• Access to Care for Non-Communicable Diseases in Mosul, Iraq Between 2014 and 2017: A Rapid Qualitative Study.

      Baxter, LM; Eldin, MS; Al Mohammed, A; Saim, M; Checchi, F (BioMed Central, 2018-12-29)
      During June 2014 to April 2017, the population of Mosul, Iraq lived in a state of increasing isolation from the rest of Iraq due to the city's occupation by the Islamic State group. As part of a study to develop a generalisable method for estimating the excess burden of non-communicable diseases (NCDs) in conflict-affected settings, in April-May 2017 we conducted a brief qualitative study of self-reported care for NCDs among 15 adult patients who had fled Mosul and presented to Médecins Sans Frontières clinics in the Kurdistan region with hypertension and/or diabetes. Participants reported consistent barriers to NCD care during the so-called Islamic State period, including drug shortages, insecurity and inability to afford privately sold medication. Coping strategies included drug rationing. By 2016, all patients had completely or partially lost access to care. Though limited, this study suggests a profound effect of the conflict on NCD burden.
    • The burden of diabetes and use of diabetes care in humanitarian crises in low-income and middle-income countries

      Kehlenbrink, S; Smith, J; Ansbro, E; Fuhr, D; Cheung, A; Ratnayake, R; Boulle, P; Jobanputra, K; Perel, P; Roberts, B (Elsevier, 2019-03-13)
      Human suffering as a result of natural disasters or conflict includes death and disability from non-communicable diseases, including diabetes, which have largely been neglected in humanitarian crises. The objectives of this Series paper were to examine the evidence on the burden of diabetes, use of health services, and access to care for people with diabetes among populations affected by humanitarian crises in low-income and middle-income countries, and to identify research gaps for future studies. We reviewed the scientific literature on this topic published between 1992 and 2018. The results emphasise that the burden of diabetes in humanitarian settings is not being captured, clinical guidance is insufficient, and diabetes is not being adequately addressed. Crisis-affected populations with diabetes face enormous constraints accessing care, mainly because of high medical costs. Further research is needed to characterise the epidemiology of diabetes in humanitarian settings and to develop simplified, cost-effective models of care to improve the delivery of diabetes care during humanitarian crises.
    • Cardiovascular Disease Risk and Prevention Amongst Syrian Refugees: Mixed Methods Study of Médecins Sans Frontières Programme in Jordan

      Collins, D; Jobanputra, K; Frost, T; Muhammed, S; Ward, A; Shafei, A; Fardous, T; Gabashneh, S; Heneghan, C (BioMed Central, 2017-07-17)
      The growing burden of non-communicable diseases (NCDs) presented new challenges for medical humanitarian aid and little was known about primary health care approaches for these diseases in humanitarian response. We aimed to evaluate Médecins Sans Frontières (MSF's) use of total CVD risk based prevention strategies amongst Syrian refugees in northern Jordan to identify opportunities to improve total CVD risk based guidance for humanitarian settings.
    • Care of Non-Communicable Diseases in Emergencies

      Slama, S; Kim, HJ; Roglic, G; Boulle, P; Hering, H; Varghese, C; Rasheed, S; Tonelli, M (Elsevier, 2016-09-13)
    • Challenges associated with providing diabetes care in humanitarian settings

      Boulle, P; Kehlenbrink, S; Smith, J; Beran, D; Jobanputra, K (Elsevier, 2019-03-13)
      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.
    • Cost and affordability of non-communicable disease screening, diagnosis and treatment in Kenya: Patient payments in the private and public sectors

      Subramanian, S; Gakunga, R; Kibachio, J; Gathecha, G; Edwards, P; Ogola, E; Yonga, G; Busakhala, N; Munyoro, E; Chakaya, J; et al. (Public Library of Science, 2018-01-05)
      The prevalence of non-communicable diseases (NCDs) is rising in low- and middle-income countries, including Kenya, disproportionately to the rest of the world. Our objective was to quantify patient payments to obtain NCD screening, diagnosis, and treatment services in the public and private sector in Kenya and evaluate patients' ability to pay for the services.
    • Cost of Hospitalization for Non-Communicable Diseases in India: Are We Pro-Poor?

      Tripathy, J P; Prasad, B M; Shewade, H D; Kumar, A M; Zachariah, R; Chadha, S; Tonsing, J; Harries, A D (Wiley-Blackwell, 2016-06-02)
      Objectives: To estimate out-of-pocket (OOP) expenditure due to hospitalization from NCDs and its impact on households in India.
    • Delivering a primary-level non-communicable disease programme for Syrian refugees and the host population in Jordan: a descriptive costing study

      Ansbro, E; Garry, S; Karir, V; Reddy, A; Jobanputra, K; Fardous, T; Sadique, Z (Oxford University Press, 2020-07-04)
      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.
    • Diabetes Care in a Complex Humanitarian Emergency Setting: A Qualitative Evaluation

      Murphy, A; Biringanine, M; Roberts, B; Stringer, B; Perel, P; Jobanputra, K (BioMed Central, 2017-06-23)
      Evidence is urgently needed from complex emergency settings to support efforts to respond to the increasing burden of diabetes mellitus (DM). We conducted a qualitative study of a new model of DM health care (Integrated Diabetic Clinic within an Outpatient Department [IDC-OPD]) implemented by Médecins Sans Frontières (MSF) in Mweso Hospital in eastern Democratic Republic of Congo (DRC). We aimed to explore patient and provider perspectives on the model in order to identify factors that may support or impede it.
    • Diabetes in humanitarian crises: the Boston Declaration.

      Kehlenbrink, S; Jaacks, M; Aebischer Perone, S; Ansbro, E; Ashbourne, E; Atkinson, C; Atkinson, M; Atun, R; Besancon, S; Boulle, P; et al. (Elsevier, 2019-08)
    • A First Country-Wide Review of Diabetes Mellitus Care in Bhutan: Time to Do Better

      Zam, K; Kumar, A M; Achanta, S; Bhat, P; Naik, B; Zangpo, K; Dorji, T; Wangdi, Y; Zachariah, R (BMC Public Health, 2015-09-21)
      There is an increasing trend of non-communicable diseases in Bhutan including Diabetes Mellitus (DM). To address this problem, a National Diabetes Control Programme was launched in 1996. There is anecdotal evidence that many patients do not visit the DM clinics regularly, but owing to lack of cohort monitoring, the magnitude of such attrition from care is unknown. Knowledge of the extent of this problem will provide a realistic assessment of the situation on the ground and would be helpful to initiate corrective actions. In this first country-wide audit, we thus aimed to determine among type 2 DM patients registered for care the i) pre-treatment attrition ii) one-year programme outcomes including retention in care, died and Lost-to-follow-up (LTFU, defined as not having visited the clinic at least once within a year of registration) iii) factors associated with attrition from care (death + LTFU) and iv) quality of follow-up care, measured by adherence to recommended patient-monitoring protocols including glycaemic control.
    • Global Burden of Rheumatic Heart Disease

      Rossi, G (Massachusetts Medical Society, 2018-01-04)
    • Language and beliefs in relation to noma: a qualitative study, northwest Nigeria

      Farley, E; Lenglet, A; Abubakar, A; Bil, K; Fotso, A; Oluyide, B; Tirima, S; Mehta, U; Stringer, B (PLoS, 2020-01-23)
      BACKGROUND: Noma is an orofacial gangrene that rapidly disintegrates the tissues of the face. Little is known about noma, as most patients live in underserved and inaccessible regions. We aimed to assess the descriptive language used and beliefs around noma, at the Noma Children's Hospital in Sokoto, Nigeria. Findings will be used to inform prevention programs. METHODS: Five focus group discussions (FGD) were held with caretakers of patients with noma who were admitted to the hospital at the time of interview, and 12 in-depth interviews (IDI) were held with staff at the hospital. Topic guides used for interviews were adapted to encourage the natural flow of conversation. Emergent codes, patterns and themes were deciphered from the data derived from IDI's and FGDs. RESULTS: Our study uncovered two main themes: names, descriptions and explanations for the disease, and risks and consequences of noma. Naming of the disease differed between caretakers and heath care workers. The general names used for noma illustrate the beliefs and social system used to explain the disease. Beliefs were varied; participant responses demonstrate a wide range of understanding of the disease and its causes. Difficulty in accessing care for patients with noma was evident and the findings suggest a variety of actions taking place before reaching a health center or health worker. Patient caretakers mentioned that barriers to care included a lack of knowledge regarding this medical condition, as well as a lack of trust in seeking medical care. Participants in our study spoke of the mental health strain the disease placed on them, particularly due to the stigma that is associated with noma. CONCLUSIONS: Caretaker and practitioner perspectives enhance our understanding of the disease in this context and can be usedto improve treatment and prevention programs, and to better understand barriers to accessing health care. Differences in disease naming illustrate the difference in beliefs about the disease. This has an impact on health seeking behaviours, which for noma cases has important ramifications on outcomes, due to the rapid progression of the disease.
    • Non-communicable diseases - programmatic and clinical guidelines

      Jobanputra, Kiran; Manson Unit, MSF UK, London (2016-12)
    • Peripheral Neuropathy in a Diabetic Child Treated with Linezolid for Multidrug-Resistant Tuberculosis: A Case Report and Review of the Literature

      Swaminathan, A; du Cros, P; Seddon, J; Mirgayosieva, S; Asladdin, R; Dusmatova, Z (BioMed Central, 2017-06-12)
      Extensively drug-resistant (XDR) tuberculosis (TB) and multidrug resistant (MDR)-TB with additional resistance to injectable agents or fluoroquinolones are challenging to treat due to lack of available, effective drugs. Linezolid is one of the few drugs that has shown promise in treating these conditions. Long-term linezolid use is associated with toxicities such as peripheral and optic neuropathies. Diabetes mellitus (DM), especially when uncontrolled, can also result in peripheral neuropathy. The global burden of DM is increasing, and DM has been associated with a three-fold increased risk of developing TB disease. TB and DM can be a challenging combination to treat. DM can inhibit the host immune response to tuberculosis infection; and TB and some anti-TB drugs can worsen glycaemic control. A child experiencing neuropathy that is a possible complication of both DM and linezolid used to treat TB has not been reported previously. We report peripheral neuropathy in a 15-year-old boy with type 1 DM, diagnosed with MDR-TB and additional resistance to injectable TB medications.
    • Prevalence of non-communicable diseases and access to care among non-camp Syrian refugees in northern Jordan

      Rehr, M; Shoaib, M; Ellithy, S; Okour, S; Ariti, C; Ait-Bouziad, I; van den Bosch, P; Deprade, A; Altarawneh, M; Shafei, A; et al. (BioMed Central, 2018-07-11)
      Tackling the high non-communicable disease (NCD) burden among Syrian refugees poses a challenge to humanitarian actors and host countries. Current response priorities are the identification and integration of key interventions for NCD care into humanitarian programs as well as sustainable financing. To provide evidence for effective NCD intervention planning, we conducted a cross-sectional survey among non-camp Syrian refugees in northern Jordan to investigate the burden and determinants for high NCDs prevalence and NCD multi-morbidities and assess the access to NCD care.
    • Report of the WHO independent high-level commission on NCDs: where is the focus on addressing inequalities?

      Perone, SA; Bausch, FJ; Boulle, P; Chappuis, F; Miranda, JJ; Beran, D (BMJ, 2020-06-01)
    • Setting up a nurse-led model of care for management of hypertension and diabetes mellitus in a high HIV prevalence context in rural Zimbabwe: a descriptive study

      Frieden, M; Zamba, B; Mukumbi, N; Mafaune, PT; Makumbe, B; Irungu, E; Moneti, V; Isaakidis, P; Garone, D; Prasai, M (BMC, 2020-06-01)
      Background In the light of the increasing burden of non-communicable diseases (NCDs) on health systems in low- and middle-income countries, particularly in Sub-Saharan Africa, context-adapted, cost-effective service delivery models are now required as a matter of urgency. We describe the experience of setting up and organising a nurse-led Diabetes Mellitus (DM) and Hypertension (HTN) model of care in rural Zimbabwe, a low-income country with unique socio-economic challenges and a dual disease burden of HIV and NCDs. Methods Mirroring the HIV experience, we designed a conceptual framework with 9 key enablers: decentralization of services, integration of care, simplification of management guidelines, mentoring and task-sharing, provision of affordable medicines, quality assured laboratory support, patient empowerment, a dedicated monitoring and evaluation system, and a robust referral system. We selected 9 primary health care clinics (PHC) and two hospitals in Chipinge district and integrated DM and HTN either into the general out-patient department, pre-existing HIV clinics, or an integrated chronic care clinic (ICCC). We provided structured intensive mentoring for staff, using simplified protocols, and disease-specific education for patients. Free medication with differentiated periodic refills and regular monitoring with point of care (POC) glycosylated haemoglobin (HbA1c) were provided. Results Nurses in 7 PHC facilities and one hospital developed sufficient knowledge and skills to diagnose, initiate treatment and monitor DM and HTN patients, and 3094 patients were registered in the programme (188 with DM only, 2473 with HTN only, 433 with both DM and HTN). Major lessons learned from our experience include: the value of POC devices in the management of diabetes; the pressure on services of the added caseload, exacerbated by the availability of free medications in supported health facilities; and the importance of leadership in the successful implementation of care in health facilities. Conclusion Our experience demonstrates a model for nurse-led decentralized integrated DM and HTN care in a high HIV prevalence rural, low-income context. Developing a context-adapted efficient model of care is a dynamic process. We present our lessons learned with the intention of sharing experience which may be of value to other public health programme managers.
    • Sickle cell disease in anaemic children in a Sierra Leonean district hospital: a case series.

      Italia, MB; Kirolos, S (Oxford University Press, 2019-07-12)
      Sickle cell disease (SCD) is the most common inherited haemoglobinopathy wordwide, with the highest prevalence in sub-Saharan Africa. Due to the lack of national strategies and scarcity of diagnostic tools in resource-limited settings, the disease may be significantly underdiagnosed. We carried out a 6-month retrospective review of paediatric admissions in a district hospital in northern Sierra Leone. Our aim was to identify patients with severe anaemia, defined as Hb < 7 g/dl, and further analyse the records of those tested for SCD. Of the 273 patients identified, only 24.5% had had an Emmel test, among which 34.3% were positive. Furthermore, only 17% of patients with a positive Emmel test were discharged on prophylactic antibiotics. Our study shows that increased awareness of SCD symptoms is required in high-burden areas without established screening programmes. In addition, the creation or strengthening of follow-up programmes for SCD patients is essential for disease control.