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

Living with and managing type 1 diabetes in humanitarian settings: A qualitative synthesis of lived experience and stakeholder tacit knowledge

Humanitarian health actors are beginning to better consider and manage non-communicable diseases, such as diabetes, in emergency and protracted crisis settings. However, a focus on the more globally prevalent type 2 diabetes (T2D) dominates. Blind spots prevail in the unmet needs for type 1 diabetes (T1D), a chronic autoimmune condition where individuals are unable to produce insulin, thereby dependent on lifelong insulin therapy and blood glucose management. Although some T1D management requirements overlap with those of T2D, the immediate risk of fatal complications following insulin therapy disruption, the earlier age of onset during childhood, adolescence or young adulthood, and its lower prevalence compared to T2D within communities and local health systems mean that T1D requires nuanced consideration and targeted interventions. Intending to inform program and policy design for people with T1D (PWT1D), we synthesized themes of lived experience from PLWT1D and their caregivers, and the tacit working knowledge of health providers and policymakers in the context of local humanitarian operations. Through a strategic search of health databases (up to July 2023), we identified 11 articles that include interview excerpts from PWT1D, caregivers, healthcare providers and policymakers about T1D management in humanitarian settings. We used reflexive thematic analysis to guide data extraction, coding, and synthesis, resulting in the identification of four overarching themes: food and insulin security, family relations, knowledge translation, and response to diagnosis. The narratives highlight harsh trade-offs made by PWT1D and their families in the face of insulin and food insecurity, as well as the damaging impact of low T1D education in families, communities and health systems. Targeted family and community-based solutions are urgently required, alongside systemic reforms and international collaboration to enable better T1D coping and management in humanitarian settings.

Health Problems of Increasing Man-Made and Climate-Related Disasters on Forcibly Displaced populations: A Scoping Review on Global Evidence

Forcibly displaced populations are among the most vulnerable groups in disasters. They experience poorer health conditions compared with nondisplaced individuals. However, a clear picture is lacking regarding the overall health problems encountered by disaster-induced mid- to long-term displaced people. This study investigated these disorders prevalence and identified their correlates among long-settled displaced populations worldwide. The current scoping review follows the PRISMA-ScR guidelines; a systematic search was conducted on PubMed, Web of Science, and CINAHL and included original peer-reviewed studies, commentary, reviews, and grey literature published in English between January 1990 to June 2022. In the thematic and content analysis, the authors applied the narrative review approach to identify themes and sub-themes. Forty-eight documents were identified as fully relevant to this study. The largest number of published papers were from Asia, followed by the Middle East, the United States, and Europe. IDPs in developed countries were the most researched populations. Human-made disasters were addressed by 89% of the included studies. The four main thematic categories included were "physical health," "mental health," "inadequate facilities," and "lack of healthy behaviour." The worsening of noncommunicable diseases had the highest prevalence, followed by communicable diseases. Due to their condition, forcibly displaced migrants face a triple burden of communicable diseases and noncommunicable diseases such as mental health issues. Health-related research and policy need to consider the links among disasters, health problems, and forced migration as a determinant of health in the new era of climate change-driven displacements.

Multi-purpose cash transfers and health among vulnerable Syrian refugees in Jordan: A prospective cohort study

Cash assistance has rapidly expanded in the Syrian refugee response in Jordan and global humanitarian programming, yet little is known about the effect of multipurpose cash transfers (MPC) on health in humanitarian contexts. A prospective cohort study was conducted from May 2018 through July 2019 to evaluate the effectiveness of MPC in improving access to healthcare and health expenditures by Syrian refugees in Jordan. Households receiving MPCs (US$113-219 monthly) were compared to control households not receiving MPCs using difference-in-difference analyses. Overall health care-seeking was consistently high (>85%). Care-seeking for child illness improved among MPCs but declined among controls with a significant adjusted difference in change of 11.1% (P<0.05). In both groups, child outpatient visits significantly increased while emergency room visits decreased. Changes in care-seeking and medication access for adult acute illness were similar between groups; however, hospital admissions decreased among MPCs, yet increased among controls (-8.3% significant difference in change; P<0.05). There were no significant differences in change in chronic illness care utilization. Health expenditures were higher among MPCs at baseline and endline; the only significant difference in health expenditure measures' changes between groups was in borrowing money to pay for health costs, which decreased among MPCs and increased among controls with an adjusted difference in change of -10.3% (P<0.05). The impacts of MPC on health were varied and significant differences were observed for few outcomes. MPC significantly improved care-seeking for child illness, reduced hospitalizations for adult acute illness, and lowered rates of borrowing to pay for health expenditures. No significant improvements in chronic health condition indicators or shifts in sector of care-seeking were associated with MPC. While MPC should not be considered as a stand-alone health intervention, findings may be positive for humanitarian response financing given the potential for investment in MPC to translate to health sector response savings.

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.

Providing Quality of Care in Fragile and Vulnerable Settings: Lessons from South Sudan

BACKGROUND

In 2020, the World Health Organization (WHO) released a report concerning planning and actions to provide quality of care in fragile, conflict-affected, and vulnerable areas. South Sudan, the world's newest country, has encountered both natural and man-made disasters in recent years that have posed marked challenges to delivery of care. The Southern Sudan Healthcare Organization (SSHCO) operates as a non-governmental organization (NGO) in this setting, delivering and improving healthcare through war, flooding, and infectious outbreaks.

OBJECTIVE

The goal of this paper is to highlight the challenges faced in providing care in South Sudan from an NGO perspective and apply the recent WHO guidelines on quality of care to optimize practical implementation.

METHOD

Each of the WHO's eight elements for quality of care in South Sudan were examined in relation to the experience of SSHCO from 2013-2021. Analysis included: 1. summary of the WHO element; 2. examples of successful implementation; 3. barriers to implementation; and 4. recommendations to improve implementation.

FINDINGS

The team found that communication and coordination were the most important aspects of improving quality of care in South Sudan. These should be prioritized and include intergovernmental partners, the local and national Ministry of Health (MOH), NGOs, and community stakeholders. Communication and coordination should foster community engagement, improved data collecting and reporting, and sharing of publicly accessible information. Better clinical staff training and governance are also required to ensure the most effective use of limited resources.

CONCLUSION

South Sudan faces many barriers to quality of care with communication and coordination identified among the foremost issues. Practical application of the WHO elements of quality of care can assist NGOs in effectively identifying areas for improvement to deliver better quality essential health services.

Kidney disease profile and encountered problems during follow-up in Syrian refugee children: a multicenter retrospective study

BACKGROUND

Children are one of the most vulnerable groups in conflict zones, especially those with chronic diseases. This study aimed to investigate kidney disease profiles and problems during follow-up in a population of Syrian refugee children residing in Turkey.

METHODS

Syrian refugee children aged between 0 and 18 years were included in the study. Demographic data, diagnosis, particular interventions due to nephrological problems, and problems encountered during follow-up were obtained from all participating pediatric nephrology centers.

RESULTS

Data from 633 children from 22 pediatric nephrology centers were included. Mean age of the children was 94.8 ± 61.7 months and 375 were male (59%). 57.7% had parental consanguinity and 23.3% had a close relative(s) with kidney disease. The most common kidney diseases were congenital anomalies of the kidney and urinary tract (CAKUT) (31.0%), glomerular disease (19.9%), chronic kidney disease (CKD) (14.8%), and urolithiasis (10.7%). Frequent reasons for CAKUT were nonobstructive hydronephrosis (23.0%), vesico-ureteral reflux (18.4%), and neurogenic bladder (15.8%). The most common etiology of glomerular diseases was nephrotic syndrome (69%). Ninety-four children had CKD, and 58 children were on chronic dialysis. Six children had kidney transplantation. Surgical intervention was performed on 111 patients. The language barrier, lack of medical records, and frequent disruptions in periodic follow-ups were the main problems noted.

CONCLUSIONS

CAKUT, glomerular disease, and CKD were highly prevalent in Syrian refugee children. Knowing the frequency of chronic diseases and the problems encountered in refugees would facilitate better treatment options and preventive measures.

Healthcare system responses to non-communicable diseases’ needs of Syrian refugees: The cases of Jordan and Lebanon

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Hosting governments were moderately successful in providing health services to Syrian refugees through existing national health systems.

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Coverage and quality of care remain suboptimal and continuity is often interrupted due to inadequate implementation of national NCD guidelines, major government policy changes and UNHCR policy changes in cost sharing, eligibility, and vulnerability criteria which made the health system difficult to navigate. The latter are related to the lack of financing for NCDs at global level.

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There is a need for evidence-based guidelines and effective implementation models for continued NCD care in protracted emergency settings.

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Innovative financing solutions and increased advocacy for funding and prioritization of NCD care for refugees need to be envisioned.

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Strengthening existing national health systems and striving for equity in achieving universal health coverage for both nationals of host countries and refugees is imperative.

Introduction

Since the start of the Syrian conflict in 2011, Jordan and Lebanon have hosted large refugee populations, with a high pre-conflict burden of non-communicable diseases (NCDs). We aimed to explore NCD service provision to Syrian refugees in these two host countries and to identify lessons learned that may inform the global response to the changing health needs of refugees.

Methods

Between January 2017 and June 2018, we conducted 36 in-depth interviews with stakeholders from Jordan and Lebanon, as well as global stakeholders, to understand the context, the achievements, gaps and priorities in the provision and uptake of NCD prevention, testing and treatment services to Syrian refugees.

Findings

Both countries succeeded in embedding refugee health care within national health systems, yet coverage and quality of NCD health services offered to Syrian refugees in both contexts were affected by under-funding and consequent policy constraints. Changes in policies relating to cost sharing, eligibility and vulnerability criteria led to difficulties navigating the system and increased out-of-pocket payments for Syrians. Funding shortages were reported as a key barrier to NCD screening, diagnosis and management, including at the primary care level and referral from primary to secondary healthcare, particularly in Lebanon. These barriers were compounded by suboptimal implementation of NCD guidelines and high workloads for healthcare providers resulting from the large numbers of refugees.

Conclusions

Despite the extraordinary efforts made by host countries, provision and continuity of high quality NCD services at scale remains a tremendous challenge given ongoing funding shortfalls and lack of prioritization of NCD care for refugees. The development of innovative, effective and sustainable solutions is necessary to counter the threat of NCDs.

Improving diabetes control for Syrian refugees in Jordan: a longitudinal cohort study comparing the effects of cash transfers and health education interventions

Background

Cash transfers are an increasingly common intervention in the Syrian refugee response to meet basic needs, though there is little known of their potential secondary impact on health outcomes in humanitarian settings.

Methods

A quasi-experimental prospective cohort study was implemented from October 2018 through January 2020 to assess the effectiveness of multi-purpose cash (MPC), community health volunteer (CHV)-led education, combined with conditional cash transfers (CCT) with respect to health measures among Syrian refugees with type II diabetes in Jordan.

Results

CHV + CCT participants had the highest expenditures at endline and were the only group with statistically significant increases in payments for outpatient diabetes care (25.3%, P < 0.001) and monthly medication costs (13.6%, P < 0.001). Conversely, monthly spending on diabetes medication decreased significantly in the CHV only group (− 18.7%, P = 0.001) yet increased in the MPC and CHV + CCT groups. Expenditures on glucose monitoring increased in all groups but significantly more in the CHV + CCT group (39.2%, P < 0.001).

The proportion of participants reporting regular diabetes care visits increased significantly only in the CHV + CCT group (15.1%, P = 0.002). Specialist visits also increased among CHV + CCT participants (16.8%, P = 0.001), but decreased in CHV only participants (− 27.8%, P < 0.001). Decreases in cost-motivated provider selection (− 22.8%, P < 0.001) and not receiving all needed care because of cost (− 26.2%, P < 0.001) were significant only in the CHV + CCT group.

A small significant decrease in BMI was observed in the CHV + CCT group (− 1.0, P = 0.005). Decreases in HbA1C were significant in all groups with magnitudes ranging from − 0.2 to − 0.7%. The proportion of CHV + CCT participants with normal blood pressure increased significantly from baseline to endline by 11.3% (P = 0.007).

Conclusions

Combined conditional cash and health education were effective in improving expenditures, health service utilization, medication adherence, blood pressure, and diabetes control. The lower cost health education intervention was similarly effective in improving diabetes control, whereas unconditional cash transfers alone were least effective. Study findings suggest that conditional cash or combined cash and health education are promising strategies to support diabetes control among refugees and that where the purpose of MPC is to improve health outcomes, this alone is insufficient to achieve improvements in the health of refugees with diabetes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00380-7.

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.

Maternal marital status predicts self-reported stress among pregnant women following hurricane Florence

OBJECTIVES

The effects of stress caused by natural disasters may be more pronounced in individuals with preexisting disadvantages. The degree of hardship and psychological distress associated with Hurricane Florence was assessed in 83 pregnant women. This research helps identify unmarried pregnant women as a group particularly at risk of distress following a natural disaster.

METHODS

We assessed hardship associated with the hurricane using a questionnaire modeled on previous studies of stress due to natural disasters. We assessed distress using the Impact of Event Scale-Revised. We assessed social support and household food security using validated questionnaires. We used hierarchical linear regression to test predictors of distress marital status. Finally, we analyzed interactions between marital status and hardship, social support, and food security to examine whether these variables explained differences in distress among married and unmarried women.

RESULTS

Results indicated that unmarried women may be at higher risk of distress following natural disasters. Unmarried women were younger, had lower food security and education levels. We found no differences between experiences of hurricane-related hardship based on marital status. However, unmarried women were likely to have higher levels of distress following the hurricane. Hardship was a significant predictor of distress, but food security and social support were not significant predictors.

CONCLUSIONS

This study identifies unmarried pregnant women as a high risk/vulnerable group that may need additional support during emergencies. Taken together, this study further assesses how socially disadvantaged members of society may be unequally impacted by natural disasters.

Challenges to Transforming Unconventional Social Media Data into Actionable Knowledge for Public Health Systems During Disasters

Every year, there are larger and more severe disasters and health organizations are struggling to respond with services to keep public health systems running. Making decisions with limited health information can negatively affect response activities and impact morbidity and mortality. An overarching challenge is getting the right health information to the right health service personnel at the right time. As responding agencies engage in social media (eg, Twitter, Facebook) to communicate with the public, new opportunities emerge to leverage this non-traditional information for improved situational awareness. Transforming these big data is dependent on computers to process and filter content for health information categories relevant to health responders. To enable a more health-focused approach to social media analysis during disasters, 2 major research challenges should be addressed: (1) advancing methodologies to extract relevant information for health services and creating dynamic knowledge bases that address both the global and US disaster contexts, and (2) expanding social media research for disaster informatics to focus on health response activities. There is a lack of attention on health-focused social media research beyond epidemiologic surveillance. Future research will require approaches that address challenges of domain-aware, including multilingual language understanding in artificial intelligence for disaster health information extraction. New research will need to focus on the primary goal of health providers, whose priority is to get the right health information to the right medical and public health service personnel at the right time.

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.

How have researchers defined and used the concept of 'continuity of care' for chronic conditions in the context of resource-constrained settings? A scoping review of existing literature and a proposed conceptual framework

Background

Within the context of the growing burden of non-communicable diseases (NCDs) globally, there is limited evidence on how researchers have explored the response to chronic health needs in the context of health policy and systems in low- and middle-income countries. Continuity of care (CoC) is one concept that represents several elements of a long-term model of care. This scoping review aims to map and describe the state of knowledge regarding how researchers in resource-constrained settings have defined and used the concept of CoC for chronic conditions in primary healthcare.

Methods

This scoping review adopted the modified framework for interpretive scoping literature reviews. A systematic literature search in PubMed was performed, followed by a study selection process and data extraction, analysis and synthesis. Extracted data regarding the context of using CoC and the definition of CoC were analysed inductively to identify similar patterns; based on this, articles were divided into groups. MaxQDA was then used to re-code each article with themes according to the CoC definition to perform a cross-case synthesis under each identified group.

Results

A total of 55 peer-reviewed articles, comprising reviews or commentaries and qualitative or quantitative studies, were included. The number of articles has increased over the years. Five groups were identified as those (1) reflecting a change across stages or systems of care, (2) mentioning continuity or lack of continuity without a detailed definition, (3) researching CoC in HIV/AIDS programmes and its scaling up to support management of NCDs, (4) researching CoC in NCD management, and (5) measuring CoC with validated questionnaires.

Conclusion

Research or policy documents need to provide an explicit definition of CoC when this terminology is used. A framework for CoC is suggested, acknowledging three components for CoC (i.e. longitudinal care, the nature of the patient–provider relationship and coordinated care) while considering relevant contextual factors, particularly access and quality.

Electronic supplementary material

The online version of this article (10.1186/s12961-019-0426-1) contains supplementary material, which is available to authorized users.

Diabetes care in a complex humanitarian emergency setting: a qualitative evaluation

Background

Evidence is urgently needed from complex emergency settings to support efforts to respond to the increasing burden of diabetes mellitus (DM). We conducted a qualitative study of a new model of DM health care (Integrated Diabetic Clinic within an Outpatient Department [IDC-OPD]) implemented by Médecins Sans Frontières (MSF) in Mweso Hospital in eastern Democratic Republic of Congo (DRC). We aimed to explore patient and provider perspectives on the model in order to identify factors that may support or impede it.

Methods

We used focus group discussions (FGDs; two discussions, each with eight participants) and individual semi-structured qualitative interviews (seven patients and 10 staff) to explore experience of and perspectives on the IDC-OPD. Participants were recruited purposively to represent a range of DM disease severity and staff functions respectively, and to ensure the age and gender distribution was representative of the population of DM patients registered in the clinic. Data were coded in NVivo10© and analysed using an inductive thematic approach.

Results

There appears to be little awareness surrounding DM in patient communities, resulting in delays presenting to hospital. Patients describe their first reactions to symptoms as fear and confusion, often assuming symptoms are of another disease (e.g. HIV/AIDS). They often express disbelief that they could have DM (e.g. stating DM is a ‘rich man’s disease’) and lack acceptance that there is no cure. Patients experienced difficulty travelling to appointments, exacerbated by flare-ups in the conflict. Providing psycho-social and sensitisation activities in a group setting appears to offer an opportunity for patients to support each other in their effort to adhere to drug treatment and follow-up appointments. All patients reported great difficulty in adhering to the recommended diet, which was viewed as unaffordable and unavailable, and fear that this would be the biggest obstacle to maintaining their drug treatment (as treatment must be taken with food).

Conclusion

Our findings emphasize the importance of community awareness of DM and the value of treatment support, including psychosocial and educational support to DM patients and their families, and culturally sensitive, low-cost dietary advice, to ensuring the adoption and maintenance of DM treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2362-5) contains supplementary material, which is available to authorized users.

Maternal and Child Health of Internally Displaced Persons in Ukraine: A Qualitative Study

Due to the conflict that started in spring 2014 in Eastern Ukraine, a total of 1.75 million internally displaced persons (IDPs) fled the area and have been registered in government-controlled areas of the country. This paper explores perceived health, barriers to access to healthcare, caring practices, food security, and overall financial situation of mothers and young children displaced by the conflict in Ukraine. This is a qualitative study, which collected data through semi-structured in-depth interviews with nine IDP mothers via Skype and Viber with a convenience sample of participants selected through snowball technique. Contrary to the expectations, the perceived physical health of mothers and their children was found not to be affected by conflict and displacement, while psychological distress was often reported. A weak healthcare system, Ukraine’s proneness to informal payments, and heavy bureaucracy to register as an IDP were reported in our study. A precarious social safety net to IDP mothers in Ukraine, poor dietary diversity, and a generalized rupture of vaccine stocks, with halted or delayed vaccinations in children were identified. Increasing social allowances and their timely delivery to IDP mothers might be the most efficient policy measure to improve health and nutrition security. Reestablishment and sustainability of vaccine stocks in Ukraine is urgent to avoid the risks of a public health crisis. Offering psychological support for IDP mothers is recommended.

Mobilising a global response to hepatitis: Lessons learned from the HIV movement

Hepatitis caused by hepatitis B and C virus is increasingly becoming a significant global health threat, with widespread prevalence that may have severe disease and economic impacts in the future. Yet, preventative measures are not implemented universally and high costs of medicines limits treatment efforts. The global response to HIV/AIDS faced similar issues, but overcame them through a global movement that brought attention to the crisis and ultimately resulted in the creation and implementation of and access to better tools for HIV prevention and treatment. This also included effective policies and programmes behind and supporting the movement. Such could be done for hepatitis, specifically using lessons from the HIV response. Here, we will discuss the current and potentially severe future burden of hepatitis globally, the challenges in addressing this epidemic, and how principles applied from the global HIV response can facilitate a successful and similar hepatitis movement.