre from nearest health facility in home country could be a priority group for awareness intervention in the settlement.

Examining the use of economic evaluations in health-related humanitarian programmes in low- and middle-income countries: a systematic review

The costly nature of health sector responses to humanitarian crises and resource constraints means that there is a need to identify methods for priority setting and long-term planning. One method is economic evaluation. The aim of this systematic review is to examine the use of economic evaluations in health-related humanitarian programmes in low- and middle-income countries. This review used peer-reviewed literature published between January 1980 and June 2018 extracted from four main electronic bibliographic databases. The eligibility criteria were full economic evaluations (which compare the costs and outcomes of at least two interventions and provide information on efficiency) of health-related services in humanitarian crises in low- and middle-countries. The quality of eligible studies is appraised using the modified 36-question Drummond checklist. From a total of 8127 total studies, 11 full economic evaluations were identified. All economic evaluations were cost-effectiveness analyses. Three of the 11 studies used a provider perspective, 2 studies used a healthcare system perspective, 3 studies used a societal perspective and 3 studies did not specify the perspective used. The lower quality studies failed to provide 7information on the unit of costs and did not justify the time horizon of costs and discount rates, or conduct a sensitivity analysis. There was limited geographic range of the studies, with 9 of the 11 studies conducted in Africa. Recommendations include greater use of economic evaluation methods and data to enhance the microeconomic understanding of health interventions in humanitarian settings to support greater efficiency and transparency and to strengthen capacity by recruiting economists and providing training in economic methods to humanitarian agencies.

Cancer in Syrian refugees in Jordan and Lebanon between 2015 and 2017

Protracted conflicts in the Middle East have led to successive waves of refugees crossing borders. Chronic, non-communicable diseases are now recognised as diseases that need to be addressed in such crises. Cancer, in particular, with its costly, multidisciplinary care, poses considerable financial and ethical challenges for policy makers. In 2014 and with funding from the United Nations High Commissioner for Refugees, we reported on cancer cases among Iraqi refugees in Jordan (2010-12) and Syria (2009-11). In this Policy Review, we provide data on 733 refugees referred to the United Nations High Commissioner for Refugees in Lebanon (2015-17) and Jordan (2016-17), analysed by cancer type, demographic risk factors, treatment coverage status, and cost. Results show the need for increased funding and evidence-based standard operating procedures across countries to ensure that patients have equitable access to care. We recommend a holistic response to humanitarian crises that includes education, screening, treatment, and palliative care for refugees and nationals and prioritises breast cancer and childhood cancers.

The economic burden of cancer care for Syrian refugees: a population-based modelling study

BACKGROUND

Cancer represents a substantial health burden for refugees and host countries. However, no reliable data on the costs of cancer care for refugees are available, which limits the planning of official development assistance in humanitarian settings. We aimed to model the direct costs of cancer care among Syrian refugee populations residing in Jordan, Lebanon, and Turkey.

METHODS

In this population-based modelling study, direct cost per capita and per incident case for cancer care were estimated using generalised linear models, informed by a representative dataset of cancer costs drawn from 27 EU countries. A range of regression specifications were tested, in which cancer costs were modelled using different independent variables: gross domestic product (GDP) per capita, crude or age-standardised incidence, crude or age-standardised mortality, and total host country population size. Models were compared using the Akaike information criterion. Total cancer care costs for Syrian refugees in Jordan, Lebanon, and Turkey were calculated by multiplying the estimated direct cancer care costs (per capita) by the total number of Syrian refugees, or by multiplying the estimated direct cancer costs (per incident case [crude or age-standardised]) by the number of incident cancer cases in Syrian refugee populations. All costs are expressed in 2017 euros (€).

FINDINGS

Total cancer care costs for all 4·74 million Syrian refugees in Jordan, Lebanon, and Turkey in 2017 were estimated to be €140·23 million using the cost per capita approach, €79·02 million using the age-standardised incidence approach, and €33·68 million using the crude incidence approach. Under the lowest estimation, and with GDP and total country population as model predictors, the financial burden of cancer care was highest for Turkey (€25·18 million), followed by Lebanon (€6·40 million), and then Jordan (€2·09 million).

INTERPRETATION

Cancer among the Syrian refugee population represents a substantial financial burden for host countries and humanitarian agencies, such as the UN Refugee Agency. New ways to provide financial assistance need to be found and must be coupled with clear, prioritised pathways and models of care for refugees with cancer.

FUNDING

UK Research and Innovation Global Challenges Research Fund: Research for Health in Conflict-Middle East and North Africa region (R4HC-MENA).

Economics of Pediatric Cancer in Four Eastern Mediterranean Countries: A Comparative Assessment

PURPOSE

Cancer is a leading cause of death among children in the Eastern Mediterranean region, where conflict and economic downturn place additional burden on the health sector. In this context, using economic evidence to inform policy decisions is crucial for maximizing health outcomes from available resources. We summarized the available evidence on the economics of pediatric cancer in Jordan, Lebanon, the occupied Palestinian territory, and Turkey.

METHODS

A scoping review was performed of seven academic databases and gray literature pertaining to pediatric cancer in the four jurisdictions, published between January 1, 2010, and July 17, 2019. Information was extracted and organized using an analytical framework that synthesizes economic information on four dimensions: the context of the health system, the economics of health care inputs, the economics of service provision, and the economic consequences of disease.

RESULTS

Most of the economic evidence available across the four jurisdictions pertains to the availability of health care inputs (ie, drugs, human resources, cancer registration data, and treatment protocols) and individual-level outcomes (either clinical or health-related quality of life). We identified little evidence on the efficiency or quality of health care inputs and of pediatric cancer services. Moreover, we identified no studies examining the cost-effectiveness of any intervention, program, or treatment protocol. Evidence on the economic consequences of pediatric cancer on families and the society at large was predominantly qualitative.

CONCLUSION

The available economic evidence on pediatric cancer care in the four countries is limited to resource availability and, to an extent, patient outcomes, with a substantial gap in information on drug quality, service provision efficiency, and cost-effectiveness. Links between researchers and policymakers must be strengthened if pediatric cancer spending decisions, and, ultimately, treatment outcomes, are to improve.

Using Intervention Mapping to Develop Health Education and Health Policy Components to Increase Breast Cancer Screening and Chemotherapy Adherence Among Syrian and Iraqi Refugee Women in Beirut, Lebanon

Introduction: Despite the continuous increase in the incidence of metastatic breast cancer among Syrian and Iraqi refugee women residing in camp settings in Lebanon, mammography and chemotherapy adherence rates remain low due to multiple social, economic, and environmental interfering factors. This in turn led to an alarming increase in breast cancer morbidity and mortality rates among the disadvantaged population. Methods: Intervention mapping, a systematic approach which guides researchers and public health experts in the development of comprehensive evidence-based interventions (EBIs) was used to plan a health education and health policy intervention to increase breast cancer screening and chemotherapy adherence among Iraqi and Syrian refugee women aged 30 and older who are residing in refugee camps within the Beirut district of Lebanon. Results: The generation of the logic model during the needs assessment phase was guided by an extensive review of the literature and reports published in peer-reviewed journals or by international/local organizations in the country to determine breast cancer incidence and mortality rates among refugee women of Syrian and Iraqi nationalities. The underlying behavioral and environmental determinants of the disease were identified from qualitative and quantitative studies carried out among the target population and also aided in assessing the sub-behaviors related to the determinants of breast cancer screening and chemotherapy completion as well as factors affecting policy execution to formulate performance objectives. We then developed matrices of change objectives and their respective methods and practical applications for behavior change at the intrapersonal, interpersonal, organizational, and societal levels. Both educational components (brochures, flyers) and technological methods (videos disseminated via Whats app and Facebook) will be adopted to apply the different methods selected (modeling, self-reevaluation, consciousness raising, persuasion, and tailoring). We also described the development of the educational and technological tools, in addition to providing future implementers with methods for pre-testing and pilot-testing of individual and environmental prototype components. Conclusion: The use of intervention mapping in the planning and implementation of holistic health promotion interventions based on information collected from published literature, case reports, and theory can integrate the multiple disciplines of public health to attain the desired behavioral change.

Cancer care in times of conflict: cross border care in Pakistan of patients from Afghanistan

Armed conflict in Afghanistan has continued for close to 40 years and has devastated its health infrastructure. The lack of a cancer care infrastructure has meant that many Afghans seek cancer care in neighbouring countries, like Pakistan. There remains a significant lack of empirical data on the new therapeutic geographies of cancer in contemporary conflicts.

This retrospective single centre study explores the therapeutic and clinical geographies of Afghan cancer patients who were treated at the Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC) in Lahore, Pakistan over a 22-year-period (1995 to 2017) covering major periods of conflict and relative peace.

Data was available for 3,489 Afghan patients who received treatment at SKMCH&RC. The mean age at presentation was 42.7 years, and 60% were men. 30.2% came from Kabul and Nangarhar districts of Afghanistan, which have relatively short travel times to Pakistan, but patients from all parts of Afghanistan migrated to SKMCH&RC for treatment. Overall, 34.1% were diagnosed with upper gastrointestinal malignancies and 55.7% presented with late stage III/IV cancer. A wide range of treatments were provided, with 25.4% of patients receiving a combination of chemotherapy and radiation treatment. 52.7% of all patients were lost to follow-up. Outcomes were more favourable for children with cancer, 42% of whom had a complete response to therapy.

Complex migration patterns, mixed political economies (refugees, forced and unforced migrants) and models of care that must be adapted to the realities of the patients rather than notional international standards all reflect the new therapeutic geographies that long-term conflict creates. This requires significant new domestic and international (e.g., United Nations High Commissioner for Refugees) policy and practises for providing cancer care in today’s contemporary conflict ecosystems that frequently cross national borders.

Addressing noncommunicable diseases among urban refugees in the Middle East and North Africa - a scoping review

Background

More than 5.5 million Syrian refugees have fled violence and settled in mostly urban environments in neighboring countries. The Middle East and North Africa (MENA) region accounts for 6% of the global population but 25% of the population are ‘of concern’ to the UN Refugee Agency. In addition to large amounts of forced migration, the region is also undergoing an epidemiologic transition towards a heavier burden of noncommunicable diseases (NCDs), which in 2018 accounted for 74% of all deaths in the region. To address NCD needs globally, a myriad of policies and interventions have been implemented in low-income stable country settings. However, little is known about which policies and interventions are currently being implemented or are best suited for refugee hosting countries across the Middle East and North Africa.

Methods

A scoping review of peer-reviewed literature was conducted to identify policies and interventions implemented in the Middle East and North Africa to address the needs of urban refugees with noncommunicable diseases.

Results

This scoping review identified 11 studies from Jordan, Lebanon, Iran, West Bank, Gaza and Syria. These studies addressed three foci of extant work, (1) innovative financing for expensive treatments, (2) improvements to access and quality of treatment and, (3) efforts to prevent new diagnoses and secondary complications. All interventions targeted refugee populations including Palestinians, Sudanese, Syrians, Afghans and Iraqis.

Discussion

The scoping review highlighted five key findings. First, very few studies focused on the prevention of noncommunicable diseases among displaced populations. Second, several interventions made use of health information technologies, including electronic medical records and mHealth applications for patients. Third, the vast majority of publications were solely focused on tackling NCDs through primary care efforts. Fourth, the literature was very sparse in regard to national policy development, and instead favored interventions by NGOs and UN agencies. Last, the perspectives of refugees were notably absent.

Conclusion

Opportunities exist to prioritize prevention efforts, scale up eHealth interventions, expand access to secondary and tertiary services, address the scarcity of research on national policy, and incorporate the perspectives of affected persons in the broader discourse.

Understanding wellness and barriers to care among Iraqi refugee women in the United States

Iraqi refugees in the US experience a high prevalence of non-communicable diseases. In this article, we explore how cultural and structural realities intersect to influence utilisation of preventative healthcare and cancer screening with the aim of understanding health disparities in this population. We conducted three focus group discussions with a total of 14 Iraqi refugee women living in a northeastern US city in 2016 and analysed the qualitative data using a thematic analysis. Eight themes emerged from our data: (a) 'prevention is better than cure:' Iraqi refugee women maintain wellness; (b) physical and mental health are interrelated in causing and curing ill-health; (c) Iraqi refugee women embrace both biomedical and other healing practices; (d) God contributes to healing; (e) cancer is caused by dangerous environments. Three of the eight themes related to barriers to care; (f) multi-level problems within hospitals and clinics prevent the delivery of care; (g) financial barriers prevent access to care and good health; (h) competing priorities are a barrier to good health. We argue that understanding refugee health requires critical analysis of both culturally informed understandings of health and illness as well as the structural aspects of health disparities that result in limited access to life opportunities, racism and inequality for refugees and their communities.

Burden of Cancer Among Syrian Refugees in Jordan

The Syrian crisis, which started in 2011, has had a profound impact on the entire region. Jordan, with its limited resources, now has the second highest ratio of refugees to inhabitants in the world (89 to 1,000). The actual number of Syrians in Jordan is hotly contested: more than 630,776 refugees registered in November 2015 compared with 1,265,514 reported by the national census conducted at the same time. Although the numbers are slowly but steadily increasing, the number of patients with cancer who were registered by the Jordan Cancer Registry peaked in 2013 at 510 patients reported and subsequently slumped downward, which coincided with changes in funding as a result of the increasing strains on the Ministry of Health. Older individuals, women, and patients with advanced diseases were less likely to be registered. These findings overlap with data obtained from the authors’ own center registry. Using age- and sex-specific population-based incidence rates, we estimated that 869 Syrians are diagnosed with cancer in Jordan annually. Using diagnosis-specific cost records of the King Hussein Cancer Foundation, we estimated that the cost of their treatments is 15.6 million Jordan dinars (US$22.1 million).

"If I have a cancer, it is not my fault I am a refugee": A qualitative study with expert stakeholders on cancer care management for Syrian refugees in Jordan

BACKGROUND

Noncommunicable diseases including cancer are widespread amongst the 5.6 million Syrian refugees currently hosted in the Middle East. Given its prevalence as the third leading cause of death in Syria, cancer is likely to be an important health burden among Syrian refugees. Against this background, our aim was to describe the clinical, ethical and policy decision-making experiences of health actors working within the current refugee cancer care system; the impact of refugee cancer care health policies on health care providers and policy makers in this context; and provide suggestions for the way delivery of care should be optimised in a sustained emergency situation.

METHODS

From April-July 2016, we conducted in-depth interviews with 12 purposively sampled health officials and health care workers from the Jordanian Ministry of Health, multilateral donors and international non-governmental organisations. Data were analysed using a framework analysis approach to identify systemic, practical and ethical challenges to optimising care for refugees, through author agreement on issues emerging from the data and those linked more directly to areas of questioning.

RESULTS

As has been previously reported, central challenges for policy makers and health providers were the lack of quality cancer prevalence data to inform programming and care delivery for this refugee population, and insufficient health resource allocation to support services. In addition, limited access to international funding for the host country, the absence of long-term funding schemes, and barriers to coordination between institutions and frontline clinicians were seen as key barriers. In this context where economic priorities inevitably drive decision-making on public health policy and individual care provision, frontline healthcare workers and policy makers experienced significant moral distress where duties of care and humanitarian values were often impossible to uphold.

CONCLUSIONS

Our findings confirm and expand understanding of the challenges involved in resource allocation decisions for cancer care in refugee populations, and highlight these for the particular situation of long term Syrian refugees in Jordan. The insights offered by frontline clinicians and policy makers in this context reveal the unintended personal and moral impact of resource allocation decisions. With many countries facing similar challenges in the provision of cancer care for refugees, the lessons learned from Jordan suggest key areas for policy revision and international investment in developing cancer care policies for refugees internationally.

Host country responses to non-communicable diseases amongst Syrian refugees: a review

Background

Since the beginning of the Syrian conflict in 2011, Jordan, Lebanon and Turkey have hosted large refugee populations, with a high pre-conflict burden of non-communicable diseases (NCDs).

Objectives

We aimed to describe the ways in which these three host country health systems have provided NCD services to Syrian refugees over time, and to highlight the successes and challenges they encountered.

Methods

We conducted a descriptive review of the academic and grey literature, published between March 2011 and March 2017, using PubMed and Google searches complemented with documents provided by relevant stakeholders.

Results

Forty-one articles and reports met our search criteria. Despite the scarcity of systematic population-level data, these documents highlight the high burden of reported NCDs among Syrian refugees, especially amongst older adults. The three host countries utilized different approaches to the design, delivery and financing of NCD services for these refugees. In Jordan and Lebanon, Ministries of Health and the United Nations High Commissioner for Refugees (UNHCR) coordinate a diverse group of health care providers to deliver health services to Syrian refugees at a subsidized cost. In Turkey, however, services are provided solely by the Disaster and Emergency Management Presidency (AFAD), a Turkish governmental agency, with no cost to patients for primary or secondary care. Access to NCD services varied both within and between countries, with no data available from Turkey. The cost of NCD treatment is the primary barrier to accessing healthcare, with high out-of-pocket payments required for medications and secondary and tertiary care services, despite the availability of free or subsidized primary health services. Financial impediments led refugees to adopt coping strategies, including returning to Syria to seek treatment, with associated frequent treatment interruptions. These gaps were compounded by health system related barriers such as complex referral systems, lack of effective guidance on navigating the health system, limited health facility capacity and suboptimal NCD health education.

Conclusion

As funding shortages for refugee services continue, innovative service delivery models are needed to create responsive and sustainable solutions to the NCD burden among refugees in host countries.

Cancer Awareness and Barriers to Seeking Medical Help Among Syrian Refugees in Jordan: a Baseline Study

Refugees in Jordan have an increased burden of cancer due to hard conditions and low income. An increase in awareness of the early signs of cancer could prompt early diagnosis. The current study aims to explore the level of cancer knowledge and barriers to seeking care among Syrian refugees in Jordan. A descriptive cross-sectional survey design was used. Two hundred and forty-one Syrian refugees living in the north of Jordan completed the Cancer Awareness Measure. The mean age was 27.9 (SD 9.1) years, ranging from 18 to 47 years. More than half (56%) of the participants were female. Participants were able to recognize a low number of symptoms (mean 4.4, SD 2.3) and risk factors (4.7 (out of 11), SD 1.9). The most commonly reported barrier was having no medical insurance (83.4%). Refugees' knowledge of symptoms and risk factors was generally unsatisfactory. Barriers to seeking medical care were prevalent. Much work is needed to overcome barriers and enhance knowledge that can hinder early diagnosis and treatment.

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.

Developing institutions for cancer care in low-income and middle-income countries: from cancer units to comprehensive cancer centres

Global cancer centres operate across different sizes, scales, and ecosystems. Understanding the essential aspects of the creation, organisation, accreditation, and activities within these settings is crucial for developing an affordable, equitable, and quality cancer care, research, and education system. Robust guidelines are scarce for cancer units, cancer centres, and comprehensive cancer centres in low-income and middle-income countries. However, some robust examples of the delivery of complex cancer care in centres in emerging economies are available. Although it is impossible to create an optimal system to fit the unique needs of all countries for the delivery of cancer care, we summarise what has been published about the development and management of cancer centres in low-income and middle-income countries so far and highlight the need for clinical and political leadership.

Burden of cancer in the Eastern Mediterranean Region, 2005-2015: findings from the Global Burden of Disease 2015 Study

OBJECTIVES

To estimate incidence, mortality, and disability-adjusted life years (DALYs) caused by cancer in the Eastern Mediterranean Region (EMR) between 2005 and 2015.

METHODS

Vital registration system and cancer registry data from the EMR region were analyzed for 29 cancer groups in 22 EMR countries using the Global Burden of Disease Study 2015 methodology.

RESULTS

In 2015, cancer was responsible for 9.4% of all deaths and 5.1% of all DALYs. It accounted for 722,646 new cases, 379,093 deaths, and 11.7 million DALYs. Between 2005 and 2015, incident cases increased by 46%, deaths by 33%, and DALYs by 31%. The increase in cancer incidence was largely driven by population growth and population aging. Breast cancer, lung cancer, and leukemia were the most common cancers, while lung, breast, and stomach cancers caused most cancer deaths.

CONCLUSIONS

Cancer is responsible for a substantial disease burden in the EMR, which is increasing. There is an urgent need to expand cancer prevention, screening, and awareness programs in EMR countries as well as to improve diagnosis, treatment, and palliative care services.

Cancer surveillance in northern Africa, and central and western Asia: challenges and strategies in support of developing cancer registries

The Global Initiative for Cancer Registry Development partnership, led by the International Agency for Research on Cancer (IARC), was established in response to an overwhelming need for high-quality cancer incidence data from low-income and middle-income countries. The IARC Regional Hub for cancer registration in North Africa, Central and West Asia was founded in 2013 to support capacity building for cancer registration in each of the countries in this region. In this Series paper, we advocate the necessity for tailored approaches to cancer registration given the rapidly changing cancer landscape for this region, and the challenges faced at a national level in developing data systems to help support this process given present disparities in resources and health infrastructure. In addition, we provide an overview of the status of cancer surveillance and activities country-by-country, documenting tailored approaches that are informing local cancer-control policy, and potentially curbing the growing cancer burden across the region.

The role of public health information in assistance to populations living in opposition and contested areas of Syria, 2012-2014

BACKGROUND

The Syrian armed conflict is the worst humanitarian tragedy this century. With approximately 470,000 deaths and more than 13 million people displaced, the conflict continues to have a devastating impact on the health system and health outcomes within the country. Hundreds of international and national non-governmental organisations, as well as United Nations agencies have responded to the humanitarian crisis in Syria. While there has been significant attention on the challenges of meeting health needs of Syrian refugees in neighbouring countries such as Jordan, Lebanon and Turkey, very little has been documented about the humanitarian challenges within Syria, between 2013 and 2014 when non-governmental organisations operated in Syria with very little United Nations support or leadership, particularly around obtaining information to guide health responses in Syria.

METHODS

In this study, we draw on our operational experience in Syria and analyse data collected for the humanitarian health response in contested and opposition-held areas of Syria in 2013-4 from Turkey, where the largest humanitarian operation for Syria was based. This is combined with academic literature and material from open-access reports.

RESULTS

Humanitarian needs have consistently been most acute in contested and opposition-held areas of Syria due to break-down of Government of Syria services and intense warfare. Humanitarian organisations had to establish de novo data collection systems independent of the Government of Syria to provide essential services in opposition-held and contested areas of Syria. The use of technology such as social media was vital to facilitating remote data collection in Syria as many humanitarian agencies operated with a limited operational visibility given chronic levels of insecurity. Mortality data have been highly politicized and extremely difficult to verify, particularly in areas highly affected by the conflict, with shifting frontlines, populations, and allegiances.

CONCLUSIONS

More investment in data collection and use, technological investment in the use of M- and E-health, capacity building and strong technical and independent leadership should be a key priority for the humanitarian health response in Syria and other emergencies. Much more attention should be also given for the treatment gap for non-communicable diseases including mental disorders.