1
|
James O, Abbou-Abbas L, Vijayasingham L. Living with and managing type 1 diabetes in humanitarian settings: A qualitative synthesis of lived experience and stakeholder tacit knowledge. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003027. [PMID: 38905318 PMCID: PMC11192347 DOI: 10.1371/journal.pgph.0003027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 05/28/2024] [Indexed: 06/23/2024]
Abstract
Humanitarian health actors are beginning to better consider and manage non-communicable diseases, such as diabetes, in emergency and protracted crisis settings. However, a focus on the more globally prevalent type 2 diabetes (T2D) dominates. Blind spots prevail in the unmet needs for type 1 diabetes (T1D), a chronic autoimmune condition where individuals are unable to produce insulin, thereby dependent on lifelong insulin therapy and blood glucose management. Although some T1D management requirements overlap with those of T2D, the immediate risk of fatal complications following insulin therapy disruption, the earlier age of onset during childhood, adolescence or young adulthood, and its lower prevalence compared to T2D within communities and local health systems mean that T1D requires nuanced consideration and targeted interventions. Intending to inform program and policy design for people with T1D (PWT1D), we synthesized themes of lived experience from PLWT1D and their caregivers, and the tacit working knowledge of health providers and policymakers in the context of local humanitarian operations. Through a strategic search of health databases (up to July 2023), we identified 11 articles that include interview excerpts from PWT1D, caregivers, healthcare providers and policymakers about T1D management in humanitarian settings. We used reflexive thematic analysis to guide data extraction, coding, and synthesis, resulting in the identification of four overarching themes: food and insulin security, family relations, knowledge translation, and response to diagnosis. The narratives highlight harsh trade-offs made by PWT1D and their families in the face of insulin and food insecurity, as well as the damaging impact of low T1D education in families, communities and health systems. Targeted family and community-based solutions are urgently required, alongside systemic reforms and international collaboration to enable better T1D coping and management in humanitarian settings.
Collapse
Affiliation(s)
- Oria James
- MSc Public Health Graduate Class of 2023, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Linda Abbou-Abbas
- International Committee of the Red Cross, Beirut Delegation, Lebanon
- INSPECT-LB (Institut de Santé Publique, Epidemiologie Clinique et Toxicologie-Liban), Beirut, Lebanon
| | - Lavanya Vijayasingham
- NCD in Humanitarian Settings Research Group and Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, United Kingdom
| |
Collapse
|
2
|
Schmid B, Njeim C, Vijayasingham L, Sanga LA, Naimi RK, Fouad FM, Akik C, Zmeter C, Perone SA, Larsen LB, Roswall J, Ansbro É, Perel P. Implementing (and evaluating) peer support with people living with noncommunicable diseases in humanitarian settings. J Migr Health 2024; 9:100229. [PMID: 38633280 PMCID: PMC11021823 DOI: 10.1016/j.jmh.2024.100229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
In line with the peer reviewers comments, the authors have added highlights in stead of an abstract. It was felt that it was better able to capture the findings and is more in line with the paper's target audience.
Collapse
Affiliation(s)
- Benjamin Schmid
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Lavanya Vijayasingham
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Leah Anku Sanga
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | | | - Carla Zmeter
- International Committee of the Red Cross, Beirut, Lebanon
| | - Sigiriya Aebischer Perone
- International Committee of the Red Cross, Geneva, Switzerland
- Geneva University Hospitals, Geneva, Switzerland
| | | | | | - Éimhín Ansbro
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Pablo Perel
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, United Kingdom
| |
Collapse
|
3
|
Willis R, Akik C, El-Dirani Z, Truppa C, Zmeter C, Fleri F, Perone SA, Paci R, Frederiksen S, Haidar CA, Hamadeh RS, Fouad FM, Perel P, Roberts B, Ansbro É. Patient experiences of diabetes and hypertension care during an evolving humanitarian crisis in Lebanon: A qualitative study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001383. [PMID: 38055706 DOI: 10.1371/journal.pgph.0001383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/19/2023] [Indexed: 12/08/2023]
Abstract
Humanitarian health care models increasingly incorporate care for non-communicable diseases (NCDs). Current research evidence focuses on burden of disease, service provision and access to care, and less is known about patient's experience of the continuum of care in humanitarian settings. To address this gap, this study explored experiences of displaced Syrian and vulnerable Lebanese patients receiving care for hypertension and/or diabetes at four health facilities supported by humanitarian organisations in Lebanon. We conducted in-depth, semi-structured qualitative interviews with a purposive sample of patients (n = 18) and their informal caregivers (n = 10). Data were analysed thematically using both deductive and inductive approaches. Both Syrian and Lebanese patients reported interrupted pathways of care. We identified three typologies of patient experience at the time of interview; (1) managing adequately from the patient's perspective; (2) fragile management and (3) unable to manage their condition(s) adequately, with the majority falling into typologies 2 and 3. Patients and their families recognised the importance of maintaining continuity of care and self-management, but experienced substantial challenges due to changing availability and cost of medications and services, and decreasing economic resources during a period of national crises. Family support underpinned patient's response to challenges. Navigating the changing care landscape was a significant burden for patients and their families. Interactions were identified between mental health and NCD management. This study suggests that patients experienced disrupted, non-linear pathways in maintaining care for hypertension and diabetes in a humanitarian setting, and family support networks were key in absorbing treatment burden and sustaining NCD management. Recommendations are made to reduce treatment burden for patients and their families and to support sustainable condition management.
Collapse
Affiliation(s)
- Ruth Willis
- Faculty of Public Health and Policy, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chaza Akik
- Faculty of Health Sciences, Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
| | - Zeinab El-Dirani
- Faculty of Health Sciences, Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
| | - Claudia Truppa
- International Committee of the Red Cross, Beirut, Lebanon
| | - Carla Zmeter
- International Committee of the Red Cross, Beirut, Lebanon
| | - Fabrizio Fleri
- International Committee of the Red Cross, Beirut, Lebanon
| | - Sigiriya Aebischer Perone
- International Committee of the Red Cross, Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | | | | | | | - Randa S Hamadeh
- Primary Healthcare and Social Health Department, Ministry of Public Health, Lebanon
| | - Fouad M Fouad
- Faculty of Health Sciences, Department of Epidemiology and Population Health, American University of Beirut, Lebanon
| | - Pablo Perel
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Bayard Roberts
- Faculty of Public Health and Policy, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Éimhín Ansbro
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| |
Collapse
|
4
|
Kehlenbrink S, Jobanputra K, Reddy A, Boulle P, Gomber A, Nugent R, Varma V, Nakayama AT, Ellman T. Diabetes Care in Humanitarian Settings. Endocrinol Metab Clin North Am 2023; 52:603-615. [PMID: 37865476 DOI: 10.1016/j.ecl.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
Despite the increasing prevalence of diabetes in populations experiencing humanitarian crisis, along with evidence that people living with diabetes are at higher risk for poor outcomes in a crisis, diabetes care is not routinely included in humanitarian health interventions. We here describe 4 factors that have contributed to the inequities and lack of diabetes inclusion in humanitarian programmes: (1) evolving paradigms in humanitarian health care, (2) complexities of diabetes service provision in humanitarian settings, (3) social and cultural challenges, and (4) lack of financing. We also outline opportunities and possible interventions to address these challenges and improve diabetes care among crisis-affected populations.
Collapse
Affiliation(s)
- Sylvia Kehlenbrink
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, 221 Longwood Avenue RFB-2, Boston, MA 02115, USA.
| | - Kiran Jobanputra
- Médecins Sans Frontières, Chancery Exchange, Lower Ground Floor, 10 Furnival Street, London EC4A 1AB, UK
| | - Amulya Reddy
- Médecins Sans Frontières, Chancery Exchange, Lower Ground Floor, 10 Furnival Street, London EC4A 1AB, UK
| | - Philippa Boulle
- Médecins Sans Frontières, Route de Ferney 140, Geneva 1202, Switzerland
| | - Apoorva Gomber
- Division of Global Health Equity, Brigham and Women's Hospital, Center for Integration Science, 75 Francis Street, Boston MA 02115, USA
| | - Rachel Nugent
- Department of Global Health, University of Washington, 3980 15th Avenue Northeast, Seattle, WA 98195, USA
| | - Vinod Varma
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Chemin du Pommier 40, 1218 Grand-Saconnex, Geneva, Switzerland
| | - Anna T Nakayama
- International Alliance for Diabetes Action, 101 South Hanley Road, Suite 800, Saint Louis, MO 63105, USA
| | - Tom Ellman
- Médecins Sans Frontières, 9th Floor, Zurich House, 70 Fox Street, Marshalltown, Johannesburg 2001, South Africa
| |
Collapse
|
5
|
Al Assaf S, Kleiner D, Zelkó R, Hankó B. Type 2 Diabetes Patients' Views of Local Pharmacists and Fulfilment with Pharmaceutical Diabetes Care in Syria's Latakia Governorate: An Online Survey Research. Healthcare (Basel) 2023; 11:1720. [PMID: 37372838 DOI: 10.3390/healthcare11121720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/09/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023] Open
Abstract
Assessing the attitudes of diabetic patients towards community-pharmacy services and determining the demand for new services could help monitor and evaluate the therapeutic response. This study aimed to evaluate type 2 diabetes patients' satisfaction regarding pharmacy care in community pharmacies and shed a light on the reasons for diabetic patients' non-adherence to treatments. An online survey was conducted on a random sample of patients (n = 196) at the national Diabetes Centre in Latakia, Syria, from April to November 2022. The questionnaire consisted of four primary parts: (1) demographic characteristics of responders, (2) patients' therapeutic behaviors, (3) diabetes knowledge, and (4) the general level of satisfaction with pharmacy diabetes services. The data were analyzed using descriptive analysis. Around 89% of respondents were satisfied with the information provided by community pharmacists. The patients' non-adherence showed a maximum as a function of the number of concomitantly taken medicines, which indicated that in most serious cases patients' adherence was increasing. Overall, most patients were delighted with community pharmacists' expertise and pharmacy services. This positive image allows pharmacists to expand their duties as healthcare providers in diabetes care, and increase the patient therapeutic adherence by performing a reconciliation of the patient's medicines, which involves reviewing all patients' drugs and identifying realistic solutions to their adherence issues.
Collapse
Affiliation(s)
- Sarah Al Assaf
- University Pharmacy Department of Pharmacy Administration, Semmelweis University, 1092 Budapest, Hungary
| | - Dénes Kleiner
- University Pharmacy Department of Pharmacy Administration, Semmelweis University, 1092 Budapest, Hungary
| | - Romána Zelkó
- University Pharmacy Department of Pharmacy Administration, Semmelweis University, 1092 Budapest, Hungary
| | - Balázs Hankó
- University Pharmacy Department of Pharmacy Administration, Semmelweis University, 1092 Budapest, Hungary
| |
Collapse
|
6
|
Koros H, Nolte E, Kamano J, Mugo R, Murphy A, Naanyu V, Willis R, Pliakas T, Eton DT, Barasa E, Perel P. Understanding the treatment burden of people with chronic conditions in Kenya: A cross-sectional analysis using the Patient Experience with Treatment and Self-Management (PETS) questionnaire. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001407. [PMID: 36962994 PMCID: PMC10021888 DOI: 10.1371/journal.pgph.0001407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/14/2022] [Indexed: 01/19/2023]
Abstract
In Kenya, non-communicable diseases (NCDs) are an increasingly important cause of morbidity and mortality, requiring both better access to health care services and self-care support. Evidence suggests that treatment burdens can negatively affect adherence to treatment and quality of life. In this study, we explored the treatment and self-management burden among people with NCDs in in two counties in Western Kenya. We conducted a cross-sectional survey of people newly diagnosed with diabetes and/or hypertension, using the Patient Experience with Treatment and Self-Management (PETS) instrument. A total of 301 people with diabetes and/or hypertension completed the survey (63% female, mean age = 57 years). They reported the highest treatment burdens in the domains of medical and health care expenses, monitoring health, exhaustion related to self-management, diet and exercise/physical therapy. Treatment burden scores differed by county, age, gender, education, income and number of chronic conditions. Younger respondents (<60 years) reported higher burden for medication side effects (p<0.05), diet (p<0.05), and medical appointments (p = 0.075). Those with no formal education or low income also reported higher burden for diet and for medical expenses. People with health insurance cover reported lower (albeit still comparatively high) burden for medical expenses compared to those without it. Our findings provide important insights for Kenya and similar settings where governments are working to achieve universal health coverage by highlighting the importance of financial protection not only to prevent the economic burden of seeking health care for chronic conditions but also to reduce the associated treatment burden.
Collapse
Affiliation(s)
- Hillary Koros
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - Ellen Nolte
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Richard Mugo
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - Adrianna Murphy
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Violet Naanyu
- Academic Model Providing Access to Health Care, Eldoret, Kenya
- School of Arts and Social Sciences, Moi University, Eldoret, Kenya
| | - Ruth Willis
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Triantafyllos Pliakas
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - David T. Eton
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Pablo Perel
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| |
Collapse
|
7
|
Lyles E, Chua S, Barham Y, Jardenah D, Trujillo A, Spiegel P, Burton A, Doocy S. Multi-purpose cash transfers and health among vulnerable Syrian refugees in Jordan: A prospective cohort study. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001227. [PMID: 36962676 PMCID: PMC10021566 DOI: 10.1371/journal.pgph.0001227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 10/07/2022] [Indexed: 06/18/2023]
Abstract
Cash assistance has rapidly expanded in the Syrian refugee response in Jordan and global humanitarian programming, yet little is known about the effect of multipurpose cash transfers (MPC) on health in humanitarian contexts. A prospective cohort study was conducted from May 2018 through July 2019 to evaluate the effectiveness of MPC in improving access to healthcare and health expenditures by Syrian refugees in Jordan. Households receiving MPCs (US$113-219 monthly) were compared to control households not receiving MPCs using difference-in-difference analyses. Overall health care-seeking was consistently high (>85%). Care-seeking for child illness improved among MPCs but declined among controls with a significant adjusted difference in change of 11.1% (P<0.05). In both groups, child outpatient visits significantly increased while emergency room visits decreased. Changes in care-seeking and medication access for adult acute illness were similar between groups; however, hospital admissions decreased among MPCs, yet increased among controls (-8.3% significant difference in change; P<0.05). There were no significant differences in change in chronic illness care utilization. Health expenditures were higher among MPCs at baseline and endline; the only significant difference in health expenditure measures' changes between groups was in borrowing money to pay for health costs, which decreased among MPCs and increased among controls with an adjusted difference in change of -10.3% (P<0.05). The impacts of MPC on health were varied and significant differences were observed for few outcomes. MPC significantly improved care-seeking for child illness, reduced hospitalizations for adult acute illness, and lowered rates of borrowing to pay for health expenditures. No significant improvements in chronic health condition indicators or shifts in sector of care-seeking were associated with MPC. While MPC should not be considered as a stand-alone health intervention, findings may be positive for humanitarian response financing given the potential for investment in MPC to translate to health sector response savings.
Collapse
Affiliation(s)
- Emily Lyles
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | | | - Dina Jardenah
- United Nations High Commissioner for Refugees, Amman, Jordan
| | - Antonio Trujillo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Paul Spiegel
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Ann Burton
- United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - Shannon Doocy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| |
Collapse
|
8
|
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.
Collapse
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
| | | |
Collapse
|
9
|
Schmid B, Ansbro É, Raju E, Willis R, Shabila N, Perel P. Models of care for non-communicable diseases for displaced populations in Iraq: a scoping review. Confl Health 2022; 16:40. [PMID: 35841046 PMCID: PMC9283558 DOI: 10.1186/s13031-022-00474-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/08/2022] [Indexed: 11/25/2022] Open
Abstract
Non-communicable diseases (NCDs) are the leading cause of death and disability globally. Their importance in humanitarian settings is increasingly recognised, but evidence about how best to address NCDs in these setting is limited. This scoping review aimed to explore models of NCD care for displaced populations in Iraq, in order to build evidence to design context adapted models of care. A search of key databases (Medline, Embase, Scopus, EconLit, Global Health, Web of Science, and the Iraqi Academic Scientific Journals) was conducted and complemented with grey literature and snowballing searches. Documents were included if they referred to models of NCD care for displaced populations. We synthesised the data using a conceptual model of care framework. The findings were reported according to the PRISMA guidelines for scoping reviews. We identified 4036 documents of which 22 were eligible for inclusion. Only six documents were peer-reviewed studies with most being internal reports, commentaries, or press releases. Of the 14 documents that reported on their methods, most applied quantitative approaches (n = 7), followed by mixed-methods (n = 5) and qualitative approaches (n = 2). Only one document reported on outcome data and none applied longitudinal study designs. Documents generally described individual framework dimensions, mostly centring around medicines, facility-based services, and selected access dimensions. Most dimensions had few or no references. The most common model for displaced populations in Iraq was primary-level centred care that complemented or supported existing—mostly tertiary—public health system structures. Additionally, private facilities played an important role and were frequently accessed by displaced populations in most settings. Quality of care, particularly patient-perceived quality, emerged as a critical factor for designing context-adapted models of NCD care. This review also identified a strong regionality of NCD care, particularly in terms of access rates and barriers. We concluded that there is a scarcity of evidence on the effectiveness of models of NCD care for displaced populations in Iraq, calling for capacity building initiatives focused on implementation research and evaluation.
Collapse
Affiliation(s)
- Benjamin Schmid
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK. .,Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Éimhín Ansbro
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK.,Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Emmanuel Raju
- Global Health Section and Copenhagen Centre for Disaster Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Unit for Environmental Sciences and Management, African Centre for Disaster Studies, North-West University, Potchefstroom, South Africa
| | - Ruth Willis
- Research Fellow in Social Science, Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Nazar Shabila
- Department of Community Medicine, College of Medicine, Hawler Medical University, Erbil, Iraq
| | - Pablo Perel
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK.,Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| |
Collapse
|
10
|
Favas C, Ansbro É, Eweka E, Agarwal G, Lazo Porras M, Tsiligianni I, Vedanthan R, Webster R, Perel P, Murphy A. Factors Influencing the Implementation of Remote Delivery Strategies for Non-Communicable Disease Care in Low- and Middle-Income Countries: A Narrative Review. Public Health Rev 2022; 43:1604583. [PMID: 35832336 PMCID: PMC9272771 DOI: 10.3389/phrs.2022.1604583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 05/25/2022] [Indexed: 11/18/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Caroline Favas
- London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
| | - Éimhín Ansbro
- London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
| | - Evette Eweka
- Grossman School of Medicine, New York University, New York, NY, United States
| | - Gina Agarwal
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Maria Lazo Porras
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals & University of Geneva, Geneva, Switzerland
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Ioanna Tsiligianni
- Department of Social Medicine, Faculty of Medicine, University of Crete, Rethymno, Greece
| | - Rajesh Vedanthan
- Grossman School of Medicine, New York University, New York, NY, United States
| | - Ruth Webster
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, NSW, Australia
- George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia
| | - Pablo Perel
- London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
| | - Adrianna Murphy
- London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
| |
Collapse
|
11
|
Murphy A, Willis R, Ansbro É, Masri S, Kabbara N, Dabbousy T, Bahous S, Molfino L, Perel P, Boulle P. Implementation of fixed-dose combination therapy for secondary prevention of atherosclerotic cardiovascular disease among Syrian refugees in Lebanon: a qualitative evaluation. BMC Health Serv Res 2022; 22:744. [PMID: 35659222 PMCID: PMC9167520 DOI: 10.1186/s12913-022-08040-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 05/05/2022] [Indexed: 11/13/2022] Open
Abstract
Background We report findings of a qualitative evaluation of fixed-dose combination therapy for patients with established atherosclerotic cardiovascular disease (ASCVD) attending Médecins Sans Frontières (MSF) clinics in Lebanon. Cardiovascular disease is a leading cause of death and disability worldwide, and humanitarian actors are increasingly faced with the challenge of providing care for chronic diseases such as ASCVD in settings where health systems are disrupted. Secondary prevention strategies, involving 3–5 medications, are known to be effective for patients at risk of heart attack or stroke, but supply and adherence are challenging in humanitarian settings. Fixed dose combination therapy, combining two or more medications in one tablet, may be a strategy to address this. Methods The evaluation was nested within a prospective mixed-methods study in which eligible ASCVD patients were followed for 1 year during (i) 6 months of usual care then (ii) 6 months of fixed dose combination (FDC) therapy. After 1 year, we conducted in-depth interviews with a purposive sample of patients, MSF staff and external stakeholders. Interviews focused on acceptability and sustainability of the fixed dose therapy intervention. Interview data were analysed thematically, informed by thea Theoretical Framework of Acceptability. Additional attention was paid to non-typical cases in order to test and strengthen analysis. Results Patients and health care providers were positive about the FDC intervention. For patients, acceptability was related to ease of treatment and trust in MSF staff, while, for staff, it was related to perceived improvements in adherence, having a good understanding of the medication and its use, and fitting well with their priorities for patient’s wellbeing. External stakeholders were less familiar with FDC therapy. While external clinicals expressed concerns about treatment inflexibility, non-clinician stakeholder interviews suggested that cost-effectiveness would have a major influence on FDC therapy acceptability. Sustainability was tied to the future role of MSF care provision and coherence with the local health system. Conclusions For patients and clinic staff, FDC was an acceptable treatment approach for secondary prevention of ASCVD disease in two MSF clinics in Lebanon. Sustainability is more complex and calls for better alignment of care with public systems. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08040-z.
Collapse
|
12
|
Ansbro É, Issa R, Willis R, Blanchet K, Perel P, Roberts B. Chronic NCD care in crises: A qualitative study of global experts' perspectives on models of care for hypertension and diabetes in humanitarian settings. J Migr Health 2022; 5:100094. [PMID: 35434681 PMCID: PMC9010603 DOI: 10.1016/j.jmh.2022.100094] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 10/29/2022] Open
Abstract
Background The high and rising global burden of non-communicable diseases (NCDs) is reflected among crisis-affected populations. People living with NCDs are especially vulnerable in humanitarian crises. Limited guidance exists to support humanitarian actors in designing effective models of NCD care for crisis-affected populations in low- and middle-income countries (LMICs). We aimed to synthesise expert opinion on current care models for hypertension and diabetes (HTN/DM) in humanitarian settings in LMICs, to examine the gaps in delivering good quality HTN/DM care and to propose solutions to address these gaps. Methods We interviewed twenty global experts, purposively selected based on their expertise in provision of NCD care in humanitarian settings. Data were analysed using a combination of inductive and deductive methods. We used a conceptual framework for primary care models for HTN/DM in humanitarian settings, guided by the WHO health systems model, patient-centred care models and literature on NCD care in LMICs. Results HTN/DM care model design was highly dependent on the type of humanitarian crisis, the implementing organisation, the target population, the underlying health system readiness to deal with NCDs and its resilience in the face of crisis. Current models were mainly based at primary-care level, in prolonged crisis settings. Participants focussed on the basic building blocks of care, including training the workforce, and strengthening supply chains and information systems. Intermediate health system goals (responsiveness, quality and safety) and final goals received less attention. There were notable gaps in standardisation and continuity of care, integration with host systems, and coordination with other actors. Participants recommended a health system strengthening approach and aspired to providing patient-centred care. However, more evidence on effective integration and on patients' priorities and experience is needed. More funding is needed for NCD care and related research. Conclusions Comprehensive guidance would foster standardization, continuity, integration and, thus, better quality care. Future models should take a health system strengthening approach, use patient-centred design, and should be co-created with patients and providers. Those designing new models may draw on lessons learned from existing chronic care models in high- and low-income settings.
Collapse
Key Words
- BP, Blood Pressure
- COPD, Chronic Obstructive Pulmonary Disease
- Conflict
- DM I/II, Diabetes Mellitus Type I or II
- Diabetes
- FBS, Fasting Blood Sugar
- HCW, Health Care Workers
- HTN, Hypertension
- HbA1c, Glycosylated Haemoglobin
- Humanitarian
- Hypertension
- LMIC, Low- and Middle-Income Countries
- MENA, Middle East and North Africa
- MHPSS, Mental Health and Psychosocial Support
- MOH, Ministry of Health
- MSF, Médecins sans Frontières
- NCDs, Non-communicable Diseases
- NGOs, Non-governmental Organisations
- Noncommunicable disease
- Refugee
- UNHCR, United Nations High Commissioner for Refugees
- WHO, World Health Organization
Collapse
Affiliation(s)
- Éimhín Ansbro
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine,15-17 Tavistock Place, London WC1H 9SH, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, United Kingdom
| | - Rita Issa
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine,15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Ruth Willis
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, United Kingdom
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine,15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Karl Blanchet
- Health in Humanitarian Crises Centre, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, United Kingdom
| | - Pablo Perel
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, United Kingdom
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, United Kingdom
| | - Bayard Roberts
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine,15-17 Tavistock Place, London WC1H 9SH, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, United Kingdom
| |
Collapse
|
13
|
Ojeleke O, Groot W, Pavlova M. Care delivery among refugees and internally displaced persons affected by complex emergencies: a systematic review of the literature. J Public Health (Oxf) 2022. [DOI: 10.1007/s10389-020-01343-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Abstract
Aim
This study reviews the empirical evidence on care delivery in complex emergencies (CEs) to better understand ways of improving care delivery and mitigating inequity in care among refugees and internally displaced persons (IDPs) in CEs.
Subject and methods
A systematic search was conducted in Web of Science, MEDLINE, PubMed and Embase. A manual search was conducted in the WHO Global Index Medicus and Google Scholar. Peer-reviewed English-language publications that reported results on care delivery in CEs were included for review. There was no limitation on the year or the geographical location of the studies. The content of the publications was qualitatively analysed, and the results are thematically presented in tabular form.
Results
Thirty publications were identified. Information regarding coverage, accessibility, quality, continuity and comprehensiveness of care service delivery was extracted and synthesized. Findings showed that constant insecurity, funding, language barriers and gender differences were factors impeding access to and coverage and comprehensiveness of care delivery in CEs. The review also showed a preference for traditional treatment among some refugees and IDPs.
Conclusion
Evidence from this systematic review revealed a high level of unmet healthcare need among refugees and IDPs and the need for a paradigm shift in the approach to care delivery in CEs. We recommend further research aimed at a more critical evaluation of care delivery in CEs with a view to providing a more innovative and context-specific care service delivery in these settings.
Collapse
|
14
|
Akik C, Asfahani F, Elghossain T, Mesmar S, Rabkin M, El Sadr W, Fouad FM, Ghattas H. Healthcare system responses to non-communicable diseases’ needs of Syrian refugees: The cases of Jordan and Lebanon. J Migr Health 2022; 6:100136. [PMID: 36148323 PMCID: PMC9486618 DOI: 10.1016/j.jmh.2022.100136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 06/08/2022] [Accepted: 09/13/2022] [Indexed: 12/02/2022] Open
Abstract
Hosting governments were moderately successful in providing health services to Syrian refugees through existing national health systems. Coverage and quality of care remain suboptimal and continuity is often interrupted due to inadequate implementation of national NCD guidelines, major government policy changes and UNHCR policy changes in cost sharing, eligibility, and vulnerability criteria which made the health system difficult to navigate. The latter are related to the lack of financing for NCDs at global level. There is a need for evidence-based guidelines and effective implementation models for continued NCD care in protracted emergency settings. Innovative financing solutions and increased advocacy for funding and prioritization of NCD care for refugees need to be envisioned. Strengthening existing national health systems and striving for equity in achieving universal health coverage for both nationals of host countries and refugees is imperative.
Introduction Since the start of the Syrian conflict in 2011, Jordan and Lebanon have hosted large refugee populations, with a high pre-conflict burden of non-communicable diseases (NCDs). We aimed to explore NCD service provision to Syrian refugees in these two host countries and to identify lessons learned that may inform the global response to the changing health needs of refugees. Methods Between January 2017 and June 2018, we conducted 36 in-depth interviews with stakeholders from Jordan and Lebanon, as well as global stakeholders, to understand the context, the achievements, gaps and priorities in the provision and uptake of NCD prevention, testing and treatment services to Syrian refugees. Findings Both countries succeeded in embedding refugee health care within national health systems, yet coverage and quality of NCD health services offered to Syrian refugees in both contexts were affected by under-funding and consequent policy constraints. Changes in policies relating to cost sharing, eligibility and vulnerability criteria led to difficulties navigating the system and increased out-of-pocket payments for Syrians. Funding shortages were reported as a key barrier to NCD screening, diagnosis and management, including at the primary care level and referral from primary to secondary healthcare, particularly in Lebanon. These barriers were compounded by suboptimal implementation of NCD guidelines and high workloads for healthcare providers resulting from the large numbers of refugees. Conclusions Despite the extraordinary efforts made by host countries, provision and continuity of high quality NCD services at scale remains a tremendous challenge given ongoing funding shortfalls and lack of prioritization of NCD care for refugees. The development of innovative, effective and sustainable solutions is necessary to counter the threat of NCDs.
Collapse
Affiliation(s)
- Chaza Akik
- Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Lebanon
| | - Farah Asfahani
- Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Lebanon
| | - Tatiana Elghossain
- Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Lebanon
| | - Sandra Mesmar
- Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Lebanon
| | - Miriam Rabkin
- ICAP, Columbia University Mailman School of Public Health, New York, United States
| | - Wafaa El Sadr
- ICAP, Columbia University Mailman School of Public Health, New York, United States
| | - Fouad M. Fouad
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Lebanon
| | - Hala Ghattas
- Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Lebanon
- Corresponding author.
| |
Collapse
|
15
|
Challenges of Providing Health Care in Complex Emergencies: A Systematic Review. Disaster Med Public Health Prep 2021; 17:e56. [PMID: 34725022 DOI: 10.1017/dmp.2021.312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Providing health care in times of complex emergencies (CEs) is one of the most vital needs of people. CEs are situations in which a large part of the population is affected by social unrest, wars, and food shortages. This systematic review study was conducted to identify the challenges of health-care delivery in CEs. We searched terms related to health-care delivery and CEs in PubMed, Web of Sciences, Science Direct, and Google scholar databases, as well as Persian databases SID and Magiran. The searching keywords included: "Health Care, Complex Crises, War, Humanitarian, Refugees, Displaced Persons, Health Services, and Challenges." Of 409 records, we selected 6 articles based on the Preferred Reporting Items for Systematic Reviews (PRISMA) checklist. Studies were analyzed through qualitative content analysis. The results show that CEs affect health-care delivery in 4 primary areas: the workforce, infrastructure, information access, and organization of health services. These areas can pose potential threats for health-care providers and planners at times of emergencies. Thus, they should be informed about these challenges to strengthen the health-care system.
Collapse
|
16
|
Aljadeeah S, Nagel E, Wirtz VJ. Outpatient cardiovascular diseases and diabetes medicines dispensing in the population with government health insurance in Syria between 2018 and 2019: a retrospective analysis. BMC Health Serv Res 2021; 21:1088. [PMID: 34645430 PMCID: PMC8515648 DOI: 10.1186/s12913-021-07124-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/27/2021] [Indexed: 12/03/2022] Open
Abstract
Background Low- and middle-income countries bear the highest burden of non-communicable diseases (NCDs) mortality and morbidity. Syria has undergone an epidemiological transition from infectious diseases to NCDs in the past decades. Despite the high prevalence of cardiovascular diseases (CVDs) and diabetes in Syria, little is known about medicines utilization or prescriptions for these diseases. The aims of this study are to present the patterns and rates of dispensing medicines used for CVDs and diabetes among patients with government health insurance in Syria and examine age, sex, and regional variation in the dispensing of these medicines. Methods Outpatient data from June 2018 to May 2019 on dispensed medicines for 81,314 adults with government health insurance were obtained. The dispensing rate was expressed as the number of defined daily doses (DDDs) per 1000 beneficiaries per day (DID). The DID is a measurement that is used in drug utilization research to control for differences or changes in population size between or within countries. The number of DIDs was adjusted according to beneficiaries’ sex, age, and governorate. Results Beneficiaries received 302.09 DIDs of CVDs medicines and 35.66 DIDs of diabetes medicines, including 0.96 DID of insulin (2.99% of the total of diabetes medicines). CVDs and diabetes medicine dispensing rates were low during the study period and included very low rates of insulin dispensing compared to the dispensing rates of these medicines in other countries in East Mediterranean Region or in Europe. We found lower dispensing rates of CVDs medicines among female beneficiaries (249.59 DIDs) than male beneficiaries (388.80 DIDs). Similarly, the dispensing rates of diabetes medicines among female beneficiaries (29.42 DIDs) were lower than those among male beneficiaries (45.98 DIDs). In addition, there were lower rates of CVDs and diabetes medicines and very low to no dispensing of insulin in some governorates that were partly controlled by the Syrian government compared to other governorates that were completely or mostly controlled by the Syrian government. Conclusions Additional efforts are needed to raise awareness about the prevention and management of CVDs and diabetes especially among females in Syria and consider cultural issues that might influence access to healthcare services. There is a crucial need to address the political and geographical challenges caused by the conflict which have limited access to CVDs and diabetes medicines in some regions in Syria. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07124-6.
Collapse
Affiliation(s)
- Saleh Aljadeeah
- University of Bayreuth, Institute of Medical Management and Health Sciences, Prieserstr. 2, 95440, Bayreuth, Germany.
| | - Eckhard Nagel
- University of Bayreuth, Institute of Medical Management and Health Sciences, Prieserstr. 2, 95440, Bayreuth, Germany
| | - Veronika J Wirtz
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, 3rd floor, Boston, MA, 02118, USA
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Shah S, Munyuzangabo M, Gaffey MF, Kamali M, Jain RP, Als D, Meteke S, Radhakrishnan A, Siddiqui FJ, Ataullahjan A, Bhutta ZA. Delivering non-communicable disease interventions to women and children in conflict settings: a systematic review. BMJ Glob Health 2021; 5:bmjgh-2019-002047. [PMID: 32341086 PMCID: PMC7202786 DOI: 10.1136/bmjgh-2019-002047] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 03/30/2020] [Accepted: 04/04/2020] [Indexed: 12/25/2022] Open
Abstract
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
Collapse
Affiliation(s)
- Shailja Shah
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mariella Munyuzangabo
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michelle F Gaffey
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mahdis Kamali
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Reena P Jain
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Daina Als
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sarah Meteke
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Amruta Radhakrishnan
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Fahad J Siddiqui
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada.,Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore
| | - Anushka Ataullahjan
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada .,Center of Excellence in Women and Children Health, Aga Khan University, Karachi, Pakistan
| |
Collapse
|
19
|
Lyles BE, Chua S, Barham Y, Pfieffer-Mundt K, Spiegel P, Burton A, Doocy S. Improving diabetes control for Syrian refugees in Jordan: a longitudinal cohort study comparing the effects of cash transfers and health education interventions. Confl Health 2021; 15:41. [PMID: 34034780 PMCID: PMC8145855 DOI: 10.1186/s13031-021-00380-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 05/12/2021] [Indexed: 12/15/2022] Open
Abstract
Background Cash transfers are an increasingly common intervention in the Syrian refugee response to meet basic needs, though there is little known of their potential secondary impact on health outcomes in humanitarian settings. Methods A quasi-experimental prospective cohort study was implemented from October 2018 through January 2020 to assess the effectiveness of multi-purpose cash (MPC), community health volunteer (CHV)-led education, combined with conditional cash transfers (CCT) with respect to health measures among Syrian refugees with type II diabetes in Jordan. Results CHV + CCT participants had the highest expenditures at endline and were the only group with statistically significant increases in payments for outpatient diabetes care (25.3%, P < 0.001) and monthly medication costs (13.6%, P < 0.001). Conversely, monthly spending on diabetes medication decreased significantly in the CHV only group (− 18.7%, P = 0.001) yet increased in the MPC and CHV + CCT groups. Expenditures on glucose monitoring increased in all groups but significantly more in the CHV + CCT group (39.2%, P < 0.001). The proportion of participants reporting regular diabetes care visits increased significantly only in the CHV + CCT group (15.1%, P = 0.002). Specialist visits also increased among CHV + CCT participants (16.8%, P = 0.001), but decreased in CHV only participants (− 27.8%, P < 0.001). Decreases in cost-motivated provider selection (− 22.8%, P < 0.001) and not receiving all needed care because of cost (− 26.2%, P < 0.001) were significant only in the CHV + CCT group. A small significant decrease in BMI was observed in the CHV + CCT group (− 1.0, P = 0.005). Decreases in HbA1C were significant in all groups with magnitudes ranging from − 0.2 to − 0.7%. The proportion of CHV + CCT participants with normal blood pressure increased significantly from baseline to endline by 11.3% (P = 0.007). Conclusions Combined conditional cash and health education were effective in improving expenditures, health service utilization, medication adherence, blood pressure, and diabetes control. The lower cost health education intervention was similarly effective in improving diabetes control, whereas unconditional cash transfers alone were least effective. Study findings suggest that conditional cash or combined cash and health education are promising strategies to support diabetes control among refugees and that where the purpose of MPC is to improve health outcomes, this alone is insufficient to achieve improvements in the health of refugees with diabetes. Supplementary Information The online version contains supplementary material available at 10.1186/s13031-021-00380-7.
Collapse
Affiliation(s)
- By Emily Lyles
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street Suite E8132, Baltimore, MD, 21205, USA
| | | | | | - Kayla Pfieffer-Mundt
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street Suite E8132, Baltimore, MD, 21205, USA
| | - Paul Spiegel
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street Suite E8132, Baltimore, MD, 21205, USA
| | - Ann Burton
- United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - Shannon Doocy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street Suite E8132, Baltimore, MD, 21205, USA.
| |
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
Pulpal outcomes in orthodontic tooth movement in diabetes mellitus. Odontology 2021; 109:921-929. [PMID: 33914191 DOI: 10.1007/s10266-021-00609-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
Diabetes mellitus impairs angiogenesis and tissue reorganization during orthodontic tooth movement (OTM). Thus, this study evaluated pulpal outcomes in orthodontic tooth movement through metabolic changes in diabetes. Male Wistar rats were used, and the in vivo study design consisted of four groups (n = 10/group): C-non-diabetic animals not subjected to orthodontic tooth movement; D-diabetic animals not subjected to orthodontic tooth movement; OTM-non-diabetic animals subjected to orthodontic tooth movement; and D + OTM-diabetic animals subjected to orthodontic tooth movement. In addition, the pulps of the distovestibular root (DV) and mesiovestibular root (MV) were assessed by histomorphometric analyses and immunoexpression of the RANKL/OPG system. Pulpal analysis of the MV root showed an increase in blood vessels in diabetic animals. Inflammatory infiltrate and fibroblastic cells were elevated in diabetic animals with tooth movement in the DV and MV roots. In the DV and MV roots, diabetic rats with OTM showed a reduction in birefringent collagen fibers. The immunostaining for RANKL was higher in the pulp tissue of OTM in diabetic and non-diabetic animals. It was concluded that the pulp tissue has less adaptive and repair capacity during OTM in diabetes. Orthodontic strength can alter the inflammatory processes in the pulp.
Collapse
|
22
|
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.
Collapse
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
| | | |
Collapse
|
23
|
Ratnayake R, Wittcoff A, Majaribu J, Nzweve JP, Katembo L, Kasonia K, Nzanzu AK, Kiapi L, Ngoy P. Early Experiences in the Integration of Non-communicable Diseases into Emergency Primary Health Care, Beni Region, Democratic Republic of the Congo. Ann Glob Health 2021; 87:27. [PMID: 33777712 PMCID: PMC7977479 DOI: 10.5334/aogh.3019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Health services in humanitarian crises increasingly integrate the management of non-communicable diseases into primary care. As there is little description of such programs, this case study aims to describe the initial implementation of non-communicable disease management within emergency primary care in the conflict-affected Beni Region of Democratic Republic of the Congo (DRC). Objectives We implemented and evaluated a primary care approach to hypertension and diabetes management to assess the feasibility of patient monitoring, early clinical and programmatic outcomes, and costs, after seven months of care. Methods We designed clinical and programmatic modules for diabetes and hypertension management for clinical officers and the use of patient cards and community health workers to improve adherence. We used cohort analysis (April to October 2018), time-trend analysis, semi-structured interviews, and costing to evaluate the program. Findings Increases in consultations for hypertension (incidence rate ratio [IRR] 13.5, 95% CI 5.8-31.5, p < 0.00) and diabetes (IRR 3.6, 95% CI 1-12.9, p < 0.05) were demonstrated up to the onset of violence and an Ebola epidemic in August 2018. Of 833 patients, 67% were women of median age 56. Nearly all were hypertensives (88.7%) and newly diagnosed (95.9%). Treatment adherence, defined as attending ≥2 visits in the seven month period, was demonstrated by 45.4% of hypertension patients. Community health workers had contact with 3.2-3.8 patients per month. Respondents stated that diabetes care remained fragmented with insulin and laboratory testing located outside of primary care. Program and management costs were 115 USD per person per treatment course. Conclusions In an active conflict setting, we demonstrated that non-communicable disease care can be well-organized through clinical training and cohort analysis, and adherence can be addressed using patient-held cards and monitoring by community health workers. Nearly all diagnoses were new, emphasizing the need to establish self-management. Insecurity reduced access for patients but care continued for a subset of patients during the Ebola epidemic.
Collapse
Affiliation(s)
- Ruwan Ratnayake
- Health Unit, International Rescue Committee, New York, NY, United States of America
- London School of Hygiene and Tropical Medicine, London, UK
| | - Alison Wittcoff
- Health Unit, International Rescue Committee, New York, NY, United States of America
| | - John Majaribu
- International Rescue Committee, Goma, Nord Kivu, Democratic Republic of the Congo
| | - Jean-Pierre Nzweve
- International Rescue Committee, Goma, Nord Kivu, Democratic Republic of the Congo
| | - Lambert Katembo
- International Rescue Committee, Goma, Nord Kivu, Democratic Republic of the Congo
| | - Kambale Kasonia
- London School of Hygiene and Tropical Medicine, London, UK
- Division Provinciale de la Santé, Goma, Nord Kivu, Democratic Republic of the Congo
| | - Adelard Kalima Nzanzu
- Division Provinciale de la Santé, Goma, Nord Kivu, Democratic Republic of the Congo
- Université Catholique du Graben et Université Officielle de Ruwenzori, Butembo, Democratic Republic of the Congo
| | - Lilian Kiapi
- Health Unit, International Rescue Committee, London, United Kingdom
| | - Pascal Ngoy
- International Rescue Committee, Goma, Nord Kivu, Democratic Republic of the Congo
| |
Collapse
|
24
|
Ratnayake R, Rawashdeh F, AbuAlRub R, Al-Ali N, Fawad M, Bani Hani M, Goyal R, Greenough PG, Al-Amire K, AlMaaitah R, Parmar P. Access to Care and Prevalence of Hypertension and Diabetes Among Syrian Refugees in Northern Jordan. JAMA Netw Open 2020; 3:e2021678. [PMID: 33052405 PMCID: PMC7557515 DOI: 10.1001/jamanetworkopen.2020.21678] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE The management of noncommunicable diseases in humanitarian crises has been slow to progress from episodic care. Understanding disease burden and access to care among crisis-affected populations can inform more comprehensive management. OBJECTIVE To estimate the prevalence of hypertension and diabetes with biological measures and to evaluate access to care among Syrian refugees in northern Jordan. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study was undertaken from March 25 to April 26, 2019, in the districts of Ramtha and Mafraq, Jordan. Seventy clusters of 15 households were randomly sampled, and chain referral was used to sample Syrian households, representative of 59 617 Syrian refugees. Adults were screened and interviewed about their access to care. Data analysis was performed from May to September 2019. EXPOSURES Primary care delivered through a humanitarian organization since 2012. MAIN OUTCOMES AND MEASURES The main outcomes were self-reported prevalence of hypertension and diabetes among adults aged 18 years or older and biologically based prevalence among adults aged 30 years or older. The secondary outcome was access to care during the past month among adults aged 18 years or older with a diagnosis of hypertension or diabetes. RESULTS In 1022 randomly sampled households, 2798 adults aged 18 years or older, including 275 with self-reported diagnoses (mean [SD] age, 56.5 [13.2] years; 174 women [63.3%]), and 915 adults aged 30 years or older (608 women [66.5%]; mean [SD] age, 46.0 [12.8] years) were screened for diabetes and hypertension. Among adults aged 18 years or older, the self-reported prevalence was 17.2% (95% CI, 15.9%-18.6%) for hypertension, 9.8% (95% CI, 8.6%-11.1%) for diabetes, and 7.3% (95% CI, 6.3%-8.5%) for both conditions. Among adults aged 30 years or older, the biologically based prevalence was 39.5% (95% CI, 36.4%-42.6%) for hypertension, 19.3% (95% CI, 16.7%-22.1%) for diabetes, and 13.5% (95% CI, 11.4%-15.9%) for both conditions. Adjusted for age and sex, prevalence for all conditions increased with age, and women had a higher prevalence of diabetes than men (adjusted prevalence ratio, 1.3%; 95% CI, 1.0%-1.7%), although the difference was not significant. Complications (57.4%; 95% CI, 51.5%-63.1%) and obese or overweight status (82.8%; 95% CI, 79.7%-85.5%) were highly prevalent. Among adults aged 30 years or older with known diagnoses, 94.1% (95% CI, 90.9%-96.2%) currently took medication. Among adults aged 18 years or older with known diagnoses, 26.8% (95% CI, 21.3%-33.1%) missed a medication dose in the past week, and 49.1% (95% CI, 43.3%-54.9%) sought care in the last month. CONCLUSIONS AND RELEVANCE During this protracted crisis, obtaining care for noncommunicable diseases was feasible, as demonstrated by biologically based prevalence that was only moderately higher than self-reported prevalence. The high prevalence of complications and obese or overweight status, however, suggest inadequate management. Programs should focus on reinforcing adherence and secondary prevention to minimize severe morbidity.
Collapse
Affiliation(s)
- Ruwan Ratnayake
- International Rescue Committee, Amman, Jordan
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Raeda AbuAlRub
- Department of Community and Mental Health Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Nahla Al-Ali
- Department of Community and Mental Health Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | | | | | - Ravi Goyal
- Mathematica Policy Research Inc, Princeton, New Jersey
| | - P. Gregg Greenough
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Rowaida AlMaaitah
- Department of Community and Mental Health Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Parveen Parmar
- Division of Global Emergency Medicine, University of Southern California, Los Angeles
| |
Collapse
|
25
|
Warsame A, Blanchet K, Checchi F. Towards systematic evaluation of epidemic responses during humanitarian crises: a scoping review of existing public health evaluation frameworks. BMJ Glob Health 2020; 5:e002109. [PMID: 32133177 PMCID: PMC7042582 DOI: 10.1136/bmjgh-2019-002109] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/11/2019] [Accepted: 12/22/2019] [Indexed: 11/04/2022] Open
Abstract
Epidemics continue to pose a significant public health threat to populations in low and middle-income countries. However, little is known about the appropriateness and performance of response interventions in such settings. We undertook a rapid scoping review of public health evaluation frameworks for emergency settings in order to judge their suitability for assessing epidemic response. Our search identified a large variety of frameworks. However, very few are suitable for framing the response to an epidemic, or its evaluation. We propose a generic epidemic framework that draws on elements of existing frameworks. We believe that this framework may potentially be of use in closing the gap between increasing global epidemic risk and the ability to respond effectively.
Collapse
Affiliation(s)
- Abdihamid Warsame
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Karl Blanchet
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Francesco Checchi
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
26
|
Ansbro ÉM, Biringanine M, Caleo G, Prieto-Merino D, Sadique Z, Perel P, Jobanputra K, Roberts B. Management of diabetes and associated costs in a complex humanitarian setting in the Democratic Republic of Congo: a retrospective cohort study. BMJ Open 2019; 9:e030176. [PMID: 31767582 PMCID: PMC6887084 DOI: 10.1136/bmjopen-2019-030176] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE We aimed to evaluate an Integrated Diabetic Clinic within a Hospital Outpatient Department (IDC-OPD) in a complex humanitarian setting in North Kivu, Democratic Republic of Congo. Specific objectives were to: (1) analyse diabetes intermediate clinical and programmatic outcomes (blood pressure (BP)/glycaemic control, visit volume and frequency); (2) explore the association of key insecurity and related programmatic events with these outcomes; and (3) describe incremental IDC-OPD programme costs. DESIGN Retrospective cohort analysis of routine programmatic data collected from January 2014 to February 2017; analysis of programme costs for 2014/2015. SETTING Outpatient diabetes programme in Mweso hospital, supported by Médecins sans Frontières, in North Kivu, Demographic Republic of Congo. PARTICIPANTS Diabetes patients attending IDC-OPD. OUTCOME MEASURES Intermediate clinical and programmatic outcome trends (BP/ glycaemic control; visit volume/frequency); incremental programme costs. RESULTS Of 243 diabetes patients, 44.6% were women, median age was 45 (IQR 32-56); 51.4% were classified type 2. On introduction of IDC-OPD, glucose control improved and patient volume and visit interval increased. During insecurity, control rates were initially maintained by a nurse-provided, scaled-back service, while patient volume and visit interval decreased. Following service suspension due to drug stock-outs, patients were less likely to achieve control, improving on service resumption. Total costs decreased 16% from 2014 (€36 573) to 2015 (€30 861). Annual cost per patient dropped from €475 in 2014 to €214 in 2015 due to reduced supply costs and increased patient numbers. CONCLUSIONS In a chronic conflict setting, we documented that control of diabetes intermediate outcomes was achievable during stable periods. During insecure periods, a simplified, nurse-led model maintained control rates until drug stock-outs occurred. Incremental per patient annual costs were lower than chronic HIV care costs in low-income settings. Future operational research should define a simplified diabetes care package including emergency preparedness.
Collapse
Affiliation(s)
- Éimhín Mary Ansbro
- Manson Unit, Médecins sans Frontières, London, UK
- Centre for Global Chronic Conditions, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Michel Biringanine
- Mweso Hospital, Médecins Sans Frontières Operational Centre Amsterdam, Mweso, Congo (the Democratic Republic of the)
| | - Grazia Caleo
- Manson Unit, Médecins sans Frontières, London, UK
| | - David Prieto-Merino
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Zia Sadique
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Pablo Perel
- Centre for Global Chronic Conditions, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Bayard Roberts
- Centre for Global Chronic Conditions, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
27
|
Boulle P, Kehlenbrink S, Smith J, Beran D, Jobanputra K. Challenges associated with providing diabetes care in humanitarian settings. Lancet Diabetes Endocrinol 2019; 7:648-656. [PMID: 30878269 DOI: 10.1016/s2213-8587(19)30083-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 01/26/2019] [Accepted: 02/04/2019] [Indexed: 01/20/2023]
Abstract
The humanitarian health landscape is gradually changing, partly as a result of the shift in global epidemiological trends and the rise of non-communicable diseases, including diabetes. Humanitarian actors are progressively incorporating care for diabetes into emergency medical response, but challenges abound. This Series paper discusses contemporary practical challenges associated with diabetes care in humanitarian contexts in low-income and middle-income countries, using the six building blocks of health systems described by WHO (information and research, service delivery, health workforce, medical products and technologies, governance, and financing) as a framework. Challenges include the scarcity of evidence on the management of diabetes and clinical guidelines adapted to humanitarian contexts; unavailability of core indicators for surveillance and monitoring systems; and restricted access to the medicines and diagnostics necessary for adequate clinical care. Policy and system frameworks do not routinely include diabetes and little funding is allocated for diabetes care in humanitarian crises. Humanitarian organisations are increasingly gaining experience delivering diabetes care, and interagency collaboration to coordinate, improve data collection, and analyse available programmes is in progress. However, the needs around all six WHO health system building blocks are immense, and much work needs to be done to improve diabetes care for crisis-affected populations.
Collapse
Affiliation(s)
| | - Sylvia Kehlenbrink
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, MA, USA
| | - James Smith
- Health in Humanitarian Crises Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - David Beran
- Division of Tropical and Humanitarian Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland
| | | |
Collapse
|
28
|
Khan Y, Albache N, Almasri I, Gabbay RA. The Management of Diabetes in Conflict Settings: Focus on the Syrian Crisis. Diabetes Spectr 2019; 32:264-269. [PMID: 31462883 PMCID: PMC6695264 DOI: 10.2337/ds18-0070] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Humanitarian crises represent a major global health challenge as record numbers of people are being displaced worldwide. The Syrian crisis has resulted in >4 million refugees and 6 million people who are internally displaced within Syria. In 2017, there were 705,700 reported cases of adult diabetes in Syria. During periods of conflict, people with diabetes face numerous challenges, including food insecurity, inadequate access to medications and testing supplies, and a shortage of providers with expertise in diabetes care. Access to insulin represents a major challenge during a crisis, especially for individuals with type 1 diabetes, for whom the interruption of insulin constitutes a medical emergency. In the short term (days to weeks) during a crisis, it is vital to 1) prioritize insulin for patients with type 1 diabetes, 2) ensure continuous access to essential diabetes medications, and 3) provide appropriate diabetes education for patients, with a focus on hypoglycemia and sick-day guidelines. In the long term (weeks to months) during a crisis, it is important to 1) provide access to quality diabetes care and medications, 2) train local and international health care providers on diabetes care, and 3) develop clinical guidelines for diabetes management during humanitarian crises. It is imperative that we work across all sectors to promote the health of people with diabetes during humanitarian response.
Collapse
Affiliation(s)
| | | | - Ibrahim Almasri
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | |
Collapse
|