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Rimawi A, Shah A, Louis H, Scales D, Kheiran JA, Jawabreh N, Yunez S, Horino M, Seita A, Wispelwey B. Community Health Worker Program Outcomes for Diabetes and Hypertension Control in West Bank Refugee Camps: A Retrospective Matched Cohort Study. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2200168. [PMID: 36316145 PMCID: PMC9622278 DOI: 10.9745/ghsp-d-22-00168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 09/13/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Community health worker (CHW) programs have proven effective in improving diabetes control in many locations and settings, but data on feasibility and efficacy are lacking in the Middle East and settings of chronic violence. A Palestinian CHW program, Health for Palestine (H4P), addresses chronic diseases in West Bank refugee camps. Our study assesses the feasibility and effectiveness of the program's diabetes and hypertension interventions. METHODS Data on home visits, patient retention, and blood pressure were extracted from the CHW records and analyzed. To assess diabetic patient progress, we conducted a retrospective matched cohort study using data obtained from a United Nations (UN) clinical database to analyze the trajectory of hemoglobin A1c (A1c) values. Thirty of the 47 diabetic patients in the H4P CHW program met study inclusion criteria and were each matched with 3 patients from the Bethlehem UN clinic (n=120). We tested for significance using multivariable linear regression with robust standard errors. RESULTS The average number of home visits per patient per month was 7.3 (standard deviation=4.1), and the patient retention rate was 100% over an average of 11.2 months. For hypertension patients in the CHW program (n=33), mean systolic blood pressure decreased by 7.3 mmHg (95% confidence interval [CI]=1.93, 12.25; P=.009) and mean diastolic blood pressure by 4.3 mmHg (95% CI=0.80, 7.91; P=.018) from March 2018 to November 2019. On average, diabetic patients within the CHW group experienced a 1.4 point greater decline in A1c per year compared to those in the non-CHW group, after adjusting for potential confounders (95% CI=-0.66, -2.1; P<.001). DISCUSSION The results suggest that CHW accompaniment may be an effective model for improving diabetes and hypertension control in refugee camps experiencing direct violence and extreme adversity. A low exclusion cut-off for A1c (≤6.4%) may underestimate the program's impact.
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Affiliation(s)
- Asmaa Rimawi
- Harvard T.H. Chan School of Public Health; Harvard Medical School, Boston, MA, USA
| | - Adarsh Shah
- Harvard Kennedy School, Harvard University, Cambridge, MA, USA
| | - Henry Louis
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - David Scales
- New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Jawad Abu Kheiran
- United Nations Relief and Works Agency, Arroub refugee camp, occupied Palestinian territory
| | - Nashat Jawabreh
- Makassad Hospital, East Jerusalem, occupied Palestinian territory
| | - Sofia Yunez
- University of Illinois College of Medicine, Chicago, IL, USA
| | - Masako Horino
- United Nations Relief and Works Agency, Amman, Jordan
| | - Akihiro Seita
- United Nations Relief and Works Agency, Amman, Jordan
| | - Bram Wispelwey
- Brigham and Women's Hospital, Harvard Medical School; Harvard T.H. Chan School of Public Health, Boston, MA, USA.
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Kehlenbrink S, Ansbro É, Besançon S, Hassan S, Roberts B, Jobanputra K. Strengthening Diabetes Care in Humanitarian Crises in Low- and Middle-income Settings. J Clin Endocrinol Metab 2022; 107:e3553-e3561. [PMID: 35639997 DOI: 10.1210/clinem/dgac331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Indexed: 11/19/2022]
Abstract
Amid the growing global diabetes epidemic, the scale of forced displacement resulting from armed conflict and humanitarian crises is at record-high levels. More than 80% of the displaced population lives in lower- and middle-income countries, which also host 81% of the global population living with diabetes. Most crises are protracted, often lasting decades, and humanitarian aid organizations are providing long-term primary care to both the local and displaced populations. Humanitarian crises are extremely varied in nature and occur in contexts that are diverse and dynamic. The scope of providing diabetes care varies depending on the phase of the crisis. This paper describes key challenges and possible solutions to improving diabetes care in crisis settings. It focuses on (1) ensuring a reliable supply of life preserving medications and diagnostics, (2) restoring and maintaining access to health care, and (3) adapting service design to the context. These challenges are illustrated through case studies in Ukraine, Mali, the Central African Republic, and Jordan.
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Affiliation(s)
- Sylvia Kehlenbrink
- Brigham and Women's Hospital, Boston, MA 02115, USA
- Harvard Humanitarian Initiative, Cambridge, MA 02138, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Éimhín Ansbro
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, WC1H 9SH, UK
| | | | - Saria Hassan
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, 30322,USA
- Emory Rollins School of Public Health, Atlanta, GA, 30322, USA
| | - Bayard Roberts
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, WC1H 9SH, UK
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Song K, Lee A. Factors influencing the effective management of diabetes during humanitarian crises in low- and middle-income countries: a systematic review. Public Health 2021; 199:110-117. [PMID: 34626911 DOI: 10.1016/j.puhe.2021.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 06/09/2021] [Accepted: 08/26/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The management of non-communicable chronic diseases such as diabetes mellitus is often poor in humanitarian crisis settings. Poor disease management can have serious long-term consequences. This review sought to identify studies that explored the effectiveness of interventions and the determinants that may improve the management of diabetes in the humanitarian context. STUDY DESIGN A systematic review was conducted of all types of studies that implemented diabetes programmes in humanitarian settings. METHODS MEDLINE, Embase, CINAHL and Web of Science were searched for relevant articles using multiple search terms for relevant studies published in English between 2000 and June 2020. Quality assessments using valid tools, were conducted. A narrative synthesis of the findings was then performed. RESULTS The search yielded 550 citations. After de-duplicating and screening, 19 studies were eligible for inclusion. Most studies were conducted in the Middle East (74%), Asia (16%) and Africa (10%). The interventions reported to improved diabetes care included the mHealth tool, intensive lifestyle intervention, task-shifting, psychosocial support, distribution of glucometers and comprehensive care. Insufficient drug supply, out-of-pocket cost, the complexity of insulin therapy and low adherence to guidelines were identified as barriers. CONCLUSION There is a paucity of evidence on optimal diabetes care in acute crisis and natural disaster settings. The review was constrained by the low quality of the studies included. Nevertheless, it is likely that mHealth can be feasibly utilised, as educational SMS messages are cost-effective and electronic medical records can enhance disease monitoring. In addition, a multidisciplinary approach to care improves glycaemic control and is desirable due to the multifaceted nature of the disease and management required. Several key barriers have been identified that need to be tackled. Overall, the evidence base for diabetes care in humanitarian settings remains sparse, and further research is needed.
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Affiliation(s)
- K Song
- School of Health and Related Research, The University of Sheffield, United Kingdom.
| | - A Lee
- School of Health and Related Research, The University of Sheffield, United Kingdom
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Jaung MS, Willis R, Sharma P, Aebischer Perone S, Frederiksen S, Truppa C, Roberts B, Perel P, Blanchet K, Ansbro É. Models of care for patients with hypertension and diabetes in humanitarian crises: a systematic review. Health Policy Plan 2021; 36:509-532. [PMID: 33693657 PMCID: PMC8128021 DOI: 10.1093/heapol/czab007] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 01/02/2023] Open
Abstract
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.
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Affiliation(s)
- Michael S Jaung
- Department of Health Services Research & Policy and Centre for Global Chronic Conditions, Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
- Department of Emergency Medicine, Baylor College of Medicine, 1504 Ben Taub Loop, Houston, 77030, TX, USA
| | - Ruth Willis
- Department of Health Services Research & Policy and Centre for Global Chronic Conditions, Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Piyu Sharma
- Department of Health Services Research & Policy and Centre for Global Chronic Conditions, Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Sigiriya Aebischer Perone
- Health Unit, international Committee of the Red Cross, Avenue de la Paix 19, 1202 Geneva, Switzerland
| | | | - Claudia Truppa
- Health Unit, international Committee of the Red Cross, Avenue de la Paix 19, 1202 Geneva, Switzerland
| | - Bayard Roberts
- Department of Health Services Research & Policy and Centre for Global Chronic Conditions, Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Pablo Perel
- Department of Non-Communicable Disease Epidemiology and Centre for Global Chronic Conditions, Faculty of Epidemiology and Population Health, Keppel Street, London WC1E 7HT, UK
| | - Karl Blanchet
- Geneva Centre of Humanitarian Studies, University of Geneva, 24 rue du Général-Dufour, Geneva, Switzerland
| | - Éimhín Ansbro
- Department of Health Services Research & Policy and Centre for Global Chronic Conditions, Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
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Georges D, Buber-Ennser I, Rengs B, Kohlenberger J, Doblhammer G. Health determinants among refugees in Austria and Germany: A propensity-matched comparative study for Syrian, Afghan, and Iraqi refugees. PLoS One 2021; 16:e0250821. [PMID: 33909696 PMCID: PMC8081210 DOI: 10.1371/journal.pone.0250821] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/15/2021] [Indexed: 11/19/2022] Open
Abstract
In recent years, Germany and Austria have been among the leading European receiving countries for asylum seekers and refugees (AS&R). The two countries have cultural and economic similarities, but differ, for example, in their health care systems, with AS&R having unrestricted access to health services upon arrival in Austria, but not in Germany. This study investigates the determinants of health among refugees in Austria and Germany, and how these determinants differ between the two countries. We analyze comparable and harmonized survey data from both countries for Syrian, Afghan, and Iraqi nationals aged 18 to 59 years who had immigrated between 2013 and 2016 (Germany: n = 2,854; Austria: n = 374). The study adopts a cross-sectional design, and uses propensity score matching to examine comparable AS&R in the two receiving countries. The results reveal that the AS&R in Germany (72%) were significantly less likely to report being in (very) good health than their peers in Austria (89%). Age and education had large impacts on health, whereas the effects of length of stay and length of asylum process were smaller. Compositional differences in terms of age, sex, nationality, education, and partnership situation explained the country differences only in part. After applying propensity score matching to adjust for structural differences and to assess non-confounded country effects, the probability of reporting (very) good health was still 12 percentage points lower in Germany than in Austria. We conclude that many of the determinants of health among AS&R correspond to those in the non-migrant population, and thus call for the implementation of similar health policies. The health disadvantage found among the AS&R in Germany suggests that removing their initially restricted access to health care may improve their health.
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Affiliation(s)
- Daniela Georges
- Department of Sociology and Demography, University of Rostock, Rostock, Germany
| | - Isabella Buber-Ennser
- Vienna Institute of Demography (OeAW), Wittgenstein Centre for Demography and Global Human Capital (IIASA, OeAW, University of Vienna), Vienna, Austria
| | - Bernhard Rengs
- Vienna Institute of Demography (OeAW), Wittgenstein Centre for Demography and Global Human Capital (IIASA, OeAW, University of Vienna), Vienna, Austria
| | - Judith Kohlenberger
- Institute for Social Policy, Vienna University of Economics and Business, Vienna, Austria
| | - Gabriele Doblhammer
- Department of Sociology and Demography, University of Rostock, Rostock, Germany
- German Center for Neurodegenerative Diseases, Bonn, Germany
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Ansbro É, Homan T, Qasem J, Bil K, Rasoul Tarawneh M, Roberts B, Perel P, Jobanputra K. 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. BMC Health Serv Res 2021; 21:381. [PMID: 33896418 PMCID: PMC8074194 DOI: 10.1186/s12913-021-06333-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/30/2021] [Indexed: 01/28/2023] Open
Abstract
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.
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Affiliation(s)
- Éimhín Ansbro
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK.
| | | | | | - Karla Bil
- Médecins sans Frontières, Amsterdam, The Netherlands
| | | | - Bayard Roberts
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
| | - Pablo Perel
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
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