scholarly journals Delivering a primary-level non-communicable disease programme for Syrian refugees and the host population in Jordan: a descriptive costing study

2020 ◽  
Vol 35 (8) ◽  
pp. 931-940
Author(s):  
Éimhín Ansbro ◽  
Sylvia Garry ◽  
Veena Karir ◽  
Amulya Reddy ◽  
Kiran Jobanputra ◽  
...  
Keyword(s):  
Low Income ◽  
Care Delivery ◽  
Communicable Disease ◽  
Host Population ◽  
Syrian Refugees ◽  
Task Sharing ◽  
Primary Level ◽  
Costing Study ◽  
The Impact ◽  
Non Communicable Disease

Abstract The Syrian conflict has caused enormous displacement of a population with a high non-communicable disease (NCD) burden into surrounding countries, overwhelming health systems’ NCD care capacity. Médecins sans Frontières (MSF) developed a primary-level NCD programme, serving Syrian refugees and the host population in Irbid, Jordan, to assist the response. Cost data, which are currently lacking, may support programme adaptation and system scale up of such NCD services. This descriptive costing study from the provider perspective explored financial costs of the MSF NCD programme. We estimated annual total, per patient and per consultation costs for 2015–17 using a combined ingredients-based and step-down allocation approach. Data were collected via programme budgets, facility records, direct observation and informal interviews. Scenario analyses explored the impact of varying procurement processes, consultation frequency and task sharing. Total annual programme cost ranged from 4 to 6 million International Dollars (INT$), increasing annually from INT$4 206 481 (2015) to INT$6 739 438 (2017), with costs driven mainly by human resources and drugs. Per patient per year cost increased 23% from INT$1424 (2015) to 1751 (2016), and by 9% to 1904 (2017), while cost per consultation increased from INT$209 to 253 (2015–17). Annual cost increases reflected growing patient load and increasing service complexity throughout 2015–17. A scenario importing all medications cut total costs by 31%, while negotiating importation of high-cost items offered 13% savings. Leveraging pooled procurement for local purchasing could save 20%. Staff costs were more sensitive to reducing clinical review frequency than to task sharing review to nurses. Over 1000 extra patients could be enrolled without additional staffing cost if care delivery was restructured. Total costs significantly exceeded costs reported for NCD care in low-income humanitarian contexts. Efficiencies gained by revising procurement and/or restructuring consultation models could confer cost savings or facilitate cohort expansion. Cost effectiveness studies of adapted models are recommended.

scholarly journals 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

2020 ◽  
Author(s):  
Éimhín Ansbro ◽  
Tobias Homan ◽  
Jamil Quasim ◽  
Karla Bil ◽  
Mohammed Rasoul Tarawneh ◽  
...  
Keyword(s):  
Medication Adherence ◽  
Host Population ◽  
Syrian Refugees ◽  
Programme Implementation ◽  
Cross Sectional ◽  
Implementation Framework ◽  
Middle Income ◽  
Primary Level ◽  
Number Of Patients ◽  
The Impact

Abstract Background: In response to the rising global NCD burden, humanitarian actors have rapidly scaled-up NCD services in crisis-affected low-and-middle income countries. Using the RE-AIM implementation framework, we evaluated a multidisciplinary, primary-level model of NCD care for Syrian refugees and vulnerable Jordanians 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 December 2014 - December 2017; descriptive costing analysis of total annual, per-patient and per-consultation costs for 2015-2017 from the provider-perspective; clinical audit; medication adherence survey of 300 patients; 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 7 mmHg and 26 mg/dL respectively within six months of patient enrolment. Total costs increased in parallel with increased service complexity from INT$ 4,206,481 in 2015 to 6,739,438 in 2017. Staff reported that clinical guidelines were usable and patients’ self-reported medication adherence was high. Individual 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 of operating in a regulated, middle-income country. 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 highly acceptable. It achieved 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.

scholarly journals 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

PLoS Medicine ◽  
2021 ◽  
Vol 18 (1) ◽  
pp. e1003279 ◽  
Author(s):  
Éimhín Ansbro ◽  
Tobias Homan ◽  
David Prieto Merino ◽  
Kiran Jobanputra ◽  
Jamil Qasem ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Clinical Outcomes ◽  
Communicable Disease ◽  
Treatment Interruption ◽  
Diabetic Patients ◽  
Type Ii ◽  
Syrian Refugees ◽  
Primary Level ◽  
Factors Associated ◽  
Non Communicable Disease

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.

scholarly journals 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

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Éimhín Ansbro ◽  
Tobias Homan ◽  
Jamil Qasem ◽  
Karla Bil ◽  
Mohammed Rasoul Tarawneh ◽  
...  
Keyword(s):  
Medication Adherence ◽  
Household Survey ◽  
Host Population ◽  
Syrian Refugees ◽  
Programme Implementation ◽  
Cross Sectional ◽  
Implementation Framework ◽  
Primary Level ◽  
Number Of Patients ◽  
The Impact

Abstract Background In response to the rising global NCD burden, humanitarian actors have rapidly scaled-up NCD services in crisis-affected low-and-middle income countries. Using the RE-AIM implementation framework, we evaluated a multidisciplinary, primary level model of NCD care for Syrian refugees and vulnerable Jordanians delivered by MSF in Irbid, Jordan. We examined the programme’s Reach, Effectiveness, Adoption and acceptance, Implementation and Maintenance over time. Methods This mixed methods retrospective evaluation, undertaken in 2017, comprised secondary analysis of pre-existing cross-sectional household survey data; analysis of routine cohort data from 2014 to 2017; descriptive costing analysis of total annual, per-patient and per-consultation costs for 2015–2017 from the provider-perspective; a clinical audit; a medication adherence survey; and qualitative research involving thematic analysis of individual interviews and focus group discussions. Results The programme enrolled 23% of Syrian adult refugees with NCDs in Irbid governorate. The cohort mean age was 54.7 years; 71% had multi-morbidity and 9.9% self-reported a disability. The programme was acceptable to patients, staff and stakeholders. Blood pressure and glycaemic control improved as the programme matured and by 6.6 mmHg and 1.12 mmol/l respectively within 6 months of patient enrolment. Per patient per year cost increased 23% from INT$ 1424 (2015) to 1751 (2016), and by 9% to 1904 (2017). Cost per consultation increased from INT$ 209 to 253 (2015–2017). Staff reported that clinical guidelines were usable and patients’ self-reported medication adherence was high. Individual, programmatic and organisational challenges to programme implementation and maintenance included the impact of war and the refugee experience on Syrian refugees’ ability to engage; inadequate low-cost referral options; and challenges for MSF to rapidly adapt to operating in a highly regulated and complex health system. Essential programme adaptations included refinement of health education, development of mental health and psychosocial services and addition of essential referral pathways, home visit, physiotherapy and social worker services. Conclusion RE-AIM proved a valuable tool in evaluating a complex intervention in a protracted humanitarian crisis setting. This multidisciplinary programme was largely acceptable, achieving good clinical outcomes, but for a limited number of patients and at relatively high cost. We propose that model simplification, adapted procurement practices and use of technology could improve cost effectiveness without reducing acceptability, and may facilitate replication.

The Impact of Hurricane Maria on Individuals Living with Non-Communicable Disease in Puerto Rico: The experience of 10 communities

2021 ◽  
Author(s):  
Elizabeth L. Andrade ◽  
Amalis Cordova Mustafa ◽  
Courtney Riggle-vanSchagen ◽  
Megan Jula ◽  
Carlos E. Rodriguez-Diaz ◽  
...  
Keyword(s):  
Puerto Rico ◽  
Natural Hazards ◽  
Structural Damage ◽  
Communicable Disease ◽  
Community Level ◽  
Morbidity And Mortality ◽  
Health Concern ◽  
Increased Risk ◽  
The Impact ◽  
Non Communicable Disease

Abstract Background Coinciding with the rising non-communicable disease (NCD) prevalence worldwide is the increasing frequency and severity of natural hazards. Protecting populations with NCDs against natural hazards is ever more pressing given their increased risk of morbidity and mortality in disaster contexts. Methods This investigation examined Hurricane Maria’s impact across 10 communities in Puerto Rico to determine whether and how disaster impact and community attributes affected NCD management. We conducted 40 qualitative interviews with mayors, first responders, faith leaders, community leaders, and municipal employees, with 4 interviews per selected municipality. Using QSR NVivo software, we coded interview transcripts and created categorical community-level impact variables based on participant responses. We undertook thematic analysis to characterize community-level impact and consequences for NCD management, and to identify convergent and divergent themes. Using a matrix coding query, we compared NCD management experiences across communities by impact variables and community attributes. Results The delivery of healthcare, pharmacy, and dialysis services was compromised due to facility structural damage and ineffective contingencies for electrical power and water supply. The challenges resulting from power outages were immediate, and individuals who were reliant on life-sustaining medical equipment, dialysis, or the refrigeration of medications were most vulnerable. Inaccessible roadways and the need to travel greater distances to locate operational health services were major impediments to transporting patients in need of NCD care, with those requiring dialysis and living in remote, mountainous communities at highest risk due to landslides and lengthy roadway obstruction. These barriers were compounded by limited communication to locate services and coordinate care. Two weeks post-hurricane, emerging challenges to NCD management included widespread diesel fuel shortages for generators, and shortages in medications, oxygen, and medical supplies. In the weeks to months post-hurricane, the emergence or exacerbation of mental health disorders was characterized as a pressing health concern. Conclusions Study findings identify contributors to morbidity and mortality among individuals with NCDs following Hurricane Maria. The degree to which these impacts were experienced across communities with different characteristics is discussed, offering important lessons regarding the impact of catastrophic disasters on NCD management for improve community disaster resilience.

Association of Presence of a School Nurse With Increased Sixth-Grade Immunization Rates in Low-Income Arizona Schools in 2014–2015

2019 ◽  
Vol 36 (5) ◽  
pp. 360-368
Author(s):  
J. Mac McCullough ◽  
Rebecca Sunenshine ◽  
Ramona Rusinak ◽  
Patty Mead ◽  
Bob England
Keyword(s):  
Low Income ◽  
Communicable Disease ◽  
Sixth Grade ◽  
School Nurse ◽  
School Nurses ◽  
School Level ◽  
Licensed Practical Nurse ◽  
Vaccination Rates ◽  
Immunization Rates ◽  
The Impact

School nurses often play large roles in implementation of school vaccination requirements aimed at controlling the spread of communicable disease. We analyzed the association between the presence of a school nurse and school-level vaccination rates in Arizona. Using school-level data from Arizona sixth-grade schools ( n = 749), we regressed average sixth-grade school-level immunization rates on presence of a school nurse (registered nurse [RN] or licensed practical nurse [LPN]) and school-level socioeconomic status (SES), controlling for other school- and district-level characteristics. Schools with a nurse had higher overall vaccination rates than those without a nurse (96.1% vs. 95.0%, p < .01). For schools in the lowest SES quartile, the presence of a school nurse was associated with approximately 2 percentage point higher immunization rates. These findings add to the growing literature that defines the impact of school nurses on student health status and outcomes, emphasizing the value of school nurses, especially in lower SES schools.

scholarly journals Chronic Disease Stigma, Skepticism of the Health System, and Socio-economic Fragility: Qualitative Assessment of Factors Impacting Receptiveness to Group Medical Visits and Microfinance for Non-Communicable Disease Care in Rural Kenya

2020 ◽  
Author(s):  
Rae Dong ◽  
Claudia Leung ◽  
Mackenzie N. Naert ◽  
Violet Naanyu ◽  
Peninah Kiptoo ◽  
...  
Keyword(s):  
Chronic Disease ◽  
Health System ◽  
Health Workers ◽  
Care Delivery ◽  
Communicable Disease ◽  
Qualitative Assessment ◽  
East African Community ◽  
Group Medical Visits ◽  
Medical Visits ◽  
The Impact

Abstract Background: Non-communicable diseases (NCDs) are the leading cause of mortality in the world, and innovative approaches to NCD care delivery are being actively developed and evaluated. Combining the group-based experience of microfinance and group medical visits is a novel approach to NCD care delivery that has demonstrated beneficial impact in previous pilot studies. However, the contextual factors, facilitators, and barriers impacting wide-scale implementation of these approaches within a low- and middle-income country setting are not well known.Methods: Two types of qualitative group discussion were conducted: 1) mabaraza (singular, baraza), a traditional East African community gathering used to discuss and exchange information in large group settings; and 2) focus group discussions (FGDs) among rural clinicians, community health workers, microfinance group members, and patients with NCDs. Trained research staff members led the discussions using structured question guides. Content analysis was performed with NVivo using deductive and inductive codes that were then grouped into themes.Results: We conducted 5 mabaraza and 16 FGDs. A total of 205 individuals (113 men and 92 women) participated in the mabaraza, while 162 individuals (57 men and 105 women) participated in the FGDs. Participants expressed interest in participating in microfinance and group medical visits, but cited several key challenges: 1) stigma of chronic disease, 2) earned skepticism of the health system, and 3) socio-economic fragility.Conclusions: Our qualitative study revealed and illuminated actionable factors that could impact the success of implementation of group medical visits and microfinance initiatives for NCD care. While several challenges were highlighted, participants also felt that planned interventions could address and mitigate the impact of these dynamic factors. We anticipate that our approach and analysis provides new insights and methodological techniques that will be relevant to other low-resource settings worldwide.Trial Registration: Clinicaltrials.gov, NCT02501746, registration date: July 17, 2015

scholarly journals Epidemiology of surgery in a protracted humanitarian setting: a 20-year retrospective study of Nyarugusu Refugee Camp, Kigoma, Western Tanzania

BMC Surgery ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Sarah Rapaport ◽  
Hilary Ngude ◽  
Amber Lekey ◽  
Mohamed Abbas ◽  
Peter J. Winch ◽  
...  
Keyword(s):  
Communicable Disease ◽  
Descriptive Analysis ◽  
Host Population ◽  
Health Needs ◽  
Refugee Camps ◽  
Surgical Services ◽  
Procedural Volume ◽  
Consistent Increase ◽  
Humanitarian Setting ◽  
Non Communicable Disease

Abstract Background There are 80 million forcibly displaced persons worldwide, 26.3 million of whom are refugees. Many refugees live in camps and have complex health needs, including a high burden of non-communicable disease. It is estimated that 3 million procedures are needed for refugees worldwide, yet very few studies exist on surgery in refugee camps, particularly protracted refugee settings. This study utilizes a 20-year dataset, the longest dataset of surgery in a refugee setting to be published to date, to assess surgical output in a setting of protracted displacement. Methods A retrospective review of surgeries performed in Nyarugusu Camp was conducted using paper logbooks containing entries between November 2000 and September 2020 inclusive. Abstracted data were digitized into standard electronic form and included date, patient nationality, sex, age, indication, procedure performed, and anesthesia used. A second reviewer checked 10% of entries for accuracy. Entries illegible to both reviewers were excluded. Demographics, indication for surgery, procedures performed, and type of anesthesia were standardized for descriptive analysis, which was performed in STATA. Results There were 10,799 operations performed over the 20-year period. Tanzanians underwent a quarter of the operations while refugees underwent the remaining 75%. Ninety percent of patients were female and 88% were 18 years of age or older. Caesarean sections were the most common performed procedure followed by herniorrhaphies, tubal ligations, exploratory laparotomies, hysterectomies, appendectomies, and repairs. The most common indications for laparotomy procedures were ectopic pregnancy, uterine rupture, and acute abdomen. Spinal anesthesia was the most common anesthesia type used. Although there was a consistent increase in procedural volume over the study period, this is largely explained by an increase in overall camp population and an increase in caesarean sections rather than increases in other, specific surgical procedures. Conclusion There is significant surgical volume in Nyarugusu Camp, performed by staff physicians and visiting surgeons. Both refugees and the host population utilize these surgical services. This work provides context to the surgical training these settings require, but further study is needed to assess the burden of surgical disease and the extent to which it is met in this setting and others.

Is health coaching the next panacea in healthcare reform?

2021 ◽  
Vol 32 (8) ◽  
pp. 323-326
Author(s):  
Catherine Best
Keyword(s):  
Chronic Disease ◽  
Healthcare Reform ◽  
Healthy Lifestyle ◽  
Communicable Disease ◽  
Essential Element ◽  
Health Coaching ◽  
Health Conditions ◽  
The Impact ◽  
Non Communicable Disease

Health coaching aims to empower patients to self-manage their long-term health conditions. Catherine Best explores the effect health coaching can have on patients and the shifts that are required to deliver it Non-communicable diseases now account for the vast majority of deaths globally. It is recognised that personalised care is key to managing non-communicable disease and health coaching is considered an essential element. Health coaching is a developing field of practice that encourages patients to adopt healthy lifestyle behaviours that can avert the impact of chronic disease. This article explores the effect health coaching can have on patients and the shifts that are required to deliver it.

Sex differences in the impact of a community-based program for non-communicable disease prevention: The Isfahan Healthy Heart Program (IHHP)

2009 ◽  
Vol 17 (4) ◽  
pp. 257-263
Author(s):  
Nizal Sarrafzadegan ◽  
Masoumeh Sadeghi ◽  
Aliakbar Tavassoli ◽  
Masood Mohseni ◽  
Hasan Alikhasi ◽  
...  
Keyword(s):  
Sex Differences ◽  
Disease Prevention ◽  
Communicable Disease ◽  
Community Based ◽  
The Impact ◽  
Non Communicable Disease

scholarly journals A model for point of care testing for non-communicable disease diagnosis in resource-limited countries

2019 ◽  
Vol 4 ◽  
Author(s):  
Stuart Malcolm ◽  
Joane Cadet ◽  
Lindsay Crompton ◽  
Vincent DeGennaro
Keyword(s):  
Data Collection ◽  
Low Income ◽  
Communicable Disease ◽  
Point Of Care ◽  
Disease Diagnosis ◽  
Health Study ◽  
Point Of Care Testing ◽  
Physical Measurements ◽  
Geographical Regions ◽  
Non Communicable Disease

Abstract Non-communicable disease diagnosis frequently relies on biochemical measurements but laboratory infrastructure in low-income settings is often insufficient and distances to clinics may be vast. We present a model for point of care (POC) epidemiology as used in our study of chronic disease in the Haiti Health Study, in rural and urban Haiti. Point of care testing (POCT) of creatinine, cholesterol, and hemoglobin A1c as well as physical measurements of weight, height, and waist circumference allowed for diagnosis of diabetes, chronic kidney disease, dyslipidemias, and obesity. Methods and troubleshooting techniques for the data collection of this study are presented. We discuss our method of community-health worker (CHW) training, community engagement, study design, and field data collection. We also discuss the machines used and our quality control across CHWs and across geographical regions. Pitfalls tended to include equipment malfunction, transportation issues, and cultural differences. May this paper provide information for those attempting to perform similar diagnostic and screening studies using POCT in resource poor settings.

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