Evolution and lessons from an integrated service delivery network in North West Syria

Background

Northwest Syria (NWS) is a complex and extremely fragile operating environment, with more than 2.8 million people needing humanitarian assistance. To support a common standard of care delivery and enable coordination among the multiple providers in NWS, WHO developed an Essential Health Services package (EHSP) in 2016-17 and subsequently supported a facility network model to deliver the EHSP. This article provides an evaluation of the network to date, aiming to inform further development of the network and draw wider lessons for application of similar approaches in complex emergency settings.

Methods

This mixed method study included document review, participatory, qualitative and quantitative data, gathered in the first half of 2021. Participatory data came from two group model building workshops with 21 funders and implementers. Semi-structured interviews with 81 funders, health professionals and community members were also conducted. Analyses of the workshops and interviews was inductive, however a deductive approach was used for synthesising insights across this and the document review. The final component was a survey of health providers (59 health care professionals) and service users (233 pregnant women and 214 persons living with NCDs) across network and other comparable facilities, analysed using routine descriptive and inferential statistics. Findings across all methods were triangulated.

Results

The study finds that the network and its accompanying essential service package were relevant to the dynamic and challenging context, with high but shifting population needs and multiple uncoordinated providers. Judged in relation to its original goals of comprehensive, coordinated services, equitable access and efficient service delivery, the data indicate that gains have been made in all three areas through the network, although attribution is challenging, given the complex environment. The context remains challenging, with shifting boundaries and populations displaced by conflict, difficulties in retaining staff, the need to import medicines and supplies across borders, and governance gaps.

Conclusion

This study adds to a very limited literature on coordinated network approaches used to raise care quality and improve referrals and efficiency in a complex emergency setting. Although areas of ongoing challenge, including for sustainability, are noted, the network demonstrated some resilience strategies and can provide lessons for other similar contexts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-023-00510-3.

Social determinants and mental health needs of Palestine refugees and UNRWA responses in Gaza during the COVID-19 pandemic: a qualitative assessment

BACKGROUND

Due to pre-existing difficulties, refugees are especially susceptible to the negative effects of the pandemic; nonetheless, the pandemic's effect on this group is still unclear. The purpose of this study was to determine the effects of the COVID-19 pandemic on the mental health of Palestine refugees in Gaza by identifying the role of social determinants. During the pandemic, the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) enacted a number of policies and measures. The purpose of this research was to assess their efficacy and acceptability.

METHODS

This qualitative study took place between August and November 2020. Twenty-nine key-informant interviews were conducted remotely with UNRWA Headquarters, field and clinical staff in Gaza and with community members, aged ≥18 years and residing in Rafah and Jabalia camps. We sought informed consent verbally or via email. Data was coded based on the framework for social determinants of mental health.

RESULTS

Interview results indicated that the relationship might be unidirectional, with COVID-19 causing the degradation of living conditions and vice versa, with living conditions exacerbating the COVID-19 situation by facilitating virus transmission. In other instances, the association between mental health determinants and COVID-19 might be bidirectional. In terms of experiencing violence and anxieties, women, children, and daily-paid employees were significantly more disadvantaged than other groups in the community. UNRWA modified its service delivery techniques in order to continue providing essential services. In general, UNRWA's strategies throughout the pandemic were deemed beneficial, but insufficient to meet the needs of Gazans.

CONCLUSION

The pandemic highlights the need to go beyond disease treatment and prevention to address social determinants to improve refugees' health and reduce their susceptibility to future shocks. UNRWA has rapidly implemented telemedicine and mental telehealth services, making it imperative to assess the efficacy of these novel approaches to provide care at a distance. A long-term option may be to employ a hybrid strategy, which combines online and in-person therapy.

Health system resilience in the face of crisis: analysing the challenges, strategies and capacities for UNRWA in Syria

Health system resilience reflects the ability to continue service delivery in the face of extraordinary shocks. We examined the case of the United Nations Relief and Works Agency (UNRWA) and its delivery of services to Palestine refugees in Syria during the ongoing crisis to identify factors enabling system resilience. The study is a retrospective qualitative case study utilizing diverse methods. We conducted 35 semi-structured interviews with UNRWA clinical and administrative professionals engaged in health service delivery over the period of the Syria conflict. Through a group model building session with a sub-group of eight of these participants, we then elicited a causal loop diagram of health system functioning over the course of the war, identifying pathways of threat and mitigating resilience strategies. We triangulated analysis with data from UNRWA annual reports and routine health management information. The UNRWA health system generally sustained service provision despite individual, community and system challenges that arose during the conflict. We distinguish absorptive, adaptive and transformative capacities of the system facilitating this resilience. Absorptive capacities enabled immediate crisis response, drawing on available human and organizational resources. Adaptive capacities sustained service delivery through revised logistical arrangements, enhanced collaborative mechanisms and organizational flexibility. Transformative capacity was evidenced by the creation of new services in response to changing community needs. Analysis suggests factors such as staff commitment, organizational flexibility and availability of collaboration mechanisms were important assets in maintaining service continuity and quality. This evidence regarding alternative strategies adopted to sustain service delivery in Syria is of clear relevance to other actors seeking organizational resilience in crisis contexts.

The people living with HIV stigma survey UK 2015: HIV-related sexual rejection and other experiences of stigma and discrimination among gay and heterosexual men

We aim to understand the difference in stigma and discrimination, in particular sexual rejection, experienced between gay and heterosexual men living with HIV in the UK. The People Living with HIV StigmaSurvey UK 2015 recruited a convenience sample of persons with HIV through over 120 cross sector community organisations and 46 HIV clinics to complete an online survey. 1162 men completed the survey, 969 (83%) gay men and 193 (17%) heterosexual men, 92% were on antiretroviral therapy. Compared to heterosexual men, gay men were significantly more likely to report worrying about workplace treatment in relation to their HIV (21% vs. 11%), worrying about HIV-related sexual rejection (42% vs 21%), avoiding sex because of their HIV status (37% vs. 23%), and experiencing HIV-related sexual rejection (27% vs. 9%) in the past 12 months. In a multivariate logistic regression controlling for other sociodemographic factors, being gay was a predictor of reporting HIV-related sexual rejection in the past 12 months (aOR 2.17, CI 1.16, 4.02). Both gay and heterosexual men living with HIV experienced stigma and discrimination in the past 12 months, and this was higher for gay men in terms of HIV-related sexual rejection. Due to the high proportion of men reporting sexual rejection, greater awareness and education of the low risk of transmission of HIV among people on effective treatment is needed to reduce stigma and sexual prejudice towards people living with HIV.

Experiences of stigma and discrimination in social and healthcare settings among trans people living with HIV in the UK

The People Living with HIV StigmaSurvey UK 2015 was a community led national survey investigating experiences of people living with HIV in the UK in the past 12 months. Participants aged 18 and over were recruited through over 120 cross-sector community organisations and 46 HIV clinics to complete an anonymous online survey. Trans is an umbrella term which refers to individuals whose current gender identity is different to the gender they were assigned at birth. Trans participants self-identified via gender identity and gender at birth questions. Descriptive analyses of reported experiences in social and health care settings were conducted and multivariate logistic regression analyses were used to identify sociodemographic predictors of reporting being treated differently to non-HIV patients, and being delayed or refused healthcare treatment in the past 12 months. 31 out of 1576 participants (2%) identified as trans (19 trans women, 5 trans men, 2 gender queer/non-binary, 5 other). High levels of social stigma were reported for all participants, with trans participants significantly more likely to report worrying about verbal harassment (39% vs. 23%), and exclusion from family gatherings (23% vs. 9%) in the last 12 months, compared to cisgender participants. Furthermore, 10% of trans participants reported physical assault in the last 12 months, compared to 4% of cisgender participants. Identifying as trans was a predictor of reporting being treated differently to non-HIV patients (48% vs. 30%; aOR 2.61, CI 1.06, 6.42) and being delayed or refused healthcare (41% vs. 16%; aOR 4.58, CI 1.83, 11.44). Trans people living with HIV in the UK experience high levels of stigma and discrimination, including within healthcare settings, which is likely to impact upon health outcomes. Trans-specific education and awareness within healthcare settings could help to improve service provision for this demographic.

Energy balance and macronutrient distribution in relation to C-reactive protein and HbA1c levels among patients with type 2 diabetes

Background

Recently growing evidence indicates that obesity and diabetes are states of inflammation associated with elevated circulation of inflammatory mediators. Excess adiposity and oxidative stress, induced by feeding, may also lead to a state of low-grade inflammation.

Objective

This study aimed at investigating energy balance and distribution in relation to low-grade inflammation among patients with type 2 diabetes.

Design

A cross-sectional study included 198 male and female patients with type 2 diabetes. Patients’ weight, height, waist circumference, total body fat and truncal fat percent, energy, and macronutrient intake were measured. Venous blood specimens were collected, and levels of HbA1c and serum levels of high-sensitivity C-reactive protein (hs-CRP) were determined.

Results

After adjusting for covariates (body mass index, total body fat, and truncal fat), energy balance was positively correlated with hs-CRP and HbA1c. A positive energy balance was also associated with increased waist circumference and truncal fat percent (p<0.05). Total energy intake, percent energy from fat (p=0.04), and percent energy from proteins (p=0.03), but not percent energy from carbohydrates (p=0.12), were also correlated with higher hs-CRP levels among poorly glycemic-controlled patients.

Conclusion

Positive energy balance is associated with elevations in hs-CRP. Increased energy intake and increased percentages of energy from fat and protein are associated with elevated hs-CRP among patients with poor glycemic control.

Phosphatidate phosphohydrolases in liver, heart and adipose tissue of the JCR:LA corpulent rat and the lean genotypes: implications for glycerolipid synthesis and signal transduction

The activities of two distinct phosphatidate phosphohydrolases (PAP) were measured in livers, hearts and adipose tissues of the JCR:LA corpulent rat which is hyperphagic, hypertriglyceridaemic and insulin resistant. The specific activity of PAP-1, which requires Mg2+, was similar in the livers of lean and corpulent female rats and in male corpulent rats, but these activities were about 1.6-fold higher than in lean males. There was a correlation between the specific activity of PAP-1 and the concentrations of hepatic and serum triacylglycerols in the males, but not in the females. Chronic treatment of the corpulent rats with ethanol did not significantly alter the hepatic activity of PAP-1, or the concentrations of hepatic or serum triacylglycerols. Specific activities of PAP-1 in the heart were higher in the lean compared to the corpulent males. There was no significant difference for the females. Specific activities of PAP-1 were over 5-fold higher in the subcutaneous adipose tissue of the corpulent males and females compared to the lean genotypes. The differences were smaller (1.6-1.9-fold) in the gonadal adipose tissue of both sexes and in the peri-renal depot for the males. PAP-1 activity in the peri-renal depots of corpulent females was 23% lower than in lean females. PAP-2 activity was insensitive to N-ethylmaleimide and did not require Mg2+ for activity. Its activity was 1.5-2.0-fold higher in the livers and hearts of the lean male and female rats than in the corpulent genotypes. Chronic treatment with ethanol increased the activity of PAP-2 in the hearts of the corpulent males, but had no effect in the corpulent females. The specific activity of PAP-2 was higher in subcutaneous, gonadal and peri-renal adipose depots in the females and in the peri-renal depot of the corpulent males compared with the lean genotypes. Lean males had higher specific activities in all three depots compared to lean females. The tissue specificity and the sex differences in the specific activities of PAP-1 and PAP-2 are discussed in terms of their proposed functions in glycerolipid biosynthesis and signal transduction. It is proposed that a decreased activity of PAP-2 could be involved in the insulin insensitivity in the corpulent rats.

Effects of okadaic acid on the activities of two distinct phosphatidate phosphohydrolases in rat hepatocytes

Incubation of hepatocytes with okadaic acid displaced the N-ethylmaleimide-sensitive phosphatidate phosphohydrolase from the membrane fraction into the cytosol and partially prevented the oleate-induced movement of phosphohydrolase from cytosol to membranes. However, higher concentrations of oleate still caused translocation and activation of the phosphohydrolase. This enzyme is stimulated by Mg2+, and is probably involved in glycerolipid synthesis. Okadaic acid also decreased the concentration of diacylglycerol within the hepatocytes. Okadiac acid had no observable effect on the activity of an N-ethylmaleimide-insensitive phosphatidate phosphohydrolase which remained firmly attached to membranes. This activity is not stimulated by Mg2+ and is probably involved in signal transduction by the phospholipase D pathway.

Plasma membrane fractions from rat liver contain a phosphatidate phosphohydrolase distinct from that in the endoplasmic reticulum and cytosol

Assays for two distinct phosphatidate phosphohydrolase activities were established based upon a differential inhibition by N-ethylmaleimide (NEM). The activity that is insensitive to this reagent in rat liver is predominantly in the plasma membrane fraction, whereas the NEM-sensitive activity is in the cytosolic and microsomal fractions. The NEM-insensitive activity is further distinguished from the NEM-sensitive phosphohydrolase by: (a) being relatively stable to heat; (b) not being inhibited by phenylglyoxal, butane-2,3-dione, cyclohexane-1,2-dione, 2,4-dinitrofluorobenzene, 7-chloro-4-nitrobenz-2-oxa-1,3-diazole, and diethyl pyrocarbonate; (c) being inhibited by NaF and phosphatidylcholine; and (d) not being stimulated by Mg2+. The NEM-insensitive activity was specific for phosphatidate. Both phosphohydrolase activities could be inhibited by chlorpromazine, propranolol, sphingosine, and spermine. The NEM-sensitive phosphatidate phosphohydrolase activity was increased by incubating hepatocytes for 12 h with glucagon and dexamethasone, and this effect was antagonized by insulin. The NEM-sensitive phosphohydrolase is concluded to be involved in glycerolipid synthesis. The activity of the NEM-insensitive phosphohydrolase was not altered by preincubation of rat hepatocytes in the short or long term with vasopressin, glucagon, insulin, triiodothyronine, or dexamethasone, but it might be modulated indirectly by sphingosine. The NEM-insensitive enzyme of the plasma membranes could be involved in signal transduction via the agonist-stimulated degradation of phosphatidylcholine through the phospholipase D pathway.

Differences in the properties of A1-type adenosine receptors in rat white and brown adipocytes

1. White adipocytes were found to be more responsive than brown adipocytes to inhibition of lipolysis by the A1 adenosine receptor agonist phenylisopropyladenosine. 2. Radioligand binding studies with plasma membranes isolated from the two adipocyte types indicated differences in the properties of the A1 receptors. Kd values (high and low affinity) for phenylisopropyladenosine were higher in membranes from brown adipocytes. The Kd values for the antagonist dipropylcyclopentylxanthine were also higher in brown adipocyte membranes. 3. The effects of guanine nucleotides in converting adipocyte A1 receptors into a low-affinity state were enhanced by dithiothreitol.

Changes in brown-adipose-tissue mitochondrial processes in streptozotocin-diabetes

Diabetic rats were used as a source of brown-adipose-tissue mitochondria 2 days after a single subcutaneous injection of streptozotocin (100 mg/kg). Diabetes caused an 80% decrease in carnitine-dependent oxidation of palmitoyl-CoA and a 50-60% decrease in overt carnitine palmitoyltransferase activity. An additional lesion in brown-adipose-tissue mitochondrial oxidative capacity was also indicated, since diabetes increased by 30-50% the rate of oxidation under uncoupled conditions of several respiratory substrates (i.e. malate + palmitoylcarnitine, malate + pyruvate, succinate, NNN'N'-tetramethyl-p-phenylenediamine + ascorbate). This decrease in mitochondrial function was accompanied by an approx. 30% decrease in the abundance of cytochromes (a + a3) and total cytochromes b.

A novel assay for 5'-nucleotidase using 1,N6-etheno-AMP as substrate, and comments on the properties of the reaction product, ethenoadenosine

A novel assay for 5'-nucleotidase is described in which 1,N6-etheno-AMP is converted into ethenoadenosine. The product ethenoadenosine is neither a substrate for nor an inhibitor of adenosine deaminase. Ethenoadenosine appears to have little effect at adenosine receptors on adipose-tissue cells.

Factors influencing the altered thermogenic response of rat brown adipose tissue in streptozotocin-diabetes

1. Adipocytes were isolated from the interscapular brown fat of male rats maintained at 21 degrees C. These animals were controls, streptozotocin-diabetics or 2-day insulin-treated diabetics. 2. With adipocytes from diabetic animals, maximum rates of noradrenaline-stimulated O2 uptake were decreased by 58%, and the Bmax. of [3H]GDP binding to mitochondria was decreased by 55%. Insulin administration reversed both of these changes. 3. Streptozotocin-diabetes increased basal lipolysis in adipocytes incubated with adenosine deaminase (1 unit/ml), decreased the EC50 (concn. giving 50% of maximum effect) for noradrenaline, but did not change the maximum rate of noradrenaline-stimulated lipolysis. Except for some small differences at very low concentrations (10-100 pM), diabetes or insulin treatment did not alter the sensitivity of noradrenaline-stimulated lipolysis or O2 uptake to the inhibitory effect of N6-phenylisopropyladenosine. It is therefore concluded that the lesion(s) in thermogenesis in diabetes are not attributable to any changes in lipolysis. 4. Blood flow through interscapular brown fat, measured by accumulation of [14C]DDT [14C-labelled 1,1,1-trichloro-2,2-bis-(p-chlorophenyl)ethane] was increased by 2.3-fold 70 min after a single administration of insulin to diabetic rats. This treatment decreased blood flow through epididymal white fat by 58%. 5. Propranolol treatment of diabetic rats muted the ability of insulin treatment to increase the maximum rate of noradrenaline-stimulated O2 uptake, suggesting that this action of insulin may be a secondary one rather than a direct effect of the hormone on the adipocytes.

Enzymes involved in adenosine metabolism in rat white and brown adipocytes. Effects of streptozotocin-diabetes, hypothyroidism, age and sex differences

1. Adipocytes were isolated from epididymal white fat and interscapular brown fat of male rats, and activities of 5'-nucleotidase, adenosine deaminase and adenosine kinase were measured in cell extracts. 2. 5'-Nucleotidase activity in white adipocytes was increased in streptozotocin-diabetes, decreased in hypothyroidism and increased with age. That activity in brown adipocytes was unchanged in diabetes, decreased in hypothyroidism and increased with age. 5'-Nucleotidase activity was higher in white adipocytes from female rats. 3. Adenosine deaminase activity in white adipocytes was increased in diabetes, decreased in hypothyroidism and increased with age. That activity in brown adipocytes was decreased in diabetes and hypothyroidism. 4. Adenosine kinase activity in both cell types was unchanged in diabetes or hypothyroidism, but increased with age.

Effects of 2-mercaptopropionyl glycine on radiation-induced lipid peroxidation in liposomes and in rat liver microsomal suspensions

gamma-Irradiation of rat liver microsomal suspensions resulted in the accumulation of both malondialdehyde (MDA) and lipid hydroperoxides. The presence of 2-mercaptopropionylglycine (MPG) during the irradiation period decreased the formation of MDA and lipid hydroperoxides in a dose (MPG)-dependent manner. This may be attributed to the ability of MPG to scavenge the free radicals produced by irradiation. Post-irradiation incubation of microsomes further enhanced the production of both MDA and lipid hydroperoxides; when high concentrations of MPG were present during the incubations the production of MDA and lipid hydroperoxides was substantially decreased. This antioxidant role of MPG was demonstrated for both pre-irradiated microsomes and liposomes and is thought to be due to the conversion of the hydroperoxy to hydroxy fatty acids within the lipid bilayer, as well as the scavenging action on initiating free radicals.

Separation of plasma from whole blood by membrane filtration in oscillatory flows

This paper describes the performance of a microfiltration plasmapheresis unit operating with reversing oscillatory flows. The device consists of a flat channel duct between cellulose nitrate membranes and was used to extract plasma from anticoagulated fresh whole bovine blood. Measurements were made of plasma flux, haematocrit concentration, haemolysis and protein sieving coefficients. The effects on plasma flux are reported for alterations in the stroke and frequency of flow pulsations, transmembrane pressure, membrane properties and blood throughput. It was found that the imposition of oscillatory flows enhanced the plasma extraction rate by a factor of 3, producing about 0.9 litre/min/m2 membrane.

Metabolism of cholesteryl ester in monolayers of bovine adrenal cortical cells. Effect of an inhibitor of acyl-CoA: cholesterol acyltransferase

The effect of Sandoz compound 58-035 on cholesterol metabolism in monolayers of bovine adrenal cortical cells was studied. 58-035 did not inhibit cholesterol ester hydrolase, cholesterol side-chain cleavage, cholesterol synthesis from acetate, or cortisol synthesis in cells stimulated with ACTH or in unstimulated cells. It was, however, an effective inhibitor of formation of cholesteryl ester. The rate of formation of cholesteryl ester in the cells was increased by additional cholesterol derived from mevalonic acid or from the hydrolysis of intracellular lipid droplets. 58-035 caused an increase in the secretion of cortisol from cells maintained on a limited supply of cholesterol from bovine lipoproteins added to the medium when the cells were not stimulated with ACTH. This effect was not observed in stimulated cells. The results suggest that the bovine adrenal cortical cell can direct the flux of exogenous cholesterol very precisely according to its metabolic state.