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

    Webster, R; Murphy, A; Bygrave, H; Ansbro, E; Grobbee, DE; Perel, P (BMC, 2020-09-01)
    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 politics of exclusion: fighting for patients with Kidney failure in Yemen’s War

    Heller Perarche, A; Fall, C; van Leeuwen, C; MSF London; MSF OCA; MSF USA (Oxford University Press (OUP), 2019-12-15)
    Background To contribute toward the dialogue on addressing non-communicable and chronic disease in humanitarian emergencies, this article will explore the experiences of Médecins Sans Frontières in attempting to find support for the haemodialysis network in Yemen. With the changing profile of the global disease burden and a broadening concept of emergency health needs to include chronic illness and disability, the aid sector has committed through the World Humanitarian Summit and the Sustainable Development Goals to leave no one behind and thus to meet the health needs of these previously excluded and highly vulnerable people. The civil war in Yemen compromised the medical supply chain supporting the health facilities providing dialysis for patients with end-stage renal disease. The article will critique the aid sector’s slow response to this issue and expose the gap between principles, commitments, and practice related to noncommunicable disease in emergencies. Method Following direct experiences from the authors as leaders in the aid response in Yemen, reviews of grey literature from aid and health actors in Yemen were conducted along with a review of literature and policy documents related to noncommunicable disease in emergency. Key informant interviews and press statements supported analysis and events that took place in the time span of roughly 4 years that frames this period of analysis. Results Examination of the impacted patient population, interviews, literature and documented events indicates that there is discord between policy, commitments stated by aid donors and practice. Conclusion The aid sector must use a more contextualised approach when designing programmes to manage the burden of non-communicable diseases in health contexts where crises occur, particularly for lifesaving forms of therapy. Aid agencies and the global health community must increase pressure on donors and implementing agencies to live up to their commitments to include these patient populations.
  • Management of diabetes and associated costs in a complex humanitarian setting in the Democratic Republic of Congo: a retrospective cohort study

    Ansbro, EM; Roberts, B; Jobanputra, K; Biringanine, M; Caleo, G; Prieto-Merino, D; Sadique, Z; Perel, P (BMJ, 2019-11-24)
    Objective We aimed to evaluate an Integrated Diabetic Clinic within a Hospital Outpatient Department (IDC-OPD) in a complex humanitarian setting in North Kivu, Democratic Republic of Congo. Specific objectives were to: (1) analyse diabetes intermediate clinical and programmatic outcomes (blood pressure (BP)/glycaemic control, visit volume and frequency); (2) explore the association of key insecurity and related programmatic events with these outcomes; and (3) describe incremental IDC-OPD programme costs. Design Retrospective cohort analysis of routine programmatic data collected from January 2014 to February 2017; analysis of programme costs for 2014/2015. Setting Outpatient diabetes programme in Mweso hospital, supported by Médecins sans Frontières, in North Kivu, Demographic Republic of Congo. Participants Diabetes patients attending IDC-OPD. Outcome measures Intermediate clinical and programmatic outcome trends (BP/ glycaemic control; visit volume/frequency); incremental programme costs. Results Of 243 diabetes patients, 44.6% were women, median age was 45 (IQR 32–56); 51.4% were classified type 2. On introduction of IDC-OPD, glucose control improved and patient volume and visit interval increased. During insecurity, control rates were initially maintained by a nurse-provided, scaled-back service, while patient volume and visit interval decreased. Following service suspension due to drug stock-outs, patients were less likely to achieve control, improving on service resumption. Total costs decreased 16% from 2014 (€36 573) to 2015 (€30 861). Annual cost per patient dropped from €475 in 2014 to €214 in 2015 due to reduced supply costs and increased patient numbers. Conclusions In a chronic conflict setting, we documented that control of diabetes intermediate outcomes was achievable during stable periods. During insecure periods, a simplified, nurse-led model maintained control rates until drug stock-outs occurred. Incremental per patient annual costs were lower than chronic HIV care costs in low-income settings. Future operational research should define a simplified diabetes care package including emergency preparedness.
  • Cardiovascular Disease among Syrian refugees: a descriptive study of patients in two Médecins Sans Frontières clinics in northern Lebanon.

    Boulle, P; Sibourd-Baudry, A; Ansbro, E; Merino, DP; Saleh, N; Zeidan, RK; Perel, P (BioMed Central, 2019-08-09)
    We included 514 patients with ASCVD in the cross-sectional study, performed in 2017. Most (61.9%) were male and mean age was 60.4 years (95% CI, 59.6-61.3). Over half (58.8%) underwent revascularization and 26.1% had known cerebrovascular disease. ASCVD risk factors included 51.8% with diabetes and 72.2% with hypertension. While prescription (75.7 to 98.2%) and self-reported adherence rates (78.4 to 93.9%) for individual ASCVD secondary prevention drugs (ACE-inhibitor, statin and antiplatelet) were high, the use of all three was low at 41.3% (CI95%: 37.0-45.6). The 5-year retrospective cohort study (ending April 2017) identified 1286 patients with ASCVD and 16,618 related consultations (comprising 24% of all NCD consultations). Over one third (39.7%) of patients were lost to follow-up, with lower risk among men.
  • How can integrated care and research assist in achieving the SDG targets for diabetes, tuberculosis and HIV/AIDS?

    Harries, AD; Lin, Y; Kumar, AMV; Satyanarayana, S; Zachariah, R; Dlodlo, RA (The International Union Against Tuberculosis and Lung Disease, 2018-10-01)
    Integrating the management and care of communicable diseases, such as tuberculosis (TB) and human immunodeficiency virus/acquired immune-deficiency syndrome (HIV/AIDS), and non-communicable diseases, particularly diabetes mellitus (DM), may help to achieve the ambitious health-related targets of the Sustainable Development Goals (SDG 3.3 and 3.4) by 2030. There are five important reasons to integrate. First, we need to integrate to prevent disease. In sub-Saharan Africa, in particular, HIV infection is the main driver of the TB epidemic, and antiretroviral therapy combined with isoniazid preventive therapy (IPT) can reduce TB case notification rates. In Asia, DM is another important driver of the TB epidemic, and preventing or controlling DM can reduce the risk of TB. Second, we need to integrate to diagnose cases. Between a third to a half of those living with HIV, TB or DM do not know they have the disease, and bi-directional screening, whereby TB patients are screened for HIV and DM or people living with HIV and DM are screened for TB, can help to identify these 'missing cases'. Third, we need to integrate to better treat and manage patients who have a combination of two or more of these diseases, so that treatment success and retention on treatment can be optimised. Fourth, we should integrate to ensure better infection control practices for both TB and HIV infection in health facilities and congregate settings, such as prisons. Finally, we should integrate and learn how to monitor, record and report, particularly in relation to the cascade of events implicit in the HIV/AIDS and TB 90-90-90 targets.
  • A cross-sectional assessment of diabetes self-management, education and support needs of Syrian refugee patients living with diabetes in Bekaa Valley Lebanon

    Elliott, JA; Das, D; Cavailler, P; Schneider, F; Shah, M; Ravaud, A; Lightowler, M; Boulle, P (BMC, 2018-09-12)
    Patients with diabetes require knowledge and skills to self-manage their disease, a challenging aspect of treatment that is difficult to address in humanitarian settings. Due to the lack of literature and experience regarding diabetes self-management, education and support (DSMES) in refugee populations, Medecins Sans Frontieres (MSF) undertook a DSMES survey in a cohort of diabetes patients seen in their primary health care program in Lebanon.
  • Assessing the Burden of Rheumatic Heart Disease Among Refugee Children: a Call to Action.

    Rossi, G; Lee, VSW (Edinburgh University Global Health Society, 2016-08-03)
  • Monitoring Treatment Outcomes in Patients with Chronic Disease: Lessons from Tuberculosis and HIV/AIDS Care and Treatment Programmes

    Harries, A D; Kumar, A M V; Karpati, A; Jahn, A; Douglas, G P; Gadabu, O J; Chimbwandira, F; Zachariah, R (Wiley-Blackwell, 2015-07)
  • HIV with non-communicable diseases in primary care in Kibera, Nairobi, Kenya: characteristics and outcomes 2010-2013

    Edwards, J K; Bygrave, H; Van den Bergh, R; Kizito, W; Cheti, E; Kosgei, R J; Sobry, A; Vandenbulcke, A; Vakil, S N; Reid, T (Oxford University Press, 2015-05-21)
    Antiretroviral therapy (ART) has increased the life expectancy of people living with HIV (PLHIV); HIV is now considered a chronic disease. Non-communicable diseases (NCDs) and HIV care were integrated into primary care clinics operated within the informal settlement of Kibera, Nairobi, Kenya. We describe early cohort outcomes among PLHIV and HIV-negative patients, both of whom had NCDs.
  • Important co-morbidity in patients with diabetes mellitus in three clinics in Western Kenya

    Kirui, N K; Pastakia, S D; Kamano, J H; Cheng, S; Manuthu, E; Chege, P; Gardner, A; Mwangi, A; Enarson, D A; Reid, A J; et al. (The TB Union, 2012-12)
  • Cohort monitoring of persons with diabetes mellitus in a primary healthcare clinic for Palestine refugees in Jordan.

    Khader, A; Farajallah, L; Shahin, Y; Hababeh, M; Abu-Zayed, I; Kochi, A; Harries, A D; Zachariah, R; Kapur, A; Venter, W; et al. (2012-10-11)
    Objective  To illustrate the method of cohort reporting of persons with diabetes mellitus (DM) in a primary healthcare clinic in Amman, Jordan, serving Palestine refugees with the aim of improving quality of DM care services. Method  A descriptive study using quarterly and cumulative case findings, as well as cumulative and 12-month analyses of cohort outcomes collected through E-Health in UNRWA Nuzha Primary Health Care Clinic. Results  There were 55 newly registered patients with DM in quarter 1, 2012, and a total of 2851 patients with DM ever registered on E-Health because this was established in 2009. By 31 March 2012, 70% of 2851 patients were alive in care, 18% had failed to present to a healthcare worker in the last 3 months and the remainder had died, transferred out or were lost to follow-up. Cumulative and 12-month cohort outcome analysis indicated deficiencies in several components of clinical care: measurement of blood pressure, annual assessments for foot care and blood tests for glucose, cholesterol and renal function. 10-20% of patients with DM in the different cohorts had serious late complications such as blindness, stroke, cardiovascular disease and amputations. Conclusion  Cohort analysis provides data about incidence and prevalence of DM at the clinic level, clinical management performance and prevalence of serious morbidity. It needs to be more widely applied for the monitoring and management of non-communicable chronic diseases.
  • Cohort monitoring of persons with hypertension: an illustrated example from a primary healthcare clinic for Palestine refugees in Jordan.

    Khader, A; Farajallah, L; Shahin, Y; Hababeh, M; Abu-Zayed, I; Kochi, A; Harries, A D; Zachariah, R; Kapur, A; Venter, W; et al. (2012-09)
    Recording and reporting systems borrowed from the DOTS framework for tuberculosis control can be used to record, monitor and report on chronic disease. In a primary healthcare clinic run by UNRWA in Amman, Jordan, serving Palestine refugees with hypertension, we set out to illustrate the method of cohort reporting for persons with hypertension by presenting on quarterly and cumulative case finding, cumulative and 12-month analysis of cohort outcomes and to assess how these data may inform and improve the quality of hypertension care services.
  • Screening patients with Diabetes Mellitus for Tuberculosis in China.

    Lin, Y; Li, L; Mi, F; Du, J; Dong, Y; Li, Z; Qi, W; Zhao, X; Cui, Y; Hou, F; et al. (2012-07-25)
    Objective  There is a high burden of both diabetes (DM) and tuberculosis (TB) in China, and as DM increases the risk of TB and adversely affects TB treatment outcomes, there is a need for bidirectional screening of the two diseases. How this is best performed is not well determined. In this pilot project in China, we aimed to assess the feasibility and results of screening DM patients for TB within the routine healthcare setting of five DM clinics. Method  Agreement on how to screen, monitor and record was reached in May 2011 at a national stakeholders meeting, and training was carried out for staff in the five clinics in July 2011. Implementation started in September 2011, and we report on 7 months of activities up to 31 March 2012. DM patients were screened for TB at each clinic attendance using a symptom-based enquiry, and those positive to any symptom were referred for TB investigations. Results  In the three quarters, 72% of 3174 patients, 79% of 7196 patients and 68% of 4972 patients were recorded as having been screened for TB, resulting in 7 patients found who were already known to have TB, 92 with a positive TB symptom screen and 48 of these newly diagnosed with TB as a result of referral and investigation. All patients except one were started on anti-TB treatment. TB case notification rates in screened DM patients were several times higher than those of the general population, were highest for the five sites combined in the final quarter (774/100 000) and were highest in one of the five clinics in the final quarter (804/100 000) where there was intensive in-house training, special assignment of staff for screening and colocation of services. Conclusion  This pilot project shows that it is feasible to carry out screening of DM patients for TB resulting in high detection rates of TB. This has major public health and patient-related implications.
  • Treatment of hypertension in rural Cambodia: results of a 6-year programme

    Isaakidis P; Raguenaud M-E; Say C; De Clerck H; Khim C; Pottier R; Kuoch S; Prahors U; Chour S; Van Damme W; et al. (2010-04)
  • Scaling up antiretroviral therapy in Malawi-implications for managing other chronic diseases in resource-limited countries.

    Harries, A D; Zachariah, R; Jahn, A; Schouten, E J; Kamoto, K; International Union against Tuberculosis and Lung Disease, Paris, France. (2009-11-01)
    The national scale-up of antiretroviral therapy (ART) in Malawi is based on the public health approach, with principles and practices borrowed from the successful DOTS (directly observed treatment, short course) tuberculosis control framework. The key principles include political commitment, free care, and standardized systems for case finding, treatment, recording and reporting, and drug procurement. Scale-up of ART started in June 2004, and by December 2008, 223,437 patients were registered for treatment within a health system that is severely underresourced. The Malawi model for delivering lifelong ART can be adapted and used for managing patients with chronic noncommunicable diseases, the burden of which is already high and continues to grow in low-income and middle-income countries. This article discusses how the principles behind the successful Malawi model of ART delivery can be applied to the management of other chronic diseases in resource-limited settings and how this paradigm can be used for health systems strengthening.
  • A global framework for action to improve the primary care response to chronic non-communicable diseases: a solution to a neglected problem.

    Maher, D; Harries, A D; Zachariah, R; Enarson, D (2009-09-22)
    BACKGROUND: Although in developing countries the burden of morbidity and mortality due to infectious diseases has often overshadowed that due to chronic non-communicable diseases (NCDs), there is evidence now of a shift of attention to NCDs. DISCUSSION: Decreasing the chronic NCD burden requires a two-pronged approach: implementation of the multisectoral policies aimed at decreasing population-level risks for NCDs, and effective and affordable delivery of primary care interventions for patients with chronic NCDs. The primary care response to common NCDs is often unstructured and inadequate. We therefore propose a programmatic, standardized approach to the delivery of primary care interventions for patients with NCDs, with a focus on hypertension, diabetes mellitus, chronic airflow obstruction, and obesity. The benefits of this approach will extend to patients with related conditions, e.g. those with chronic kidney disease caused by hypertension or diabetes. This framework for a "public health approach" is informed by experience of scaling up interventions for chronic infectious diseases (tuberculosis and HIV). The lessons learned from progress in rolling out these interventions include the importance of gaining political commitment, developing a robust strategy, delivering standardised interventions, and ensuring rigorous monitoring and evaluation of progress towards defined targets. The goal of the framework is to reduce the burden of morbidity, disability and premature mortality related to NCDs through a primary care strategy which has three elements: 1) identify and address modifiable risk factors, 2) screen for common NCDs and 3) and diagnose, treat and follow-up patients with common NCDs using standard protocols. The proposed framework for NCDs borrows the same elements as those developed for tuberculosis control, comprising a goal, strategy and targets for NCD control, a package of interventions for quality care, key operations for national implementation of these interventions (political commitment, case-finding among people attending primary care services, standardised diagnostic and treatment protocols, regular drug supply, and systematic monitoring and evaluation), and indicators to measure progress towards increasing the impact of primary care interventions on chronic NCDs. The framework needs evaluation, then adaptation in different settings. SUMMARY: A framework for a programmatic "public health approach" has the potential to improve on the current unstructured approach to primary care of people with chronic NCDs. Research to establish the cost, value and feasibility of implementing the framework will pave the way for international support to extend the benefit of this approach to the millions of people worldwide with chronic NCDs.