Cohort monitoring of persons with hypertension: an illustrated example from a primary healthcare clinic for Palestine refugees in Jordan

Adoption of Electronic Medical Records for Chronic Disease Care in Kenyan Refugee Camps: Quantitative and Qualitative Prospective Evaluation

Background

Noncommunicable disease (NCD) prevention and control in humanitarian emergencies is a well-recognized need, but there is little evidence to guide responses, leading to varying care delivery. The Sana.NCD mobile health (mHealth) app, initially developed in Lebanon, is the only known mHealth tool for NCD management designed to increase care quality and coverage for providers in humanitarian settings.

Objective

We evaluated a specialized mHealth app consisting of an abbreviated medical record for patients with hypertension or diabetes, adapted for a Kenyan refugee camp setting.

Methods

We tested an adapted version of the Sana.NCD app (diabetes and hypertension medical record) in an 11-month (May 2021 to March 2022) quantitative and qualitative prospective evaluation in Kenya's Hagadera refugee camp. Leveraging the rollout of a general electronic medical record (EMR) system in the Kakuma refugee camp, we compared a specialized NCD management app to a general EMR. We analyzed secondary data collected from the Sana.NCD app for 1539 patients, EMR data for 68 patients with NCD from Kakuma's surgical and outpatient departments, and key informant interviews that focused on Hagadera clinic staff perceptions of the Sana.NCD app.

Results

The Hagadera NCD clinic reported 18,801 consultations, 42.1% (n=7918) of which were reported in the NCD app. The Kakuma EMR reported 350,776 visits, of which 9385 (2.7%) were for NCDs (n=4264, 1.2% hypertension; n=2415, 0.7% diabetes). The completeness of reporting was used as a quality-of-care metric. Age, sex, prescribed medicines, random blood sugar, and smoking status were consistently reported in both the NCD app (>98%) and EMR (100%), whereas comorbidities, complications, hemoglobin A1c, and diet were rarely reported in either platform (≤7% NCD app; 0% EMR). The number of visits, BMI, physical activity, and next visit were frequently reported in the NCD app (≥99%) but not in the EMR (≤15%). In the NCD app, the completeness of reporting was high across the implementation period, with little meaningful change. Although not significantly changed during the study, elevated blood sugar (P=.82) and blood pressure (P=.12) were reported for sizable proportions of patients in the first (302/481, 62.8%, and 599/1094, 54.8%, respectively) and last (374/602, 62.1%, and 720/1395, 51.6%, respectively) study quarters. Providers were satisfied with the app, as it standardized patient information and made consultations easier. Providers also indicated that access to historic patient information was easier, benefiting NCD control and follow-up.

Conclusions

A specialized record for NCDs outperformed a more general record intended for use in all patients in terms of reporting completeness. This CommCare-based NCD app can easily be rolled out in similar humanitarian settings with minimal adaptation. However, the adaptation of technologies to the local context and use case is critical for uptake and ensuring that workflows and time burden do not outweigh the benefits of EMRs.

Managing hypertension in a Rohingya refugee camp: a brief report

Non-communicable diseases have overtaken communicable diseases as the most common cause of death worldwide, with the majority of these deaths in low-income and middle-income countries. Hypertension alone causes over nine million deaths per year.Since 2017, around 750 000 Rohingya refugees have fled violence in Myanmar into Cox's Bazar District in Bangladesh. We describe a quality improvement project focused on the management of hypertension in Rohingya refugees in three primary health facilities within the Rohingya refugee camps. The aim of the project was to create a sustainable hypertension service within existing primary care services.A number of plan-do-study-act cycles were performed to improve care, with methods including: creating a specialised clinic, writing a treatment algorithm, training of pharmacists, engaging community health workers and educational programmes for staff and patients.In 2020, 554 patients were engaged in the new hypertension service. Of these, 358 (64.6%) returned for follow-up at least once. Mean systolic blood pressure (BP) was 141.7 (SD 60.0) mm Hg and mean diastolic BP was 88.1 (SD 11.1) mm Hg. Patients engaged in treatment had a significant reduction of BP of 8.2 (95% CI 5.4 to 11.0)/6.0 (95% CI 4.1 to 7.9) mm Hg (p<0.0001).Our project shows that it is possible to create a hypertension service in a challenging humanitarian crisis, which can successfully improve the control of hypertension, although retention in care can be difficult.

Systematic review of electronic health records to manage chronic conditions among displaced populations

OBJECTIVES

The objective of this study was to assess the impact of electronic health records (EHRs) on health outcomes and care of displaced people with chronic health conditions and determine barriers and facilitators to EHR implementation in displaced populations.

DESIGN

A systematic review protocol was developed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Systematic Reviews.

DATA SOURCES

MEDLINE, Embase, PsycINFO, CINAHL, Health Technology Assessment, Epub Ahead of Print, In-Process and Other Non-Indexed Citations, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews was searched from inception to 12 April 2021.

ELIGIBILITY CRITERIA FOR SELECTED STUDIES

Inclusion criteria were original research articles, case reports and descriptions of EHR implementation in populations of displaced people, refugees or asylum seekers with related chronic diseases. Grey literature, reviews and research articles unrelated to chronic diseases or the care of refugees or asylum populations were excluded. Studies were assessed for risk of bias using a modified Cochrane, Newcastle-Ottawa and Joanna Briggs Institute tools.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data from each study using Covidence. Due to heterogeneity across study design and specific outcomes, a meta-analysis was not possible. An inductive thematic analysis was conducted using NVivo V.12 (QSR International, Melbourne, Australia). An inductive analysis was used in order to uncover patterns and themes in the experiences, general outcomes and perceptions of EHR implementation.

RESULTS

A total of 32 studies across nine countries were included: 14 in refugee camps/settlements and 18 in asylum countries. Our analysis suggested that EHRs improve health outcomes for chronic diseases by increasing provider adherence to guidelines or treatment algorithms, monitoring of disease indicators, patient counselling and patient adherence. In asylum countries, EHRs resource allocation to direct clinical care and public health services, as well as screening efforts. EHR implementation was facilitated by their adaptability and ability to integrate into management systems. However, barriers to EHR development, deployment and data analysis were identified in refugee settings.

CONCLUSION

Our results suggest that well-designed and integrated EHRs can be a powerful tool to improve healthcare systems and chronic disease outcomes in refugee settings. However, attention should be paid to the common barriers and facilitating actions that we have identified such as utilising a user-centred design. By implementing adaptable EHR solutions, health systems can be strengthened, providers better supported and the health of refugees improved.

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

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

Factors Influencing the Implementation of Remote Delivery Strategies for Non-Communicable Disease Care in Low- and Middle-Income Countries: A Narrative Review

Objectives: The COVID-19 pandemic has disrupted health care for non-communicable diseases (NCDs) and necessitated strategies to minimize contact with facilities. We aimed to examine factors influencing implementation of remote (non-facility-based) delivery approaches for people with hypertension and/or diabetes in low- and middle-income countries (LMICs), to inform NCD care delivery during health service disruption, including humanitarian crises.

Methods: Our narrative review used a hermeneutic and purposive approach, including primary studies conducted in LMICs, which assessed implementation factors influencing remote NCD care delivery. Results were analyzed using the Consolidated Framework for Implementation Research.

Results: Twenty-eight included studies revealed the strong influence of both internal organizational and broader contextual factors, such as community health worker policies or technological environment. Addressing patients’ specific characteristics, needs and resources was important for implementation success.

Conclusion: This review highlighted the multiple, complex, interdependent factors influencing implementation of remote NCD care in LMICs. Our findings may inform actors designing NCD care delivery in contexts where facility-based access is challenging. Implementation research is needed to evaluate context-adapted e-Health, community-based, and simplified clinical management strategies to facilitate remote NCD care.

Vulnerabilities of Arab refugees in primary health care: a scoping review

OBJECTIVE

To map and analyze the vulnerabilities of Arab refugees in the context of primary health care.

METHOD

Scoping review in which studies published in English, Spanish and Portuguese languages from 2011 onwards were reviewed. The following databases were surveyed: Cochrane, Scopus, Health System Evidence, MedLine-PubMed, CINAHL, Embase, Lilacs, Web of Science, SciELO, NYAM Grey Literature, BVS, Capes Thesis and Dissertation Database, Refworld and Journal of Refugee Studies. Data were analyzed in light of the concept of vulnerability.

RESULTS

Of the 854 studies identified, 40 articles were held for analysis and extraction of vulnerability indicators in the individual, social and programmatic dimensions. Regarding the individual dimension, the main indicators identified were unemployment, unstable and overcrowded housing, lack of sanitation and access to water, mental disorders, communicable and chronic noncommunicable diseases, etc. In the programmatic dimension, were identified, mainly, health teams with work overload, lack of preparation to deal with cultural and linguistic barriers, and delays in providing care. In relation to the social dimension, lack of access to schools, to information about health programs in the host countries, and to rights, among others, were found.

CONCLUSION

Vulnerabilities found highlight the disadvantage of refugees regarding health programs, services and system in host countries, in addition to highlighting the deep inequalities that affect this group. It is pointed out the need for programs and policies that promote actions, within the scope of primary health care, which recognize and respond to the health needs of refugees.

A free, open-source, offline digital health system for refugee care (Preprint)

Background

Objective

Methods

Results

Conclusions

A systematic review of the burden of hypertension, access to services and patient views of hypertension in humanitarian crisis settings

INTRODUCTION

Globally, a record number of people are affected by humanitarian crises caused by conflict and natural disasters. Many such populations live in settings where epidemiological transition is underway. Following the United Nations high level meeting on non-communicable diseases, the global commitment to Universal Health Coverage and needs expressed by humanitarian agencies, there is increasing effort to develop guidelines for the management of hypertension in humanitarian settings. The objective was to investigate the prevalence and incidence of hypertension in populations directly affected by humanitarian crises; the cascade of care in these populations and patient knowledge of and attitude to hypertension.

METHODS

A literature search was carried out in five databases. Grey literature was searched. The population of interest was adult, non-pregnant, civilians living in any country who were directly exposed to a crisis since 1999. Eligibility assessment, data extraction and quality appraisal were carried out in duplicate.

RESULTS

Sixty-one studies were included in the narrative synthesis. They reported on a range of crises including the wars in Syria and Iraq, the Great East Japan Earthquake, Hurricane Katrina and Palestinian refugees. There were few studies from Africa or Asia (excluding Japan). The studies predominantly assessed prevalence of hypertension. This varied with geography and age of the population. Access to care, patient understanding and patient views on hypertension were poorly examined. Most of the studies had a high risk of bias due to methods used in the diagnosis of hypertension and in the selection of study populations.

CONCLUSION

Hypertension is seen in a range of humanitarian settings and the burden can be considerable. Further studies are needed to accurately estimate prevalence of hypertension in crisis-affected populations throughout the world. An appreciation of patient knowledge and understanding of hypertension as well as the cascade of care would be invaluable in informing service provision.

Delivering non-communicable disease interventions to women and children in conflict settings: a systematic review

Background

Non-communicable diseases (NCDs) are the leading cause of death worldwide. In the context of conflict settings, population displacement, disrupted treatment, infrastructure damage and other factors impose serious NCD intervention delivery challenges, but relatively little attention has been paid to addressing these challenges. Here we synthesise the available indexed and grey literature reporting on the delivery of NCD interventions to conflict-affected women and children in low- and middle-income countries (LMICs).

Methods

A systematic search in MEDLINE, Embase, CINAHL and PsycINFO databases for indexed articles published between 1 January 1990 and 31 March 2018 was conducted, and publications reporting on NCD intervention delivery to conflict-affected women or children in LMICs were included. A grey literature search of 10 major humanitarian organisation websites for publications dated between 1 January 2013 and 30 November 2018 was also conducted. We extracted and synthesised information on intervention delivery characteristics and delivery barriers and facilitators.

Results

Of 27 included publications, most reported on observational research studies, half reported on studies in the Middle East and North Africa region and 80% reported on interventions targeted to refugees. Screening and medication for cardiovascular disease and diabetes were the most commonly reported interventions, with most publications reporting facility-based delivery and very few reporting outreach or community approaches. Doctors were the most frequently reported delivery personnel. No publications reported on intervention coverage or on the effectiveness of interventions among women or children. Limited population access and logistical constraints were key delivery barriers reported, while innovative technology use, training of workforce and multidisciplinary care were reported to have facilitated NCD intervention delivery.

Conclusion

Large and persistent gaps in information and evidence make it difficult to recommend effective strategies for improving the reach of quality NCD care among conflict-affected women and children. More rigorous research and reporting on effective strategies for delivering NCD care in conflict contexts is urgently needed.

PROSPERO registration number

CRD42019125221

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.

UNRWA's role in promoting health outcomes of Palestinian refugees in Jordan: A systematic literature review

INTRODUCTION

The mandate of the United Nations Relief and Work Agency in the Near East (UNRWA) includes education and health services of registered Palestinian refugees in Jordan and other countries. UNRWA is facing limited funding because of unstable political circumstances. This review aims to spotlight the importance of UNRWA's role in promoting Palestinian refugees' health inside and outside camps in Jordan.

METHOD

This systematic review was conducted through iteratively searching electronic research databases for original, recent, full-text literature regarding the health and social outcomes of Palestinian refugees in Jordan.

RESULTS

The 12 reviewed studies showed that UNRWA's programs through its clinics and schools have a crucial role in improving Palestinian refugees' health outcomes such as adolescents' cigarette smoking prevalence, infant mortality, non-communicable disease management, health-related quality of life, mental/psychological health services, and reproductive health. Access to UNRWA's health services may account for better or comparable health outcomes among Palestinian refugees.

CONCLUSION

Despite the short funding and political pressures, UNRWA has provided aid and services to Palestinian refugees inside and outside refugee camps in Jordan. UNRWA's role is crucial in maintaining decent health outcomes in this vulnerable, underserved population. The further limiting of UNRWA funding may jeopardize the health of millions.

Epidemiology and management of hypertension among refugees in the Middle East: a review of the literature

This review aims to explore the burden of hypertension among refugees in the Middle East by reporting its prevalence, risk factors and access to care. A comprehensive literature search was performed using Web of Science, Ovid MEDLINE, PubMed, SCOPUS, CINHAL+, WHO Regional Office for the Eastern Mediterranean (EMRO) and United Nations High Commissioner for Refugees (UNHCR) on articles spanning from 1948 until 2020. Most studies were cross-sectional in design. After applying eligibility criteria 17 articles and 4 reports were included. Findings showed that hypertension represents a major burden among refugees. Hypertension risk factors present among the refugee population included increased salt intake, physical inactivity, and smoking. The majority of hypertensive refugees sought care for their condition at the public health care services. Barriers to seeking care included high cost of healthcare, accessibility to provided services, and lack of knowledge for the need to seek care. Non-adherence to medication among refugees was primarily linked to cost and lack of symptoms. This review highlights the need for further studies to shed light on the importance of targeting hypertension among refugees, to lower morbidity and mortality, in addition to providing adequate healthcare services to this population.

Clinical outcomes in a primary-level non-communicable disease programme for Syrian refugees and the host population in Jordan: A cohort analysis using routine data

BACKGROUND

Little is known about the content or quality of non-communicable disease (NCD) care in humanitarian settings. Since 2014, Médecins Sans Frontières (MSF) has provided primary-level NCD services in Irbid, Jordan, targeting Syrian refugees and vulnerable Jordanians who struggle to access NCD care through the overburdened national health system. This retrospective cohort study explored programme and patient-level patterns in achievement of blood pressure and glycaemic control, patterns in treatment interruption, and the factors associated with these patterns.

METHODS AND FINDINGS

The MSF multidisciplinary, primary-level NCD programme provided facility-based care for cardiovascular disease, diabetes, and chronic respiratory disease using context-adapted guidelines and generic medications. Generalist physicians managed patients with the support of family medicine specialists, nurses, health educators, pharmacists, and psychosocial and home care teams. Among the 5,045 patients enrolled between December 2014 and December 2017, 4,044 eligible adult patients were included in our analysis, of whom 72% (2,913) had hypertension and 63% (2,546) had type II diabetes. Using visits as the unit of analysis, we plotted the following on a monthly basis: mean blood pressure among hypertensive patients, mean fasting blood glucose and HbA1c among type II diabetic patients, the proportion of each group achieving control, mean days of delayed appointment attendance, and the proportion of patients experiencing a treatment interruption. Results are presented from programmatic and patient perspectives (using months since programme initiation and months since cohort entry/diagnosis, respectively). General linear mixed models explored factors associated with clinical control and with treatment interruption. Mean age was 58.5 years, and 60.1% (2,432) were women. Within the programme's first 6 months, mean systolic blood pressure decreased by 12.4 mm Hg from 143.9 mm Hg (95% CI 140.9 to 146.9) to 131.5 mm Hg (95% CI 130.2 to 132.9) among hypertensive patients, while fasting glucose improved by 1.12 mmol/l, from 10.75 mmol/l (95% CI 10.04 to 11.47) to 9.63 mmol/l (95% CI 9.22 to 10.04), among type II diabetic patients. The probability of achieving treatment target in a visit was 63%-75% by end of 2017, improving with programme maturation but with notable seasonable variation. The probability of experiencing a treatment interruption declined as the programme matured and with patients' length of time in the programme. Routine operational data proved useful in evaluating a humanitarian programme in a real-world setting, but were somewhat limited in terms of data quality and completeness. We used intermediate clinical outcomes proven to be strongly associated with hard clinical outcomes (such as death), since we had neither the data nor statistical power to measure hard outcomes.

CONCLUSIONS

Good treatment outcomes and reasonable rates of treatment interruption were achieved in a multidisciplinary, primary-level NCD programme in Jordan. Our approach to using continuous programmatic data may be a feasible way for humanitarian organisations to account for the complex and dynamic nature of interventions in unstable humanitarian settings when undertaking routine monitoring and evaluation. We suggest that frequency of patient contact could be reduced without negatively impacting patient outcomes and that season should be taken into account in analysing programme performance.

Sijilli: A Scalable Model of Cloud-Based Electronic Health Records for Migrating Populations in Low-Resource Settings

The world is witnessing an alarming rate of displacement and migration, with more than 70.8 million forcibly displaced individuals, including 26 million refugees. These populations are known to have increased vulnerability and susceptibility to mental and physical health problems due to the migration journey. Access of these individuals to health services, whether during their trajectory of displacement or in refugee-hosting countries, remains limited and challenging due to multiple factors, including language and cultural barriers and unavailability of the refugees' health records. Cloud-based electronic health records (EHRs) are considered among the top five health technologies integrated in humanitarian crisis preparedness and response during times of conflict. This viewpoint describes the design and implementation of a scalable and innovative cloud-based EHR named Sijilli, which targets refugees in low-resource settings. This paper discusses this solution compared with other similar practices, shedding light on its potential for scalability.

Strengthening Primary Health-Care Services to Help Prevent and Control Long-Term (Chronic) Non-Communicable Diseases in Low- and Middle-Income Countries

The prevalence of long-term (chronic) non-communicable diseases (NCDs) is increasing globally due to an ageing global population, urbanization, changes in lifestyles, and inequitable access to healthcare. Although previously more common in high- and upper-middle-income countries, lower-middle-income countries (LMICs) are more affected, with NCDs in LMICs currently accounting for 85–90% of premature deaths among 30–69 years old. NCDs have both high morbidity and mortality and high treatment costs, not only for the diseases themselves but also for their complications. Primary health care (PHC) services are a vital component in the prevention and control of long-term NCDs, particularly in LMICs, where the health infrastructure and hospital services may be under strain. Drawing from published studies, this review analyses how PHC services can be utilized and strengthened to help prevent and control long-term NCDs in LMICs. The review finds that a PHC service approach, which deals with health in a comprehensive way, including the promotion, prevention, and control of diseases, can be useful in both high and low resource settings. Further, a PHC based approach also provides opportunities for communities to better access appropriate healthcare, which ensures more significant equity, efficiency, effectiveness, safety, and timeliness, empowers service users, and helps healthcare providers to achieve better health outcomes at lower costs.

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Cardiovascular diseases and their risk factors among Syrian refugees in Turkey

BACKGROUND

Information on the world distribution of cardiovascular disease and its risk factors in refugees/migrants is not available at the same rate for all countries or for different ethnic and socioeconomic groups. Today, Syria's humanitarian catastrophe has become a public health concern, which cannot be ignored.

METHODS

A search was conducted across PubMed and Google Scholar for papers on cardiovascular diseases among refugees/migrants worldwide with a focus on Syrian in Turkey.

RESULTS

The total number of papers identified through the database searches and from reference lists was 486. Of these, 62 were found to be relevant after further screening. A further 42 papers were considered not eligible after full-text, language and data assessments, resulting in a final 20 papers included in the qualitative analysis. These studies discussed several major themes: cardiovascular diseases and their risk factors among refugees/migrants, the effects of changing living conditions on refugees/migrants, the effects of psychological and socioeconomic factors, and the prevention and treatment of cardiovascular diseases in refugees/migrants. The risk of cardiovascular disease varied by country of origin, country of destination, and duration of residence. The findings suggest that cardiovascular diseases and their risk factors are increased for Syrian refugees in Turkey.

CONCLUSION

Raising awareness, prevention, early detection, and good management as well as monitoring and reporting of risk factors are the key components to controlling cardiovascular diseases in refugees. Further studies and greater acquisition of survey data are urgently needed.

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.

The burden of diabetes and use of diabetes care in humanitarian crises in low-income and middle-income countries

Human suffering as a result of natural disasters or conflict includes death and disability from non-communicable diseases, including diabetes, which have largely been neglected in humanitarian crises. The objectives of this Series paper were to examine the evidence on the burden of diabetes, use of health services, and access to care for people with diabetes among populations affected by humanitarian crises in low-income and middle-income countries, and to identify research gaps for future studies. We reviewed the scientific literature on this topic published between 1992 and 2018. The results emphasise that the burden of diabetes in humanitarian settings is not being captured, clinical guidance is insufficient, and diabetes is not being adequately addressed. Crisis-affected populations with diabetes face enormous constraints accessing care, mainly because of high medical costs. Further research is needed to characterise the epidemiology of diabetes in humanitarian settings and to develop simplified, cost-effective models of care to improve the delivery of diabetes care during humanitarian crises.

Health records for migrants and refugees: A systematic review

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSIONS

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

Burden of non-communicable diseases among Syrian refugees: a scoping review

Background

The scarcity of evidence-based research on non-communicable diseases (NCDs) among Syrian refugees has hampered efforts to address the high burden of these diseases in host countries. The objective of this study is to examine published research on NCDs among Syrian refugees in order to inform future research, practice, programs, and policy. .

Methods

Using the scoping review framework proposed by Arksey et al., 17 different databases were searched to identify studies reporting on NCDs among Syrian refugees. The number of relevant documents found was 34, with the earliest going back to 2013—2 years after the beginning of the Syrian conflict.

Results

The majority of these documents were descriptive in nature and only two studies addressed the effectiveness of interventions in the management of NCDs. No studies investigated the prevention of these diseases. Furthermore, only 7 studies addressed the host community and only one research article, conducted in Lebanon, included subjects from the host community. The increasing number of documents over the past 5 years illustrates a growing interest in studying NCDs among Syrian refugees. Examination of the papers showed high prevalence of NCDs among Syrian refugees as well as unmet healthcare needs.

Conclusion

The findings of this review highlighted the dire need for further research on the burden of NCDs among Syrian refugees. Future studies should diversify research design to include interventions, address the host community in addition to the refugees, tackle prevention as well as treatment of NCDs, and explore strategies to enhance the resilience of the host country’s health system while ensuring quality of care for NCDs. The increasing momentum for research found in this review presents an opportunity to fill current knowledge gaps, which could result in preventing, controlling and ultimately reducing the burden of NCDs among Syrian refugees and their host communities.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6977-9) contains supplementary material, which is available to authorized users.

Diabetes care in public health facilities in India: a situational analysis using a mixed methods approach

BACKGROUND

Weak public health systems have been identified as major bottlenecks in providing good quality diabetic care in low- and middle-income countries.

METHODOLOGY

The present study assessed diabetic care services at public health facilities across six districts in three states of India using a mixed methods approach. The study described diabetes care services available at public health facilities and identified challenges and solutions needed to tackle them. The quantitative component included assessment of availability of services and resources, whilst the qualitative component was comprised of semistructured interviews with health care providers and persons with diabetes to understand the pathway of care.

RESULTS

A total of 30 health facilities were visited: five tertiary; eight secondary and 17 primary health facilities. Patient clinical records were not maintained at the facilities; the onus was on patients to keep their own clinical records. All had the facility for blood glucose measurement, but HbA1c estimation was available only at tertiary centers. None of the primary health centers in the three states provided HbA1c estimation, lipid examination, or foot care. Lifestyle modification support was available in only a few tertiary facilities. Antidiabetic drugs (biguanides and sulphonyl ureas) were available in most facilities, and given for 14 days. Insulin and statins were available only at secondary and tertiary care centers. Forty-two physicians were interviewed and poor follow-up, patient overload, and lack of specialized training were the major barriers that emerged from the interview responses. A total of 37 patients were interviewed. Patients had to visit tertiary facilities for drugs and routine follow-up, thereby congesting the facilities. There was no formal referral or follow-up mechanism to link patients to decentralized facilities.

CONCLUSION

There is a wide gap between effective diabetes management practices and their implementation. There should be a greater role of secondary care facilities in follow-up investigations and screening for complications. A holistic diabetic care package with a robust recording and cohort monitoring system and adequate referral mechanism is needed.

Approaches to Improve the Surveillance, Monitoring, and Management of Noncommunicable Diseases in HIV-Infected Persons: Viewpoint

Low-income and middle-income countries (LMICs) are undergoing an epidemiological transition, in which the burden of noncommunicable diseases (NCDs) is rising and mortality will shift from infectious diseases to NCDs. Specifically, cardiovascular disease, diabetes, renal diseases, chronic respiratory diseases, and cancer are becoming more prevalent. In some regions, particularly sub-Saharan Africa, the dual HIV and NCD epidemics will pose challenges because their joint burden will have adverse effects on the quality of life and will likely increase global inequities. Given the austere clinical infrastructure in many LMICs, innovative models of care delivery are needed to provide comprehensive care in resource-limited settings. Improved data collection and surveillance of NCDs among HIV-infected persons in LMICs are necessary to inform integrated NCD-HIV prevention, care, and treatment models that are effective across a range of geographic settings. These efforts will preserve the considerable investments that have been made to prevent the number of lives lost to HIV, promote healthy aging of persons living with HIV, and contribute to meeting United Nations Sustainable Development Goals.

Crisis-Affected Populations and Tuberculosis

By definition, humanitarian crises can severely affect human health, directly through violence or indirectly through breakdown of infrastructure or lack of provision for basic human needs, such as safe shelter, food, clean water, and suitable clothing. After the initial phase, these indirect effects are the most important determinants of morbidity and mortality in humanitarian emergencies, and infectious diseases are among the most significant causes of ill health. Tuberculosis (TB) incidence in humanitarian emergencies varies depending on a number of factors, including the country background epidemiology, but will be elevated compared with precrisis levels. TB morbidity and mortality are associated with access to appropriate care and medications, and will also be elevated due to barriers to access to diagnosis and appropriate treatment, including robust TB drug supplies. While reestablishment of TB control is challenging in the early phases, successful treatment programs have been previously established, and the WHO has issued guidance on establishing such successful programs. Such programs should be closely linked to other health programs and established in close collaboration with the country's national treatment program. Individuals who flee the emergency also have a higher TB risk and can face difficulties accessing care en route to or upon arrival in host countries. These barriers, often associated with treatment delays and worse outcomes, can be the result of uncertainties around legal status, other practical challenges, or lack of health care worker awareness. It is important to recognize and mitigate these barriers with an increasing number of tools now available and described.

Non-communicable diseases in the Western Area District, Sierra Leone, before and during the Ebola outbreak

Setting: Twenty-seven peripheral health units, five secondary hospitals and one tertiary hospital, Western Area District, Sierra Leone. Objectives: To describe reporting systems, monthly attendances and facility-based patterns of six non-communicable diseases (NCDs) in the pre-Ebola and Ebola virus disease outbreak periods. Design: A cross-sectional study using programme data. Results: Reporting was 89% complete on the six selected NCDs pre-Ebola and 86% during the Ebola outbreak (P < 0.01). Overall, marked declining trends in NCDs were reported during the Ebola period, with a monthly mean of 342 cases pre-Ebola and 164 during the Ebola outbreak. The monthly mean number of cases per disease in the pre-Ebola and Ebola outbreak periods was respectively 228 vs. 85 for hypertension, 43 vs. 27 for cardiovascular diseases, 36 vs. 18 for diabetes and 25 vs. 29 for peptic ulcer disease; this last condition increased during the outbreak. There were higher proportions of NCDs among females during the Ebola outbreak compared with the pre-Ebola period. Except for peptic ulcer disease, the number of patients with NCDs declined by 25% in peripheral health units, 91% in the secondary hospitals and 70% in the tertiary hospital between the pre-Ebola and the Ebola outbreak periods. Conclusion: Comprehensive reporting of NCDs was suboptimal, and declined during the Ebola epidemic. There were decreases in reported attendances for NCDs between the pre-Ebola and the Ebola outbreak periods, which were even more marked in the hospitals. This study has important policy implications.

Pilot Testing and Implementation of a mHealth tool for Non-communicable Diseases in a Humanitarian Setting

Introduction.

Given the protracted nature of the crisis in Syria, national and international assistance agencies face immense challenges in providing for the needs of refugees and the host Lebanese due to the high burden of noncommunicable diseases (NCDs) among both populations. These are complex conditions to manage, and the resources for refugee care limited, having dramatic implications for Lebanon’s health system.

Methods.

A longitudinal cohort study was implemented from January 2015 through August 2016 to evaluate the effectiveness of treatment guidelines and an mHealth application on quality of care and health outcomes for patients in primary health care facilities in Lebanon serving Syrian refugees and host communities.

Results.

Overall, reporting in clinic medical records remained low, however, during the mHealth phase recording of BMI and blood pressure were significantly greater in the mHealth application as compared to clinic medical records. Patient exit interviews reported a much more frequent measurement of weight, height, blood pressure, and blood glucose, suggesting these may be assessed more often than they are recorded. Satisfaction with the clinic visit improved significantly during implementation of the mHealth application as compared to both baseline and guidelines implementation in all measures. Despite positive changes, provider uptake of the application was low; patients indicated that the mHealth application was used in a minority (21.7%) of consultations. Provider perspectives on how the application changed patient interactions were mixed.

Discussion.

Similar to previous evidence, this study further demonstrates the need to incorporate new interventions with existing practices and reporting requirements to minimize duplication of efforts and, consequently, strengthen provider usage. Additional research is needed to identify organizational and provider-side factors associated with uptake of similar applications, particularly in complex settings, to optimize the benefit of such tools.

Challenges to conducting epidemiology research in chronic conflict areas: examples from PURE- Palestine

Little has been written on the challenges of conducting research in regions or countries with chronic conflict and strife. In this paper we share our experiences in conducting a population based study of chronic diseases in the occupied Palestinian territory and describe the challenges faced, some of which were unique to a conflict zone area, while others were common to low- and middle- income countries. After a short description of the situation in the occupied Palestinian territory at the time of data collection, and a brief overview of the design of the study, the challenges encountered in working within a fragmented health care system are discussed. These challenges include difficulties in planning for data collection in a fragmented healthcare system, standardizing data collection when resources are limited, working in communities with access restricted by the military, and considerations related to the study setting. Ways of overcoming these challenges are discussed. Conducting epidemiological research can be very difficult in some parts of our turbulent world, but data collected from such regions may contrast with those solely from politically and economically more stable regions. Therefore, special efforts to collect epidemiologic data from regions engulfed by strife, while challenging are essential.

Managing and monitoring chronic non-communicable diseases in a primary health care clinic, Lilongwe, Malawi

SETTING

Patients with chronic non-communicable diseases attending a primary health care centre, Lilongwe, Malawi.

OBJECTIVE

Using an electronic medical record monitoring system, to describe the quarterly and cumulative disease burden, management and outcomes of patients registered between March 2014 and June 2015.

DESIGN

A cross-sectional study.

RESULTS

Of 1135 patients, with new registrations increasing each quarter, 66% were female, 21% were aged ⩾65 years, 20% were obese, 53% had hypertension alone, 18% had diabetes alone, 12% had asthma, 10% had epilepsy and 7% had both hypertension and diabetes. In every quarter, about 30% of patients did not attend the clinic and 19% were registered as lost to follow-up (not seen for ⩾1 year) in the last quarter. Of those attending, over 90% were prescribed medication, and 80-90% with hypertension and/or diabetes had blood pressure/blood glucose measured. Over 85% of those with epilepsy had no seizures and 60-75% with asthma had no severe attacks. Control of blood pressure (41-51%) and diabetes (15-38%) was poor.

CONCLUSION

It is feasible to manage patients with non-communicable diseases in a primary health care setting in Malawi, although more attention is needed to improve clinic attendance and the control of hypertension and diabetes.

The Effectiveness of Interventions for Non-Communicable Diseases in Humanitarian Crises: A Systematic Review

Background

Non-communicable diseases (NCDs) are of increasing concern in low- and middle-income countries (LMICs) affected humanitarian crises. Humanitarian agencies and governments are increasingly challenged with how to effectively tackle NCDs. Reviewing the evidence of interventions for NCDs in humanitarian crises can help guide future policies and research by identifying effective interventions and evidence gaps. The aim of this paper is to systematically review evidence on the effectiveness of interventions targeting NCDs during humanitarian crises in LMICs.

Methods

A systematic review methodology was followed using PRISMA standards. Studies were selected on NCD interventions with civilian populations affected by humanitarian crises in low- and middle-income countries. Five bibliographic databases and a range of grey literature sources were searched. Descriptive analysis was applied and a quality assessment conducted using the Newcastle-Ottawa Quality Assessment Scale for observational studies and the Cochrane Risk of Bias Tool for experimental studies.

Results

The search yielded 4919 references of which 8 studies met inclusion criteria. Seven of the 8 studies were observational, and one study was a non-blinded randomised-controlled trial. Diseases examined included hypertension, heart failure, diabetes mellitus, chronic kidney disease, thalassaemia, and arthritis. Study settings included locations in the Middle East, Eastern Europe, and South Asia. Interventions featuring disease-management protocols and/or cohort monitoring demonstrated the strongest evidence of effectiveness. No studies examined intervention costs. The quality of studies was limited, with a reliance on observational study designs, limited use of control groups, biases associated with missing data and inadequate patient-follow-up, and confounding was poorly addressed.

Conclusions

The review highlights the extremely limited quantity and quality of evidence on this topic. Interventions that incorporate standardisation and facilitate patient follow-up appear beneficial. However, substantially more research is needed, including data on costs.

Diabetes mellitus and treatment outcomes in Palestine refugees in UNRWA primary health care clinics in Jordan

SETTING

Six primary health care clinics in Jordan, serving Palestine refugees diagnosed with diabetes mellitus (DM).

OBJECTIVES

To report on the number and characteristics of new DM patients registered in the second quarter of 2013 and of all DM patients ever registered by 30 June 2013, with treatment outcomes and cumulative burden of late-stage complications.

DESIGN

A descriptive cohort study using routine data collected through e-Health.

RESULTS

Of the 288 new patients in Q2 2013 and 12 548 patients ever registered with DM by 30 June 2013, smoking, physical inactivity and obesity were recorded in 19%, 50% and 47%, respectively. In Q2 2013, 9740 (78%) patients attended a clinic, with >99% having undergone disease control measures: of these, 72% had postprandial blood glucose ⩽ 180 mg/dl, 71% had blood cholesterol < 200 mg/dl, 82% had blood pressure < 140/90 and 40% had body mass index < 30 kg/m(2). Late-stage complications were present in 1130 (11.6%) patients who attended a clinic, with cardiovascular disease and stroke being the most common. Several differences in outcomes were found between males and females.

CONCLUSION

There is a high burden of disease due to DM at primary health care clinics in Jordan. Cohort analysis using e-Health is a vital way to assess management and follow-up.

Diabetes care in refugee camps: the experience of UNRWA

United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) was established in 1949 and has delivered health care services for over 65 years. The epidemiological transition in disease burden is changing the context in which UNRWA's health programme operates and poses new challenges that require new ways of providing health services. Hypertension and diabetes are two major health problems for Palestine refugees. UNRWA has been providing diabetes and hypertension care since 1992 in its primary health care centres. Of late, through a structured process of care delivery the UNRWA health system is making significant strides in addressing diabetes and hypertension and consequently the nine voluntary global targets as envisaged in the WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020. Given that most developing countries either have no or only rudimentary services for diabetes and hypertension at the primary care level and may face similar resource and capacity constraints, UNRWA's efforts can serve as a model and inspiration to set up similar initiatives.

Quality of diabetes care in low- and middle-income Asian and Middle Eastern countries (1993-2012): 20-year systematic review

OBJECTIVE

To assess the extent to which people with diabetes in low- and middle-income countries (LMIC) of Asia and the Middle East met evidence-based care recommendations through a systematic review of published literature.

METHODS

Electronic searches of Medline and Embase were carried out for studies assessing quality of care among people with diabetes in Asia and the Middle East between 1993 and 2012. Benchmarking against American Diabetes Association guidelines, we reported level and proportions meeting recommended risk factor control (glycated hemoglobin [HbA1c], blood pressure, and low density lipoprotein-cholesterol [LDL]) and preventive care processes across different settings.

RESULTS

One hundred and fifteen publications met eligibility for inclusion (91 reported risk factor control, 7 reported preventive processes, and 17 reported both). Only China, Thailand, Malaysia and Philippines had nationally representative data. Mean HbA1c (6.5-11% or 48-97 mmol/mol), SBP (120-152 mm Hg), and LDL (2.4-3.8 mmol/l) varied greatly. Despite variation in availability of data, studies consistently showed that recommended care goals were not being achieved.

CONCLUSIONS

The practice of auditing and benchmarking against evidence-based guidelines appears to be uncommon in Asia and the Middle East and there was heterogeneity of reporting across studies, populations, and methods used. The available data showed inadequate care.

How well are asthma treatment cards filled out in public health centres in Gazeera State, Sudan?

SETTING

Four public district hospitals offering asthma treatment in Gazeera State, Sudan. Incomplete recording of patient data directly affects the quality of asthma care and the evaluation of asthma management programmes.

OBJECTIVE

To assess the completeness of filling out of treatment cards and accuracy of calculating peak expiratory flow (PEF) for confirming diagnosis and grading severity of asthma.

DESIGN

Cross-sectional audit of asthma treatment cards from asthma centres, 2006-2012.

RESULTS

Of 959 patient cards assessed, completeness ranged from 47% to 98%. Six of 13 variables had an unsatisfactory grade of completeness (<80% complete). Calculated PEF was indicated in 885 (92%) cards, but was correct in only 609 (69%). PEF variability was recorded in 835 (87%) cards, but was correctly calculated in 442 (53%). A scheduled follow-up visit was attended by only 359 (37%) patients, indicating 63% loss to follow-up. Contact telephone numbers were missing from 453 (47%) cards.

CONCLUSION

This is the first study in Africa to assess the data completeness and integrity of asthma patient cards, identifying important shortcomings. This affects quality of management of asthma patients and programme evaluation. Steps to rectify this situation are urgently needed.

Cohort analysis of antenatal care and delivery outcomes in pregnancy: a basis for improving maternal health

Cohort analysis has been the cornerstone of tuberculosis (TB) monitoring and evaluation for nearly two decades; these principles have been adapted for patients with the human immunodeficiency virus/acquired immune-deficiency syndrome on antiretroviral treatment and patients with diabetes mellitus and hypertension. We now make the case for using cohort analyses for monitoring pregnant women during antenatal care, up to and including childbirth. We believe that this approach would strengthen the current monitoring and evaluation systems used in antenatal care by providing more precise information at regular time intervals. Accurate real-time data on how many pregnant women are enrolled in antenatal care, their characteristics, the interventions they are receiving and the outcomes for mother and child should provide a solid basis for action to reduce maternal mortality.

Failure of miltefosine treatment for visceral leishmaniasis in children and men in South-East Asia

Background

High frequency of relapse in miltefosine-treated visceral leishmaniasis (VL) patients in India and Nepal followed up for twelve months.

Objective

To identify epidemiological and clinical risk factors for relapse of VL in patients recently treated with standard dosing of miltefosine in India and Nepal.

Design

Prospective observational study in three Primary Health Centers and one reference center in Muzaffarpur district, Bihar, India; and two zonal hospitals and a university hospital in South-east Nepal; records of all consenting patients diagnosed with VL and treated with miltefosine according to the current treatment guidelines of the Kala azar elimination program between 2009 and 2011.

Results

We compared the clinical records of 78 cases of relapse with those of 775 patients who had no record of subsequent relapse. Relapse was 2 times more common amongst male patients (IRR 2.14, 95% CI 1.27–3.61), and 2 to 3 times more frequent in the age groups below 15 compared to the over 25 year olds (age 10 to 14: IRR 2.53; 95% CI 1.37–4.65 and Age 2 to 9: IRR 3.19; 95% CI 1.77–5.77). History of earlier VL episodes, or specific clinical features at time of diagnosis such as duration of symptoms or spleen size were no predictors of relapse.

Conclusions

Young age and male gender were associated with increased risk of VL relapse after miltefosine, suggesting that the mechanism of relapse is mainly host-related i.e. immunological factors and/or drug exposure (pharmacokinetics). The observed decrease in efficacy of miltefosine may be explained by the inclusion of younger patients compared to the earlier clinical trials, rather than by a decreased susceptibility of the parasite to miltefosine. Our findings highlight the importance of proper clinical trials in children, including pharmacokinetics, to determine the safety, efficacy, drug exposure and therapeutic response of new drugs in this age group.

Caseload, management and treatment outcomes of patients with hypertension and/or diabetes mellitus in a primary health care programme in an informal setting

OBJECTIVE

In three primary health care clinics run by Médecins Sans Frontières in the informal settlement of Kibera, Nairobi, Kenya, we describe the caseload, management and treatment outcomes of patients with hypertension (HT) and/or diabetes mellitus (DM) receiving care from January 2010 to June 2012.

METHOD

Descriptive study using prospectively collected routine programme data.

RESULTS

Overall, 1465 patients were registered in three clinics during the study period, of whom 87% were hypertensive only and 13% had DM with or without HT. Patients were predominantly female (71%) and the median age was 48 years. On admission, 24% of the patients were obese, with a body mass index (BMI) > 30 kg/m2. Overall, 55% of non-diabetic hypertensive patients reached their blood pressure (BP) target at 24 months. Only 28% of diabetic patients reached their BP target at 24 months. For non-diabetic patients, there was a significant decrease in BP between first consultation and 3 months of treatment, maintained over the 18-month period. Only 20% of diabetic patients with or without hypertension achieved glycaemic control. By the end of the study period,1003 (68%) patients were alive and in care, one (<1%) had died, eight (0.5%) had transferred out and 453 (31%) were lost to follow-up.

CONCLUSION

Good management of HT and DM can be achieved in a primary care setting within an informal settlement. This model of intervention appears feasible to address the growing burden of non-communicable diseases in developing countries.

Treatment outcomes in a cohort of Palestine refugees with diabetes mellitus followed through use of E-Health over 3 years in Jordan

OBJECTIVE

The aim of this study was to use E-Health to report on 12-month, 24-month and 36-month outcomes and late-stage complications of a cohort of Palestine refugees with diabetes mellitus (DM) registered in the second quarter of 2010 in a primary healthcare clinic in Amman, Jordan.

METHOD

Retrospective cohort study with treatment outcomes censored at 12-month time points using E-Health in UNRWA's Nuzha Primary Health Care Clinic.

RESULTS

Of 119 newly registered DM patients, 61% were female, 90% were aged ≥40 years, 92% had type 2 DM with 73% of those having hypertension and one-third of patients were newly diagnosed. In the first 3 years of follow-up, the proportion of clinic attendees decreased from 72% to 64% and then to 61%; the proportion lost to-follow-up increased from 9% to 19% and then to 29%. At the three time points of follow-up, 71-78% had blood glucose ≤180 mg/dl; 63-74% had cholesterol <200 mg/dl; and about 90% had blood pressure <140/90 mmHg. Obesity remained constant at 50%. The proportion of patients with late-stage complications increased from 1% at baseline to 7% at 1 year, 14% at 2 years and 15% at 3 years.

CONCLUSION

Nuzha PHC Clinic was able to monitor a cohort of DM patients for 3 years using E-Health and the principles of cohort analysis. This further endorses the use of cohort analysis for managing patients with DM and other non-communicable diseases.

Cohort monitoring - as a tool to improve diabetes care services

The need to stem the rising tide of non-communicable diseases (NCDs) including diabetes has been recognised at the highest levels through the UN political declaration. Diabetes care services are largely unavailable in the primary care setting in most developing countries and where available the services are unstructured, with poor record keeping, stock outs and frequent disruption in supplies. With no systematic monitoring of care and programme implementation, treatment outcomes are poor and are consequently associated with a high economic burden. Systematic evaluation of programmes through cohort monitoring has been shown to be effective in large-scale interventions for two chronic infectious diseases-tuberculosis and HIV/AIDS. Can the same simple tool of cohort monitoring be applied to improve diabetes care delivery in the developing world? Pilot projects show it is possible, but scale up and expansion would require investment in information technology. In a scenario where systems for NCD are just beginning to be set up, it makes sense to learn from and build further on the initial pilot programmes.

The double burden of diabetes and tuberculosis - public health implications

Diabetes mellitus (DM) and tuberculosis (TB) have existed for thousands of years and even now the global disease burden from DM and TB is huge. The incidence of TB is declining slowly but it still remains a big problem in many populous large low and middle income countries. On the other, hand the burden of diabetes is increasing very rapidly, particularly in the very same countries where TB is endemic. The intersecting double burden is therefore ominous particularly as several studies and systematic reviews have indicated that DM increases the risk of TB disease and results in poor treatment outcomes. To address the double burden, WHO and the International Union Against Tuberculosis and Lung Disease (The Union) in 2011 launched a collaborative framework for the care and control of diabetes and tuberculosis, to encourage collaborative research and implement bidirectional screening of the two diseases in routine settings. This review article (i) explores some of the new evidence for the association between TB and DM, (ii) discusses issues with regard to clinical presentation and outcomes, (iii) presents the evidence, challenges and strategies for bidirectional screening based on field studies to implement the framework and (iv) finally presents suggestions on how diabetes care delivery may benefit from the lessons of the TB DOTS approach and public health principles for structured care delivery.

High loss to follow-up following obstetric fistula repair surgery in rural Burundi: is there a way forward?

SETTING

Gitega Fistula Centre (GFC), a dedicated obstetric fistula repair centre providing comprehensive care at the Gitega District Hospital, rural Burundi.

OBJECTIVES

To describe 1) the proportion who returned for scheduled 3- and 6-month follow-up visits and 2) outcomes (fistula closure rates and continence status) at discharge from hospital and after 3 and 6 months among patients who underwent fistula repair surgery.

DESIGN

Retrospective cohort analysis using programme data from April 2010 to December 2011.

RESULTS

A total of 475 women with obstetric fistula underwent surgical repair. At discharge from hospital, 415 (87%) had a closed fistula, of whom 318 (77%) were continent of urine and/or faeces, while 97 (23%) remained incontinent despite closure. Of the 415 patients with closed fistula, only 244 (59%) were followed up at 3 months and 73 (18%) at 6 months (χ(2) for linear trend 576, P < 0.0001). This indicates progressive loss to follow-up, reaching 82% by 6 months.

CONCLUSION

Women undergoing obstetric fistula repair surgery at GFC achieve good hospital exit outcomes. Thereafter, substantial and progressive loss to follow-up hinder the ability to judge programme success over time. Steps to address this operational problem are discussed.

Management of asthma in Benin: the challenge of loss to follow-up

SETTING

An asthma pilot project in Benin.

OBJECTIVE

To assess the implementation of standard case management of asthma at three referral centres and three primary care centres.

METHODS

The project began with local adaptation of international asthma guidelines, followed by situation analysis, pre-intervention, training and intervention. The initial dosage of inhaled beclometasone was determined by asthma severity. Outcome of treatment was assessed annually, starting from one year after enrolment.

RESULTS

Of 103 asthma patients identified during situation analysis, only 11 (11%) were prescribed inhaled corticosteroids. After health worker training, a total of 430 asthma patients were identified in 2008, of whom 273 (63.5%) returned after initial management with 7-day oral prednisolone. Of the 273 patients, 261 (95.6%) had persistent asthma, 231 (86.2%) had peak flow measurement variability of ≥20%, and 155 (56.8%) had had one or more unplanned visits to health facilities in the previous year. Outcome at one year evaluation was as follows: 63 (24.1%) had improved, 48 (18.4%) remained stable, 14 (5.4%) were worse and 136 (52.4%) were lost to follow-up.

CONCLUSION

It is feasible to train health workers to manage asthma patients in a standardised manner. However, a high proportion of patients were lost to follow-up during treatment.

Retrospective Quarterly Cohort Monitoring for patients with Visceral Leishmaniasis in the Indian subcontinent: outcomes of a pilot project

OBJECTIVE

To evaluate a new tool for the monitoring of Visceral Leishmaniasis (VL) treatment outcomes in primary healthcare (PHC) settings, adapted from the standardised Retrospective Quarterly Cohort Monitoring done in tuberculosis control.

METHODS

We developed standard case definitions for early and late VL treatment outcomes, a single register allowing for one-line entry per patient as registration tool, and quarterly reporting formats for the clinical outcomes. We pilot-tested these tools in three Indian Primary Health Centres and two Nepalese district hospitals, as well as in a charity VL treatment centre and a university hospital.

RESULTS

Data collection for early treatment outcome was easily implemented but information on late treatment outcome was hard to obtain. Effectiveness of Miltefosine under routine care conditions was about 87% at end of treatment, and 76% at 6 months post-treatment related to the high number of patients lost to follow up at the latter end point.

CONCLUSION

A retrospective cohort monitoring methodology is conceptually a good framework for monitoring clinical outcomes for chronic conditions as VL. The monitoring of early outcomes of VL treatment is perfectly feasible in Primary Care settings. The completeness of information on late outcomes can be improved by a number of strategies that remain to be field tested. Generally, clinical outcome monitoring should be strengthened in the VL control programmes.

Cohort monitoring of persons with diabetes mellitus in a primary healthcare clinic for Palestine refugees in Jordan

OBJECTIVE

To illustrate the method of cohort reporting of persons with diabetes mellitus (DM) in a primary healthcare clinic in Amman, Jordan, serving Palestine refugees with the aim of improving quality of DM care services.

METHOD

A descriptive study using quarterly and cumulative case findings, as well as cumulative and 12-month analyses of cohort outcomes collected through E-Health in UNRWA Nuzha Primary Health Care Clinic.

RESULTS

There were 55 newly registered patients with DM in quarter 1, 2012, and a total of 2851 patients with DM ever registered on E-Health because this was established in 2009. By 31 March 2012, 70% of 2851 patients were alive in care, 18% had failed to present to a healthcare worker in the last 3 months and the remainder had died, transferred out or were lost to follow-up. Cumulative and 12-month cohort outcome analysis indicated deficiencies in several components of clinical care: measurement of blood pressure, annual assessments for foot care and blood tests for glucose, cholesterol and renal function. 10-20% of patients with DM in the different cohorts had serious late complications such as blindness, stroke, cardiovascular disease and amputations.

CONCLUSION

Cohort analysis provides data about incidence and prevalence of DM at the clinic level, clinical management performance and prevalence of serious morbidity. It needs to be more widely applied for the monitoring and management of non-communicable chronic diseases.