Non-communicable diseases in humanitarian settings: ten essential questions

Exploring the patient perspective in pulmonary hypertension

The global impacts of pulmonary hypertension (PH) were formally recognised in 1973 at the 1st World Health Organization meeting dedicated to primary pulmonary hypertension, held in Geneva. Investigations into disease pathogenesis and classification led to the development of numerous therapies over the ensuing decades. While the impacts of the disease have been lessened due to treatments, the symptoms and adverse effects of PH and its therapies on patients' wellbeing and mental health remain significant. As such, there is a critical need to enhance understanding of the challenges patients face on a global scale with respect to care access, multidimensional patient support and advocacy. In addition, thoughtful analysis of the potential benefits and utilisation of mechanisms for the incorporation of patient-reported outcomes into diagnosis and treatment plans is needed. A summary of these areas is included here. We present a report of global surveys of patient and provider experiences and challenges regarding care access and discuss possible solutions. Also addressed is the current state of PH patient associations around the world. Potential ways to enhance patient associations and enable them to provide the utmost support are discussed. A summary of relevant patient-reported outcome measures to assess health-related quality of life in PH is presented, with suggestions regarding incorporation of these tools in patient care and research. Finally, information on how current global threats such as pandemics, climate change and armed conflict may impact PH patients is offered, along with insights as to how they may be mitigated with advanced contingency planning.

The effect of COVID-19 on the non-COVID health outcomes of crisis-affected peoples: a systematic review

BACKGROUND

The COVID-19 pandemic posed considerable risks to populations affected by humanitarian crises in low- and middle-income countries (LMICs). However, there is limited understanding of how the pandemic may have affected non-COVID health outcomes among crisis-affected populations. Our aim was to examine the evidence on the impact of the COVID-19 pandemic on non-COVID-19 health outcomes for crisis-affected populations in LMICs.

METHODS

A systematic review methodology was applied following PRISMA guidelines. Eligibility criteria were: crisis-affected populations in LMICS; COVID-19; and all health topics, except for sexual and reproductive health which was covered in a linked review. Five bibliographic databases and additional grey literature sources were searched. The search period was from 2019 to 31 July 2022. Eligible papers were extracted and analysed using a narrative synthesis approach based on the study objectives and relevant health access and systems frameworks. A quality appraisal was also conducted.

FINDINGS

4320 articles were screened, and 15 eligible studies were identified and included in this review. Ten studies collected health outcomes data. Eight related to mental health, which generally showed worse mental health outcomes because of the pandemic, and pandemic-related stressors were identified. Two studies assessed physical health outcomes in children, while none addressed physical health outcomes among adults. Nine studies reported on access to healthcare, revealing worse access levels due to the pandemic and noting key barriers to care. Seven studies reported on the impact on health systems, with key challenges including reduced and distorted health care funding, reduced staff capacity, interrupted medicines and supplies, weak information and mixed-messaging, and weak leadership. All fifteen studies on the social determinants of health, particularly highlighting the effect of increasing poverty, the role of gender, and food insecurity on health outcomes. The quality of papers was limited overall.

CONCLUSION

This review found some limited evidence indicating negative mental health effects, increased barriers to accessing care, damage to health systems and magnified impacts on the social determinants of health for crisis-affected people during the COVID-19 pandemic. However, the small number and limited quality of the studies make the overall strength of evidence quite weak.

Implementing (and evaluating) peer support with people living with noncommunicable diseases in humanitarian settings

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.

Neurological Practice in the Time of War: Perspectives and Experiences from Ukraine

The full-scale Russian invasion of Ukraine has significantly impacted the country's healthcare system. Insufficient infrastructure, destruction of medical facilities, and barriers to prevention and treatment efforts hinder the provision of timely, high-quality care to our patients. We aim to describe the impact of the war on neurological care across Ukraine. In this article, leading national experts in stroke, epilepsy, multiple sclerosis, and movement disorders describe their personal experience and efforts in organizing and providing care since the war started in February 2022. A neurologist who cared for patients in Mariupol recounts the first weeks of the war when the city was under constant attacks. An international stroke expert describes the role of Task Force for Ukraine, a European Stroke Organization initiative to support the Ukrainian stroke community. We discuss a series of critical challenges facing Ukraine's neurologists, patients, and healthcare delivery system, including shortages of personnel and medical supplies, disrupted logistics, and lack of funding. In addition, we highlight various interventions and strategies aimed at counteracting these challenges, including international support, collaborations within Ukraine, and initiatives enhancing the resilience of the Ukrainian neurology community. As the war is ongoing, this article emphasizes the pressing need for continuous support and investment in the Ukrainian healthcare system to preserve guaranteed access to high-quality healthcare for the Ukrainian people during the war and in its aftermath. Insights from the essays can inform the development and implementation of effective strategies and interventions tailored to such extraordinary circumstances.

Implementing and evaluating integrated care models for non-communicable diseases in fragile and humanitarian settings

In this commentary, we advocate for the wider implementation of integrated care models for NCDs within humanitarian preparedness, response, and resilience efforts. Since experience and evidence on integrated NCD care in humanitarian settings is limited, we discuss potential benefits, key lessons learned from other settings, and lessons from the integration of other conditions that may be useful for stakeholders considering an integrated model of NCD care. We also introduce our ongoing project in North Lebanon as a case example currently undergoing parallel tracks of program implementation and process evaluation that aims to strengthen the evidence base on implementing an integrated NCD care model in a crisis setting.

Patient experiences of diabetes and hypertension care during an evolving humanitarian crisis in Lebanon: A qualitative study

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.

The hypertension cascade of care in the midst of conflict: the case of the Gaza Strip

Although hypertension constitutes a substantial burden in conflict-affected areas, little is known about its prevalence, control, and management in Gaza. This study aims to estimate the prevalence and correlates of hypertension, its diagnosis and control among adults in Gaza. We conducted a representative, cross-sectional, anonymous, household survey of 4576 persons older than 40 years in Gaza in mid-2020. Data were collected through face-to-face interviews, anthropometric, and blood pressure measurements. Hypertension was defined in anyone with an average systolic blood pressure ≥140 mmHg or average diastolic blood pressure ≥90 mmHg from two consecutive readings or a hypertension diagnosis. The mean age of participants was 56.9 ± 10.5 years, 54.0% were female and 68.5% were Palestinian refugees. The prevalence of hypertension was 56.5%, of whom 71.5% had been diagnosed. Hypertension was significantly higher among older participants, refugees, ex-smokers, those who were overweight or obese, and had other co-morbidities including mental illnesses. Two-thirds (68.3%) of those with hypertension were on treatment with one in three (35.6%) having their hypertension controlled. Having controlled hypertension was significantly higher in females, those receiving all medications for high blood pressure and those who never or rarely added salt to food. Investing in comprehensive but cost-effective initiatives that strengthen the prevention, early detection and timely treatment of hypertension in conflict settings is critical. It is essential to better understand the underlying barriers behind the lack of control and develop multi-sectoral programs to address these barriers.

The impact of UN high-level meetings on non-communicable disease funding and policy implementation

Since the original UN General Assembly 'special session' for HIV/AIDS, there has been a proliferation of health-related high-level meetings (HLMs), including three for non-communicable diseases (NCDs) and a 2019 HLM on universal health coverage that was closely aligned to the NCD framework. This paper attempts to assess the impact of these meetings in terms of funding allocations, domestic NCD policy implementation, as well as the level of international engagement with the HLMs by reviewing attendance data and records of statements ('interventions') made by country delegations. In contrast to HIV/AIDS, whilst NCDs have enjoyed a marked rise in international political exposure and high-level political commitments, these have not always translated into national policy implementation or greater funding allocations. This is true even for countries that have engaged most deeply with HLMs. These findings should give pause to NCD advocacy groups that expend substantial energy in calling for further high-level political commitments and highlight the need to focus support on the translation of commitments into sustainably funded action.

Insomnia and common mental disorder among patients with pre-existing chronic non-communicable diseases in southern Ethiopia: a survey during COVID-19 pandemic

Background

COVID-19 has been causing significant mental health problems and other health-related issues. Despite the fact that COVID-19 has a significant impact on chronic disease patients, there is scant research on insomnia, common mental health disorders (CMD), and their associated factors among chronic disease patients.

Objective

The purpose of this study was to assess the prevalence of insomnia and common mental disorders (CMD) and their associated factors among patients with pre-existing chronic NCDs in Sidama, southern Ethiopia.

Methods

A multicenter cross-sectional study was undertaken between June 1 and September 1, 2021. The study included 633 participants. CMD and insomnia were assessed using a 20-item Self-Reported Questionnaire (SRQ-20) and a 7-item Insomnia Severity Index (ISI) scale, respectively. To describe the various variables, descriptive statistics were used. We performed multivariable logistic regression analysis to identify independent factors associated with CMD and insomnia. A value of p < 0.05 was considered statistically significant at a 95% confidence interval.

Results

The prevalence of insomnia and CMD was found to be 39.3% and 46.8%, respectively. Being merchant (AOR = 0.33; 95% CI = 0.13, 0.82), having a diagnosis of diabetes mellitus (AOR = 1.89; 95% CI = 1.04, 3.46), comorbid diagnosis (AOR = 3.96; 95% CI = 2.27, 6.89), low social support (poor (AOR = 3.37; 95% CI = 1.51, 7.57) and moderate (AOR = 3.13; 95% CI = 1.46, 6.69)), symptoms of insomnia (AOR = 12.08; 95% CI = 7.41, 19.72) and poor quality of life (QOL) (AOR = 1.67; 95% CI = 1.04, 2.72) were independent predictors of CMD. We also found out that, having cardiovascular disorders (CVDs) (AOR = 2.48; 95% CI = 1.18, 5.19), CMD (AOR = 12.09; 95% CI = 7.46, 19.61), and poor QOL (AOR = 2.04; 95% CI = 1.27, 3.26) were significantly associated with insomnia symptoms.

Conclusion

Our study suggests that substantially high prevalence of CMD and insomnia. Significant association between CMD and occupation, diagnosis, comorbidity, social support, insomnia, and QOL were found. We also revealed that having CVDs, CMD, and poor QOL were significantly associated with insomnia symptoms. Therefore, dealing with the mental health problems of patients with chronic NCDs is an essential component of public health intervention during the COVID-19 pandemic.

Developing an integrated model of care for vulnerable populations living with non-communicable diseases in Lebanon: an online theory of change workshop

INTRODUCTION

The Syrian crisis, followed by a financial crisis, port explosion, and COVID-19, have put enormous strain on Lebanon's health system. Syrian refugees and the vulnerable host population have a high burden of Non-communicable Diseases (NCD) morbidity and unmet mental health, psychosocial and rehabilitation needs. The International Committee of the Red Cross (ICRC) recently introduced integrated NCD services within its package of primary care in Lebanon, which includes NCD primary health care, rehabilitation, and mental health and psychosocial support services. We aimed to identify relevant outcomes for people living with NCDs from refugee and host communities in northern Lebanon, as well as to define the processes needed to achieve them through an integrated model of care. Given the complexity of the health system in which the interventions are delivered, and the limited practical guidance on integration, we considered systems thinking to be the most appropriate methodological approach.

METHODS

A Theory of Change (ToC) workshop and follow-up meetings were held online by the ICRC, the London School of Hygiene and Tropical Medicine and the American University of Beirut in 2021. ToC is a participatory and iterative planning process involving key stakeholders, and seeks to understand a process of change by mapping out intermediate and long-term outcomes along hypothesised causal pathways. Participants included academics, and ICRC regional, coordination, and headquarters staff.

RESULTS

We identified two distinct pathways to integrated NCD primary care: a multidisciplinary service pathway and a patient and family support pathway. These were interdependent and linked via an essential social worker role and a robust information system. We also defined a list of key assumptions and interventions to achieve integration, and developed a list of monitoring indicators.

DISCUSSION

ToC is a useful tool to deconstruct the complexity of integrating NCD services. We highlight that integrated care rests on multidisciplinary and patient-centred approaches, which depend on a well-trained and resourced team, strong leadership, and adequate information systems. This paper provides the first theory-driven road map of implementation pathways, to help support the integration of NCD care for crises-affected populations in Lebanon and globally.

Assessment of the WHO non-communicable diseases kit for humanitarian emergencies in South Sudan: a retrospective, prospective, observational study

BACKGROUND

The WHO Non-Communicable Diseases Kit (NCDK) was developed to support care for non-communicable diseases (NCDs) in humanitarian settings. Targeting primary healthcare, each kit contains medicines and supplies that are forecasted to meet the needs of 10,000 people for 3 months. This study aimed to evaluate the NCDK deployment process, contents, usage and limitations, and to explore its acceptability and effectiveness among healthcare workers (HCWs) in South Sudan.

METHODS

This mixed-method observational study captured data from pre-and-post NCDK deployment. Six data collection tools included: (i) contextual analysis, (ii) semi-structured interviews, in addition to surveys measuring/assessing (iii) healthcare workers' knowledge about NCDs, and healthcare workers' perceptions of: (iv) health facility infrastructure, (v) pharmaceutical supply chain, and (vi) NCDK content. The pre- and post-deployment evaluations were conducted in four facilities (October-2019) and three facilities (April-2021), respectively. Descriptive statistics were used for quantitative data and content analysis for open-ended questions. A thematic analysis was applied on interviews findings and further categorized into four predetermined themes.

RESULTS

Compared to baseline, two of the re-assessed facilities had improved service availability for NCDs. Respondents described NCDs as a growing problem that is not addressed at a national level. After deployment, the same struggles were intensified with the COVID-19 pandemic. The delivery process was slow and faced delays associated with several barriers. After deployment, poor communications and the "push system" of inventories were commonly perceived by stakeholders, leading to expiry/disposal of some contents. Despite being out-of-stock at baseline, at least 55% of medicines were found to be unused post-deployment and the knowledge surveys demonstrated a need for improving HCWs knowledge of NCDs.

CONCLUSIONS

This assessment further confirmed the NCDK role in maintaining continuity of care on a short-term period. However, its effectiveness was dependent on the health system supply chain in place and the capacity of facilities to manage and treat NCDs. Availability of medicines from alternative sources made some of the NCDK medicines redundant or unnecessary for some health facilities. Several learnings were identified in this assessment, highlighting barriers that contributed to the kit underutilization.

Challenges of providing health services to patients with cardiovascular diseases during disasters in Iran: A qualitative study

BACKGROUND

Cardiovascular diseases are the most common causes of death in the world. Because of the rate of emergencies and disasters in the country, this study was conducted to investigate the challenges of providing health services to cardiovascular patients in emergencies and disasters in Iran.

MATERIALS AND METHODS

This conventional content analysis study was conducted in 2020. Subjects were selected from among 16 Iranian experts) epidemiologists, cardiologists, PhD in Disaster Health, and PhD in Nursing (using purposeful and snowball sampling methods. Data were collected using semi-structured interviews and were analyzed by the content analysis.

RESULTS

The results were obtained after analyzing the data in the pre-emergency phase (lack of training on medication and nutrition, lack of training vulnerable groups, lack of databases of cardiovascular patients, and lack of identification of patients before disasters), the emergency response phase (lack of sleep and rest patterns, lack of health forces, lack of blood pressure control, lack of proper nutrition, increased medication needs, and lack of mental health interventions), and the post-emergency phase (lack of planning, lack of management of patients' mental problems).

CONCLUSION

Developing strategies for planning, training, providing resources, and mental health during the three phases of the emergency management cycle for specific groups such as cardiovascular patients together with empowering these patients in the event of disasters is one of the key strategies which can be used after curbed emergencies and disasters to reduce the rate of mortality.

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

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

A systematic review of the burden of, access to services for and perceptions of patients with overweight and obesity, in humanitarian crisis settings

INTRODUCTION

Excess body weight causes 4 million deaths annually across the world. The number of people affected by humanitarian crises stands at a record high level with 1 in 95 people being forcibly displaced. These epidemics overlap. Addressing obesity is a post-acute phase activity in non-communicable disease management in humanitarian settings. Information is needed to inform guidelines and timing of interventions. The objective of this review was to explore the prevalence of overweight and obesity in populations directly affected by humanitarian crises; the cascade of care in these populations and perceptions of patients with overweight and obesity.

METHODS

Literature searches were carried out in five databases. Grey literature was identified. The population of interest was non-pregnant, civilian adults who had experience of humanitarian crises (armed conflict, complex emergencies and natural disasters). All study types published from January 1st, 2011, were included. Screening, data extraction and quality appraisal were carried out in duplicate. A narrative synthesis is presented.

RESULTS

Fifty-six reports from forty-five studies were included. Prevalence estimates varied widely across the studies and by subgroups. Estimates of overweight and obesity combined ranged from 6.4% to 82.8%. Studies were heterogenous. Global distribution was skewed. Increasing adiposity was seen over time, in older adults and in women. Only six studies were at low risk of bias. Body mass index was the predominant measure used. There were no studies reporting cascade of care. No qualitative studies were identified.

CONCLUSION

Overweight and obesity varied in crisis affected populations but were rarely absent. Improved reporting of existing data could provide more accurate estimates. Worsening obesity may be prevented by acting earlier in long-term crises and targeting risk groups. The use of waist circumference would provide useful additional information. Gaps remain in understanding the existing cascade of care. Cultural norms around diet and ideal body size vary.

Prehospital emergency care in a humanitarian environment: an overview of the ethical considerations

Recent history has demonstrated that UK Defence personnel can be used, potentially with little notice, in humanitarian disaster zones. The provision of prehospital emergency care (PHEC) in a humanitarian environment requires an innovative approach to overcome the technical challenges of a resource-limited setting. In addition to technical challenges, prehospital practitioners working in a humanitarian environment can expect to be faced with ethically testing situations that they are not familiar with in their usual practice. The organisational and individual ethical decision-making burden can result in significant harms. Therefore, the aim of this paper is to discuss the ethical considerations relevant to providing PHEC during a humanitarian disaster in order that personnel can be more prepared to optimally deliver care. This is a paper commissioned as a part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.

Lessons to learn from the analysis of routine health data from Moria Refugee Camp on Lesvos, Greece

Background

Refugees in humanitarian settings commonly experience many health needs and barriers to access healthcare; health data from these settings are infrequently reported, preventing effective healthcare provision. This report describes health needs of refugees in Moria Camp on Lesvos, Greece—Europe’s largest refugee camp.

Methods

A set of routinely collected service data of 18 131 consultations of 11 938 patients, attending a primary care clinic in the camp over 6 months in 2019–20, was analysed retrospectively, focusing on chronic health conditions.

Results

The most frequent chronic conditions were musculoskeletal pain (25.1%), mental health (15.9%), cardiac (12.7%) and endocrine conditions (8.9%). In all, 70.4% of consultations were for acute health problems, with high rates of injuries and wounds (20.8%), respiratory infections (12.5%), gastroenteritis (10.7%) and skin problems (9.7%), particularly scabies.

Conclusions

The prevalence of acute and chronic health problems is high in this setting, with some likely attributable to the deplorable living conditions in the camp. Despite its magnitude, the interpretability of routine health data is limited. A research agenda is identified, and a framework for chronic disease management in refugee camps is proposed.

A global mental health opportunity: How can cultural concepts of distress broaden the construct of immobility?

(Im)mobility studies often focus on people on the move, neglecting those who stay, are immobile, or are trapped. The duality of the COVID-19 pandemic and the climate crisis creates a global mental health challenge, impacting the most structurally oppressed, including immobile populations. The construct of immobility is investigated in the context of socio-political variables but lacks examination of the clinical psychological factors that impact immobility. Research is beginning to identify self-reported emotions that immobile populations experience through describing metaphors like feeling trapped. This article identifies links in the literature between Cultural Concepts of Distress drawn from transcultural psychiatry and immobility studies. Feeling trapped is described in mental health research widely. Among (im)mobile people and non-mobility contexts, populations experience various mental health conditions from depression to the cultural syndrome, nervios. The connection of feeling trapped to CCD research lends itself to potential utility in immobility research. The conceptualisation can support broadening and deepening the comprehension of this global mental health challenge - how immobile populations' experience feeling trapped. To broaden the analytical framework of immobility and incorporate CCD, evidence is needed to fill the gaps on the psychological aspects of immobility research.

Estimating treatment costs for uncomplicated diabetes at a hospital serving refugees in Kenya

Diabetes mellitus (DM) is increasing markedly in low- and middle-income countries where over three-quarters of global deaths occur due to non-communicable diseases. Unfortunately, these conditions are considered costly and often deprioritized in humanitarian settings with competing goals. Using a mixed methods approach, this study aimed to quantify the cost of outpatient treatment for uncomplicated type-1 (T1DM) and type-2 (T2DM) diabetes at a secondary care facility serving refugees in Kenya. A retrospective cost analysis combining micro- and gross-costings from a provider perspective was employed. The main outcomes included unit costs per health service activity to cover the total cost of labor, capital, medications and consumables, and overheads. A care pathway was mapped out for uncomplicated diabetes patients to identify direct and indirect medical costs. Interviews were conducted to determine inputs required for diabetes care and estimate staff time allocation. A total of 360 patients, predominantly Somali refugees, were treated for T2DM (92%, n = 331) and T1DM (8%, n = 29) in 2017. Of the 3,140 outpatient consultations identified in 2017; 48% (n = 1,522) were for males and 52% (n = 1,618) for females. A total of 56,144 tests were run in the setting, of which 9,512 (16.94%) were Random Blood Sugar (RBS) tests, and 90 (0.16%) HbA1c tests. Mean costs were estimated as: $2.58 per outpatient consultation, $1.37 per RBS test and $14.84 per HbA1c test. The annual pharmacotherapy regimens cost $91.93 for T1DM and $20.34 for T2DM. Investment in holistic and sustainable non-communicable disease management should be at the forefront of humanitarian response. It is expected to be beneficial with immediate implications on the COVID-19 response while also reducing the burden of care over time. Despite study limitations, essential services for the management of uncomplicated diabetes in a humanitarian setting can be modest and affordable. Therefore, integrating diabetes care into primary health care should be a fundamental pillar of long-term policy response by stakeholders.

Strengthening Diabetes Care in Humanitarian Crises in Low- and Middle-income Settings

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.

Models of care for non-communicable diseases for displaced populations in Iraq: a scoping review

Non-communicable diseases (NCDs) are the leading cause of death and disability globally. Their importance in humanitarian settings is increasingly recognised, but evidence about how best to address NCDs in these setting is limited. This scoping review aimed to explore models of NCD care for displaced populations in Iraq, in order to build evidence to design context adapted models of care. A search of key databases (Medline, Embase, Scopus, EconLit, Global Health, Web of Science, and the Iraqi Academic Scientific Journals) was conducted and complemented with grey literature and snowballing searches. Documents were included if they referred to models of NCD care for displaced populations. We synthesised the data using a conceptual model of care framework. The findings were reported according to the PRISMA guidelines for scoping reviews. We identified 4036 documents of which 22 were eligible for inclusion. Only six documents were peer-reviewed studies with most being internal reports, commentaries, or press releases. Of the 14 documents that reported on their methods, most applied quantitative approaches (n = 7), followed by mixed-methods (n = 5) and qualitative approaches (n = 2). Only one document reported on outcome data and none applied longitudinal study designs. Documents generally described individual framework dimensions, mostly centring around medicines, facility-based services, and selected access dimensions. Most dimensions had few or no references. The most common model for displaced populations in Iraq was primary-level centred care that complemented or supported existing—mostly tertiary—public health system structures. Additionally, private facilities played an important role and were frequently accessed by displaced populations in most settings. Quality of care, particularly patient-perceived quality, emerged as a critical factor for designing context-adapted models of NCD care. This review also identified a strong regionality of NCD care, particularly in terms of access rates and barriers. We concluded that there is a scarcity of evidence on the effectiveness of models of NCD care for displaced populations in Iraq, calling for capacity building initiatives focused on implementation research and evaluation.

Strengthening the primary care workforce to deliver high-quality care for non-communicable diseases in refugee settings: lessons learnt from a UNHCR partnership

Non-communicable disease (NCD) prevention and care in humanitarian contexts has been a long-neglected issue. Healthcare systems in humanitarian settings have focused heavily on communicable diseases and immediate life-saving health needs. NCDs are a significant cause of morbidity and mortality in refugee settings, however, in many situations NCD care is not well integrated into primary healthcare services. Increased risk of poorer outcomes from COVID-19 for people living with NCDs has heightened the urgency of responding to NCDs and shone a spotlight on their relative neglect in these settings. Partnering with the United Nations Refugee Agency (UNHCR) since 2014, Primary Care International has provided clinical guidance and Training of Trainer (ToT) courses on NCDs to 649 health professionals working in primary care in refugee settings in 13 countries. Approximately 2300 healthcare workers (HCW) have been reached through cascade trainings over the last 6 years. Our experience has shown that, despite fragile health services, high staff turnover and competing clinical priorities, it is possible to improve NCD knowledge, skills and practice. ToT programmes are a feasible and practical format to deliver NCD training to mixed groups of HCW (doctors, nurses, technical officers, pharmacy technicians and community health workers). Clinical guidance must be adapted to local settings while co-creating an enabling environment for health workers is essential to deliver accessible, high-quality continuity of care for NCDs. On-going support for non-clinical systems change is equally critical for sustained impact. A shared responsibility for cascade training—and commitment from local health partners—is necessary to raise NCD awareness, influence local and national policy and to meet the UNHCR’s objective of facilitating access to integrated prevention and control of NCDs.

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

Objectives: The COVID-19 pandemic has disrupted health care for non-communicable diseases (NCDs) and necessitated strategies to minimize contact with facilities. We aimed to examine factors influencing implementation of remote (non-facility-based) delivery approaches for people with hypertension and/or diabetes in low- and middle-income countries (LMICs), to inform NCD care delivery during health service disruption, including humanitarian crises. Methods: Our narrative review used a hermeneutic and purposive approach, including primary studies conducted in LMICs, which assessed implementation factors influencing remote NCD care delivery. Results were analyzed using the Consolidated Framework for Implementation Research. Results: Twenty-eight included studies revealed the strong influence of both internal organizational and broader contextual factors, such as community health worker policies or technological environment. Addressing patients' specific characteristics, needs and resources was important for implementation success. Conclusion: This review highlighted the multiple, complex, interdependent factors influencing implementation of remote NCD care in LMICs. Our findings may inform actors designing NCD care delivery in contexts where facility-based access is challenging. Implementation research is needed to evaluate context-adapted e-Health, community-based, and simplified clinical management strategies to facilitate remote NCD care.

Implementation of fixed-dose combination therapy for secondary prevention of atherosclerotic cardiovascular disease among Syrian refugees in Lebanon: a qualitative evaluation

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.

Diabetes management in the face of adversity: Experiences of asylum-seekers in Belgian reception centres

BACKGROUND

Diabetes poses a heavy burden on patients due to its progressive and chronic nature; it requires continuous management to promote a high-quality and long life. Disease management is especially challenging in emergency settings. We examined how displaced people with diabetes experienced managing their illness before and throughout the process of fleeing their home communities and seeking resettlement in Europe.

DESIGN

We designed an interview instrument with closed- and open-ended questions about diabetes diagnosis and management before fleeing the home country, during migration, stays in transit countries and reception in the European Union. We interviewed 20 asylum-seekers living in Belgian reception centres with diagnosed diabetes mellitus.

RESULTS

Primary topics emerging from interviews were availability, accessibility, and quality. Belgium was described as a setting with high availability, accessibility and quality of diabetes management components (medication, tools, care) compared with other settings before and during migration. Even in Belgium, maintaining a healthy diet as an asylum-seeker was difficult. Other concerns such as safety, other health issues and the asylum request itself often outweighed diabetes management.

CONCLUSIONS

Displaced people in non-Western countries need attention for nutrition and diabetes medicine, so aid agencies should consider providing for those needs. For people seeking asylum in the West and living in temporary facilities, care should be paid to the dietary options available for those with diabetes. For irregular migrants, diabetes can be deadly, and resources should be made available for their basic diabetes needs, even if they are not eligible for regular health services.

Chronic NCD care in crises: A qualitative study of global experts' perspectives on models of care for hypertension and diabetes in humanitarian settings

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.

Prevalence of non-communicable diseases and associated medication use among Syrian refugees in Lebanon: an analysis of country-wide data from the Sijilli electronic health records database

BACKGROUND

Globally, the number of forcibly displaced individuals has reached 70.8 million. Lebanon, a middle income country, hosts the highest number of refugees per capita worldwide. The majority of refugees are Syrians who have fled the Syrian war that started in 2011. The migration journey exposes refugees to increased susceptibility to a wide range of medical issues including non-communicable diseases (NCDs). This study aims to determine the prevalence of NCDs among adult Syrian refugees in Lebanon, with a focus on hypertension, diabetes, cardiovascular diseases (CVD) and cancer. The study also aims to explore factors potentially related to the prevalence figures and understand the medication use associated with these morbidities.

METHODS

This study is a secondary analysis of de-identified data from the "Sijilli Electronic Health Records for Refugees" Database comprising data on 10,082 Syrian refugees from across informal tented settlements located all over Lebanon. A total of 3255 records of Syrian refugees aged above 18 years old and reporting having at least one condition of the following were included in the analysis: hypertension, diabetes, cardiovascular diseases or cancer. Pearson's Chi-square, independent t-test, and multivariate logistic regressions were used for data analysis.

RESULTS

Hypertension was the most prevalent (10.0%) NCD among refugees, and a higher age was associated with higher NCDs prevalence. A strong linkage has been reported between smoking status and alcohol intake, and increased risk for NCDs. Study findings also revealed that the hypertension, diabetes and CVDs were mainly observed among refugees originating from Idlib, Aleppo and Homs. An association between medication use and location of diagnosis was noted, with females who were diagnosed before moving to Lebanon being more likely to take corresponding medications compared to those diagnosed in Lebanon, with no difference reported among males.

CONCLUSIONS

Our findings suggest that efforts should be directed towards the employment of innovative low-cost approaches for NCD detection and control among refugees, with a focus on the importance of use of adequate medication. Such efforts remain imperative to control the increasing burden of NCDs amongst refugee populations and improve equitable access to NCD services.

Preventing avoidable hospital admissions after emergency care in humanitarian settings: a cross-sectional review of Médecins Sans Frontières emergency departments

OBJECTIVES

The aim of this study was to describe the types of emergency departments (EDs), and the acuity, types and disposition of conditions managed at Médecins Sans Frontières (MSF)-supported EDs in humanitarian settings.

DESIGN, SETTING, PARTICIPANTS AND OUTCOME MEASURES

This was a multicentre, cross-sectional review of visits to MSF-supported EDs from 1 January 2014 to 31 December 2018. EDs were classified into advanced-level, general-level, paediatric and trauma. Variables analysed included: age group, condition, acuity and ED disposition. Frequencies and percentages stratified by ED type or region were reported.

RESULTS

MSF supported 26 EDs in 12 countries, with a total of 1 388 698 visits between 2014 and 2018. Most patients were discharged home (n=1 097 456, 79%), with nearly 0% mortality (n=4692). The majority of visits at general-level and paediatric EDs were for medical conditions (n=600 088, 78% and n=45 276, 96%, respectively), while nearly half of advanced-level EDs visits were for surgical conditions (n=201 189, 48%). Almost all visits to trauma EDs were for surgical conditions (n=148 078, 98%). Overall, most surgical conditions were traumatic injuries (n=484 008, 94%), the majority unintentional (n=425 487, 82%). The top three most common classified medical conditions were respiratory infections, malaria and diarrhoea.

CONCLUSIONS

EDs are critical in improving the agility and access to emergency care (EC) in humanitarian settings. This study demonstrated that EC provision resulted in the majority of patients being discharged from EDs, helping prevent avoidable hospital admissions. These results could help better understand the healthcare needs of vulnerable populations, improve responsiveness to emergency conditions and support programmatic planning in humanitarian settings.

Prevalence and risk factors for hypertension and diabetes among those screened in a refugee settlement in Uganda

Background

Diabetes and hypertension are increasingly prevalent in low and middle income countries, but they are not well documented in refugee settlements in these settings. We sought to estimate the prevalence and associated characteristics of diabetes and hypertension among adults presenting for clinic-based HIV testing in Nakivale Refugee Settlement in Uganda.

Methods

HIV-negative adults presenting to outpatient clinics for HIV testing at three health centers in Nakivale Refugee Settlement were enrolled from January 2019 through January 2020. Multi-lingual research assistants administered questionnaires aloud to ascertain medical history and sociodemographic information. The research assistants used standardized procedures to measure participants’ blood pressure to detect hypertension (systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg), and conduct a point-of-care blood glucose test for diabetes (random blood glucose ≥11.1 mmol/L with self-reported frequent urination or thirst, or fasting blood glucose ≥7.0 mmol/L regardless of symptoms), as per Uganda Ministry of Health guidelines. We used χ-square or Fisher’s exact test to test for differences in disease prevalence by refugee status and log-binomial or Poisson regression models to estimate associations of immigration status and country of origin, respectively, with hypertension and diabetes while controlling for age, sex, education level, and body mass index.

Results

Among 2127 participants, 1379 (65%) were refugees or asylum seekers and 748 (35%) were Ugandan nationals. Overall, 32 participants met criteria for diabetes (1.5%, 95% CI 1.1–2.1%) and the period prevalence was 2.3% (95% CI 1.7–3.0). There were 1067 (50%, 95% CI 48.0–52.2%) who met the criteria for pre-hypertension and 189 (9%, 95% CI 7.7–10.1%) for hypertension. These proportions did not vary by immigration status or country of origin in univariate tests or multivariable regression models.

Conclusions

Hypertension was common and diabetes was uncommon among those screened in a Ugandan refugee settlement. Routine blood pressure screening should be considered in this setting. Additional research could develop diabetes screening criteria to help identify at risk individuals in this limited resource setting.

Armed conflict and public health: into the 21st century

BACKGROUND

Many people worldwide are affected by conflict, and countries affected are less likely to meet the UN Sustainable Development Goals. This review outlines the effects of conflict on health and focuses on areas requiring more attention.

METHODS

We completed a search of the literature using Medline, Embase and Global Health.

RESULTS

Health effects of conflict include trauma; mental health; non-communicable diseases (NCDs); child health; sexual, reproductive and maternal health; and infectious diseases. Conflict damages health directly through fighting, and indirectly through wider socioeconomic effects. Health outcomes are influenced by pre-existing population health and demographics, and access to appropriate healthcare. Vulnerable populations (the elderly, children, neonates and women) are especially at risk.

CONCLUSION

Several areas pose key challenges including: tactics of war as a public health problem; a lack of focus on neonatal care and NCDs; the long-term consequences of conflict across a life-course and into future generations; and the need to focus on wellbeing beyond standard health parameters. Clear decisions about prioritisation need to be made. The effects on civilians must be documented and recorded. Further research is required to understand chronic health needs and effects on future generations, to support fair and equitable resource prioritisation to best meet the needs of conflict-affected populations.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Results

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

Conclusion

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

PROSPERO registration number

CRD42019125221

Models of care for patients with hypertension and diabetes in humanitarian crises: a systematic review

Care for non-communicable diseases, including hypertension and diabetes (HTN/DM), is recognized as a growing challenge in humanitarian crises, particularly in low- and middle-income countries (LMICs) where most crises occur. There is little evidence to support humanitarian actors and governments in designing efficient, effective, and context-adapted models of care for HTN/DM in such settings. This article aimed to systematically review the evidence on models of care targeting people with HTN/DM affected by humanitarian crises in LMICs. A search of the MEDLINE, Embase, Global Health, Global Indexus Medicus, Web of Science, and EconLit bibliographic databases and grey literature sources was performed. Studies were selected that described models of care for HTN/DM in humanitarian crises in LMICs. We descriptively analysed and compared models of care using a conceptual framework and evaluated study quality using the Mixed Methods Appraisal Tool. We report our findings according to PRISMA guidelines. The search yielded 10 645 citations, of which 45 were eligible for this review. Quantitative methods were most commonly used (n = 34), with four qualitative, three mixed methods, and four descriptive reviews of specific care models were also included. Most studies detailed primary care facility-based services for HTN/DM, focusing on health system inputs. More limited references were made to community-based services. Health care workforce and treatment protocols were commonly described framework components, whereas few studies described patient centredness, quality of care, financing and governance, broader health policy, and sociocultural contexts. There were few programme evaluations or effectiveness studies, and only one study reported costs. Most studies were of low quality. We concluded that an increasing body of literature describing models of care for patients with HTN/DM in humanitarian crises demonstrated the development of context-adapted services but showed little evidence of impact. Our conceptual framework could be used for further research and development of NCD models of care.

Addressing the double burden of the COVID-19 and noncommunicable disease pandemics: a new global governance challenge

Purpose

As the coronavirus disease 2019 (COVID-19) continues to spread across countries, it is becoming increasingly clear that the presence of pre-existing noncommunicable diseases (NCDs) dramatically increases the risk of aggravation in persons who contract the virus. The neglect in managing NCDs during emergencies may result in fatal consequences for individuals living with comorbidities. This paper aims to highlight the need for a paradigm shift in the governance of public health emergencies to simultaneously address NCD and noncommunicable disease (CD) pandemics while taking into account the needs of high-risk populations, underlying etiological factors, and the social, economic, and environmental determinants that are relevant for both CDs and NCDs.

Design/methodology/approach

The paper reviews the available global frameworks for pandemic preparedness to highlight the governance challenges of addressing the dual agenda of NCDs and CDs during a public health emergency. It proposes key strategies to strengthen multilevel governance in support of countries to better prepare for public health emergencies through the engagement of a wide range of stakeholders across sectors.

Findings

Addressing both CD and NCD pandemics during public health emergencies requires (1) a new framework that unites the narratives and overcomes service and system fragmentations; (2) a multisectoral and multistakeholder governance mechanism empowered and resourced to include stakeholders across sectors and (3) a prioritized research agenda to understand the political economy of pandemics, the role played by different political systems and actors and implementation challenges, and to identify combined strategies to address the converging agendas of CDs and NCDs.

Research limitations/implications

The article is based on the review of available published evidence.

Practical implications

The uptake of the strategies proposed will better prepare countries to respond to NCD and CD pandemics during public health emergencies.

Originality/value

The article is the first of its kind addressing the governance challenges of the dual pandemic of NCDs and CDs in emergencies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

BACKGROUND

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

METHODS AND FINDINGS

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

CONCLUSIONS

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

"To die is better for me", social suffering among Syrian refugees at a noncommunicable disease clinic in Jordan: a qualitative study

BACKGROUND

The conflict in Syria has required humanitarian agencies to implement primary-level services for non-communicable diseases (NCDs) in Jordan, given the high NCD burden amongst Syrian refugees; and to integrate mental health and psychosocial support into NCD services given their comorbidity and treatment interactions. However, no studies have explored the mental health needs of Syrian NCD patients. This paper aims to examine the interaction between physical and mental health of patients with NCDs at a Médecins Sans Frontières (MSF) clinic in Irbid, Jordan, in the context of social suffering.

METHODS

This qualitative study involved sixteen semi-structured interviews with Syrian refugee and Jordanian patients and two focus groups with Syrian refugees attending MSF's NCD services in Irbid, and eighteen semi-structured interviews with MSF clinical, managerial and administrative staff. These were conducted by research staff in August 2017 in Irbid, Amman and via Skype. Thematic analysis was used.

RESULTS

Respondents describe immense suffering and clearly perceived the interconnectedness of their physical wellbeing, mental health and social circumstances, in keeping with Kleinman's theory of social suffering. There was a 'disconnect' between staff and patients' perceptions of the potential role of the NCD and mental health service in alleviating this suffering. Possible explanations identified included respondent's low expectations of the ability of the service to impact on the root causes of their suffering, normalisation of distress, the prevailing biomedical view of mental ill-health among national clinicians and patients, and humanitarian actors' own cultural standpoints.

CONCLUSION

Syrian and Jordanian NCD patients recognise the psychological dimensions of their illness but may not utilize clinic-based humanitarian mental health and psychosocial support services. Humanitarian agencies must engage with NCD patients to elicit their needs and design culturally relevant services.

The COVID-19 Pandemic and Non-communicable Diseases-A Wake-up Call for Primary Health Care System Strengthening in Sub-Saharan Africa

Strengthening Primary Health Care Systems is the most effective policy response in low-and middle-income countries to protect against health emergencies, achieve universal health coverage, and promote health and wellbeing. Despite the Astana declaration on primary health care, respective investment is still insufficient in Sub-Sahara Africa. The SARS-CoV-2019 pandemic is a reminder that non-communicable diseases (NCDs), which are increasingly prevalent in Sub-Sahara Africa, are closely interlinked to the burden of communicable diseases, exacerbating morbidity and mortality. Governments and donors should use the momentum created by the pandemic in a sustainable and effective way by pivoting health spending towards primary health care.

Community and health staff perceptions on non-communicable disease management in El Salvador's health system: a qualitative study

Background

Non-communicable Diseases (NCDs) are the leading cause of global mortality and disability with a rising burden in low- and middle-income countries. Their multifactorial aetiology, and their requirement of long-term care, implies the need for comprehensive approaches. From 2009, the Ministry of Health (MoH) in El Salvador has developed a national public health system based on comprehensive primary health care. This study aims to describe the different stakeholders’ perceptions about the management of NCDs along the pathways of care in this health system.

Methods

During three fieldwork periods in 2018, three complementary qualitative data collection methods were deployed and conducted in settings with high prevalence of NCDs within El Salvador. First, illness narrative methodology was used to document the life histories of people living with a chronic disease and being treated in second and third level health facilities. Second, through social mapping, support resources that NCD patients used throughout the process of their illness within the same settings were analysed. Third, semi-structured interviews were conducted in the same locations, with both chronic patients and health personnel working at different levels of the primary health care setting. Participants were recruited through purposive and snowball sampling, and a deductive approach was implemented for coding during the analysis phase. After grouping codes into potential themes, a thematic framework was developed using a reflexive approach and following triangulation of the data.

Results

This innovative approach of combining three well-defined qualitative methods identified key implications for the implementation of a comprehensive approach to NCD management in resource-poor settings. The following elements are identified: 1) social risk factors and barriers to care; 2) patient pathways to NCD care; 3) available resources identified through social connections mapping; 4) trust in social connections; and 5) community health promotion and NCD prevention management.

Conclusions

The Salvadoran public health system has been able to strengthen its comprehensive approach to NCDs, combining a clinical approach – including long-term follow-up – with a preventive community-based strategy. The structural collaboration between the health system and the (self-) organised community has been essential for identifying failings, discuss tensions and work out adapted solutions.

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

Background

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

Methods

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

Results

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

Discussion

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

Conclusion

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

Health research in humanitarian crises: an urgent global imperative

Globally, humanitarian crises-such as armed conflict, forced displacement, natural disasters and major disease outbreaks-affect more people today than at any point in recorded history. These crises have immense acute and long-term health impacts on hundreds of millions of people, predominantly in low and middle-income countries (LMIC), yet the evidence base that informs how humanitarian organisations respond to them is weak. Humanitarian crises are often treated as an outlier in global health. However, they are an increasingly common and widespread driver of health that should be integrated into comprehensive approaches and strategies, especially if we hope to achieve ambitious global health targets such as the Sustainable Development Goals. The academic research community can play an important role in addressing the evidence gap in humanitarian health. There are important scientific questions of high public health relevance that can only be addressed by conducting research in humanitarian settings. While working in these settings is uniquely challenging, there are effective strategies that can be employed, such as using flexible and adaptive research methodologies, partnering with non-governmental organisations and other humanitarian actors, and devoting greater attention to issues of research ethics, community engagement, local LMIC-based partners, building humanitarian research capacity and collaborating across disciplines.

The governmental health policy-development process for Syrian refugees: an embedded qualitative case studies in Lebanon and Ontario

BACKGROUND

The unprecedented amount of resources dedicated to humanitarian aid has led many stakeholders to demand the use of reliable evidence in humanitarian aid decisions to ensure that desired impacts are achieved at acceptable costs. However, little is known about the factors that influence the use of research evidence in the policy development in humanitarian crises. We examined how research evidence was used to inform two humanitarian policies made in response to the Syrian refugee crisis.

METHODS

We identified two policies as rich potential case studies to examine the use of evidence in humanitarian aid policy decision-making: Lebanon's 2016 Health Response Strategy and Ontario's 2016 Phase 2: Health System Action Plan, Syrian Refugees. To study each, we used an embedded qualitative case study methodology and recruited senior decision-makers, policy advisors, and healthcare providers who were involved with the development of each policy. We reviewed publicly available documents and media articles that spoke to the factors that influence the process. We used the analytic technique of explanation building to understand the factors that influence the use of research evidence in the policy-development process in crisis zones.

RESULTS

We interviewed eight informants working in government and six in international agencies in Lebanon, and two informants working in healthcare provider organizations and two in non-governmental organizations in Ontario, for a total of 18 key informants. Based on our interviews and documentary analysis, we identified that there was limited use of research evidence and that four broad categories of factors helped to explain the policy-development process for Syrian refugees - development of health policies without significant chance for derailment from other government bodies (Lebanon) or opposition parties (Ontario) (i.e., facing no veto points), government's engagement with key societal actors to inform the policy-development process, the values underpinning the process, and external factors significantly influencing the policy-development process.

CONCLUSIONS

This study suggests that use of research evidence in the policy-development process for Syrian refugees was subordinate to key political factors, resulting in limited influence of research evidence in the development of both the Lebanese and Ontarian policy.

Challenges associated with providing diabetes care in humanitarian settings

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.

"What's happening in Syria even affects the rocks": a qualitative study of the Syrian refugee experience accessing noncommunicable disease services in Jordan

BACKGROUND

Humanitarian actors and host-countries in the Middle East and North Africa region are challenged with meeting the health needs of Syrian refugees and adjusting the response to contemporary humanitarian conditions - urban-based refugees, stressed host-country health systems and high NCD prevalence. Although several studies have explored NCD prevalence, utilization of services and barriers to access, these analyses took place prior to dramatic shifts in Jordanian health policy and did not account for nuances in health seeking and utilization behaviors or operational barriers. Accordingly, we aimed to understand the depth and nuances of Syrian refugees' experiences accessing NCD services in urban and semi-urban settings in Jordan.

METHODS

A qualitative study was conducted to explore the healthcare experiences of Syrian refugees in Jordan. The study team conducted 68 in-depth interviews with Syrian refugees in urban and semi-urban locations in central and northern Jordan.

RESULTS

The findings indicated four themes key to understanding the healthcare experience: (1) emotional distress is a central concern and is frequently highlighted as the trigger for a non-communicable disease or its exacerbation; (2) service provision across all sectors - government, NGO, private - is complex, inadequate, expensive and fragmented, making engagement with the health sector physically and financially burdensome; (3) given financial constraints, participants make harmful decisions that further damage their health in order to reduce financial burdens, and (4) host-community members actively exhibit solidarity with their refugee neighbors and specifically do so during emergency health episodes. The findings from this study can be used to inform program design for forcibly displaced persons with NCDs and identify points of entry for effective interventions.

CONCLUSIONS

Opportunities exist for humanitarian and host-country actors to provide more comprehensive NCD services and to improve the relevance and the quality of care provided to Syrian refugees in Jordan. Global and national funding will need to align with front-line realities and foster better coordination of services between host-country health systems, private actors and non-governmental organizations.