- Email: [email protected]
Diabetes care in refugee camps: The experience of UNRWA
diabetes research and clinical practice 108 (2015) 1–6
Contents available at ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Invited Review
Diabetes care in refugee camps: The experience of UNRWA Yousef Shahin a,*, Anil Kapur b, Akhiro Seita a a b
Department of Health, UNRWA, HQ, Jordan World Diabetes Foundation (WDF), Denmark
article info
abstract
Article history:
United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA)
Received 19 January 2015
was established in 1949 and has delivered health care services for over 65 years. The
Accepted 26 January 2015
epidemiological transition in disease burden is changing the context in which UNRWA’s
Available online 31 January 2015
health programme operates and poses new challenges that require new ways of providing
Keywords:
refugees. UNRWA has been providing diabetes and hypertension care since 1992 in its
UNRWA health system
primary health care centres. Of late, through a structured process of care delivery the
health services. Hypertension and diabetes are two major health problems for Palestine
Diabetes
UNRWA health system is making significant strides in addressing diabetes and hyperten-
Hypertension
sion and consequently the nine voluntary global targets as envisaged in the WHO Global
NCD global targets
Action Plan for the Prevention and Control of NCDs 2013–2020. Given that most developing
Clinical audit
countries either have no or only rudimentary services for diabetes and hypertension at the primary care level and may face similar resource and capacity constraints, UNRWA’s efforts can serve as a model and inspiration to set up similar initiatives. # 2015 Elsevier Ireland Ltd. All rights reserved.
Contents 1. 2. 3. 4. 5. 6.
UNRWA health services – a background . . . . . . . . . . . . . . . . . . . Burden of diabetes and hypertension . . . . . . . . . . . . . . . . . . . . . UNRWA strategy for NCD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diabetes and hypertension care within UNRWA health system Health care provider training, knowledge, and perceptions . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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* Corresponding author at: UNRWA Headquarters, Health Department, P.O. Box 140157, Amman 11814, Jordan. Tel.: +962 5808315; fax: +962 65808318; mobile: +962 791300822. E-mail address: [email protected] (Y. Shahin). http://dx.doi.org/10.1016/j.diabres.2015.01.035 0168-8227/# 2015 Elsevier Ireland Ltd. All rights reserved.
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1.
diabetes research and clinical practice 108 (2015) 1–6
diabetes and hypertension care since 1992 in its primary health care centres. Around 11.0% and 16.2%, of people 40 years attending UNRWA health facilities in 2013 had diabetes and hypertension respectively, with almost 200,000 people with diabetes and/or hypertension being cared for at UNRWA clinics in the region excluding Syria from where accurate statistics were not possible during last 2 years because of ongoing armed conflict [3]. The number of people with diabetes has been steadily increasing (Fig. 1), and 111,562 people with diabetes with or without hypertension were being treated within the UNRWA health system in 2013, almost double of the number in 2004 [3]. The exact prevalence of diabetes and hypertension among Palestine refugees is not known. It is presumed similar to the general population of the countries where they live. The rates of diabetes and hypertension reported by UNRWA are similar to those reported amongst nonrefugee Palestinians living within the occupied Palestinian territory of the West Bank and Gaza [4,5]. Diabetes prevalence among general population (20–79 years) is known to be 10.1% in Jordan, 7.8% in Lebanon, 8.6% in Palestine and 10.8% in Syria [5–7]. Therefore, the prevalence of diabetes among Palestine refugees 20–79 years old is probably between 8 and 11%.
UNRWA health services – a background
United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) was established in 1949 by the United Nations General Assembly resolution to carry out direct relief and works programmes for Palestine refugees. UNRWA provides assistance and protection for 5.3 million Palestine refugees and has contributed to the welfare and human development of four generations of refugees [1]. As part of the mandate UNRWA has delivered comprehensive primary health care services to Palestine refugees in the Gaza Strip, West Bank, Jordan, Lebanon and Syria for over 65 years and has achieved some remarkable health gains, particularly in maternal and child health and communicable diseases. For example, the infant mortality rate among UNRWA beneficiaries has declined from 160 per 1000 live births during the 1950s, to less than 25 in the first decade of the 21st century [2] – a remarkable achievement – better than some large independent countries with better resources. UNRWA currently provides health services from 138 primary healthcare (PHC) centres and one hospital in the West Bank [3]. The epidemiological transition in disease burden is changing the context in which UNRWA’s health programme operates and poses new challenges that require new ways of providing health services. Over the last 65 years, as living conditions have changed with better sanitation and availability of food, life expectancy has risen and the incidence of communicable disease has gradually fallen. While food availability has improved, its quality has deteriorated. Additionally, the unpredictable, ongoing tension and conflict and lack of security, low employment opportunities, reduced physical activity, both, work and leisure related, and boredom, frustration and hopelessness has led to high levels of stress, smoking, obesity and the consequent rise in non-communicable diseases, especially diabetes, hypertension and mental disorders. The main causes of mortality and morbidity among Palestine refugees now, as in most of the world, are non-communicable diseases (NCDs) such as diabetes, cardiovascular diseases and cancer [2].
2.
3.
UNRWA strategy for NCD
The UNRWA NCD strategy is primarily directed at reducing risk factors and providing services for common conditions such as hypertension and diabetes. It has been revised four times since 1992 with the latest change in 2009 [8] and a new revision is under development. The current strategy has three main elements
Healthy life style promotion – emphasizes the importance of weight control and regular exercise; Early detection of diabetes and hypertension – achieved by active screening of at risk individuals; Implementation of treatment protocols and effective case management – emphasizes dietary management and physical exercise and risk assessment and screening for cardiovascular, cerebrovascular and peripheral vascular disease to prevent secondary complications.
Burden of diabetes and hypertension
Among NCDs, hypertension and diabetes are two major health problems for Palestine refugees. UNRWA has been providing
No. of paents (Thousand)
250 200 150 100
85
96
105
112
2002
2003
122
135
150
164
177
188
199
212
193
199
50 0
2000
2001
2004
2005
2006
2007
2008
2009
2010
2011
2012* 2013*
Fig. 1 – Number of diabetes patients under UNRWA care (2006–2013) (Ref. [3]). *Please note that drop in last 2 years is related to non-availability of data from Syria due to ongoing conflict.
diabetes research and clinical practice 108 (2015) 1–6
The overarching theme of the strategy is to improve programme effectiveness and quality of services to prevent, detect and provide care to improve outcomes in a cost effective manner. Given the limited funding, optimal use of resources is very important. The need for urgent action to address NCDs has been recognized and is now acknowledged at the highest level through the UN political declaration [9]. In addition to strengthen national efforts to address the burden of NCDs, the 66th World Health Assembly endorsed the WHO Global Action Plan for the Prevention and Control of NCDs 2013–2020 (resolution WHA66.10). The plan describes 9 voluntary global targets, including that of a 25% relative reduction in premature mortality from NCDs by 2025 and provides a road map and menu of policy options for Member States, WHO, other UN organizations and intergovernmental organizations, NGOs and the private sector [10]. In many parts of the world, a major obstacle to the control of diabetes, blood pressure and other non-communicable diseases is the absence of appropriate primary healthcare services [11]. These services often only provide episodic, unstructured and unmonitored care with limited or no record keeping and no assessment of incidence and prevalence, treatment outcomes, associated morbidity or mortality. Services for chronic care need to evolve and adapt approaches to provide continuing care for long periods and ability to record, retrieve and analyse patient records in a meaningful way to improve individual care delivery as well as to assess programme implementation. Developing guidelines, protocols or technical instructions based on evidence and cost effectiveness and meticulously implementing them and monitoring and evaluating the results are critical for structured chronic care delivery. It has been suggested previously that the ‘cohort’ recording and reporting systems borrowed from the ‘DOTS’ (directly observed therapy, short course) framework for tuberculosis control can be used to record, monitor and report on chronic disease [12], and indeed, this has been performed in Malawi for the management of HIV/AIDS [13] and diabetes mellitus [14]. Just as measuring simple vital signs helps to monitor individual patients and chart their recovery, at the programmatic level similar vital signs (indicators) can be used to monitor the burden and treatment outcome of chronic diseases, as well as assess the impact of interventions [15]. This concept is now being implemented within the UNRWA health system for providing diabetes and hypertension care as reported recently [16,17].
4. Diabetes and hypertension care within UNRWA health system For major disease burdens UNRWA issues guidance to its staff which is called UNRWA Technical Instructions (TI). The staff is trained to implement these TIs and periodic assessment and evaluation of the collected data is done also for resource planning. UNRWA TIs indicate [8] that all Palestine refugees who attend health centres are screened for diabetes and hypertension if they are 40 years or older, if they are judged to be at risk of non-communicable diseases, pregnant or planning to get
3
pregnant. Blood sugar test is done by laboratory technicians and diagnosis is confirmed by medical officers if the fasting blood glucose (FBG) is 126 mg/dl on 2 separate occasions [8,18]. If the readings are between 100 and 125 mg/dl, a 75 g oral glucose tolerance test (OGTT) is performed to confirm or exclude diabetes (different criteria is used for pregnant women). If FBG results are 100 mg/dl the person is checked again the following year. Persons diagnosed with diabetes are clinically assessed at baseline for co-morbidities and complications and this data along with demographic and clinical information is recorded in either patient registration files (hard copy) or in E-Health system in health centres implementing electronic medical records. After successfully piloting the programme is six centres in Jordan the E-Health system is being gradually rolled out in all UNRWA centres. Hypertension screening is performed by a trained nurse and the diagnosis confirmed by a medical officer if the blood pressure is 140/90 mmHg on two separate occasions. Those who do not have hypertension are followed up and screened every 6 months [8]. Persons diagnosed with hypertension are clinically assessed for complications and comorbidities such as diabetes mellitus. At registration, information on risk factors such as smoking, physical activity, obesity (defined as body mass index 30 kg/m2) and alcoholic intake are recorded for all patients. Patients are classified as having new or previously diagnosed diabetes/hypertension, the diagnosis made either within or outside of the UNRWA system, and a record is also made about whether the person has been transferred in from another UNRWA health centre. People with diabetes are managed according to standard algorithm defined in the UNRWA TI, with diet and lifestyle advice and different classes of oral anti-diabetic drugs (OADs) namely glibenclamide, gliclazide and metformin and insulin injections. According to UNRWA TI, patients with diabetes and/or hypertension should receive at least four heath education sessions during assessment visits each year. People with uncontrolled diabetes are seen weekly and/or monthly; till their 2 h PPG value is 180 mg/dl and subsequently followed every 3 months. Patients with hypertension are managed according to a standard algorithm which apart from diet and lifestyle advice includes different classes of antihypertensive drugs that include beta-blockers, diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors and methyldopa used in a step care approach. Patients with diabetes and hypertension are primarily treated with diuretics and ACE inhibitors and other drugs added if required. Patients with uncontrolled hypertension are seen weekly or monthly until their blood pressure is <140/90 mmHg, and they are then followed every 3 months. During quarterly visits, weight, blood pressure, PPG value, as well as presence of complications (defined as blindness, end-stage renal failure, myocardial infarction, congestive cardiac failure, stroke, and above-ankle amputation) are recorded. Urine is assessed for glucose and protein every 6 months. Once a year all diabetes and hypertension patients undergo blood tests for total serum cholesterol and creatinine, and urine examination for macroproteinuria every 3 months. Examination and evaluation for diabetic foot and dilated fundoscopic eye exam are recommended annually.
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diabetes research and clinical practice 108 (2015) 1–6
Recent reports [2,16,17,19,23] provide comprehensive evaluation of the quality of care and challenges faced by UNRWA health system in delivering diabetes and hypertension care at the primary care level. This learning can serve as an inspiration to many developing countries. UNRWA conducted a comprehensive clinical audit on the provision of diabetes care in the primary care setting [19] and found that 95.7% of patients with diabetes had type 2 diabetes and co-morbid hypertension was present in 68.5%. 90.3% people with diabetes were either obese (64.0%) or overweight (26.3%). Clinical management of diabetes was largely in line with UNRWA’s technical instructions for diabetes. Records for 2-h postprandial glucose (2 h PPG), serum cholesterol, serum creatinine, and urine protein analysis were available in 94.7%, 96.4%, 91.4% and 87.5%, cases respectively but records of annual fundoscopic eye exam were available in less than half the cases (47.3%) and foot examinations were even less well documented. Most patients (95.6%) were on anti-diabetic medications – 68.2% on OADs only, 14.4% were receiving combination of OAD and insulin, and 12.9% insulin only. While 44.8% patients had 2 h post-prandial glucose (PPG) 180 mg/dl, only 28.2% had HbA1c 7%; 55.5% and 28.2% had BP 140/90 and 130/80 mm of Hg respectively. Serum cholesterol 200 mg/dl, serum creatinine 1.2 mg/dl and macro albuminuria was noted in 39.8%; 6.4% and 10.3% cases respectively. Peripheral neuropathy (52.6%), foot infections (17%), diabetic retinopathy (11%) and myocardial infarction (MI) (9.6%) were the most common long term complications. While one or more episodes of hypoglycaemia were reported by 25% cases; amongst insulin users it was 48%. The study confirmed that UNRWA doctors and nurses follow TIs for diabetes and hypertension fairly well. Financial constraint and its consequent effect on UNRWA TI and policy related to diabetes care such as reliance on 2 h PPG to measure control, non-availability of routine HbA1c testing, home glucose monitoring and statins within the UNRWA system were important issues in further improving care and are being discussed for the new strategy and TI. High levels of obesity in the community and high patient load in the outpatient clinics with no special day for diabetes services were the other key issues. In terms of record keeping and monitoring, data on most parameters were available in over 90% cases including records of lab tests and clinical examinations performed in the last one year which is better than in similar studies done in other developing countries in tertiary care centres [20,21]. Insufficient focus on lifestyle counselling was another shortcoming identified. More than 90% of people with DM within the UNRWA system are either obese (64%) or overweight (26.3%), around 70% have co existing hypertension and almost 40% have hyperlipidaemia as noted above and all these conditions are amenable to prevention through lifestyle measures; requiring greater attention to lifestyle counselling. According to UNRWA TI, patients should receive at least four heath education sessions during assessment visits each year. The audit revealed that 17.6% patients received no self-care education and 22.6% patients received four or more health education sessions, reflecting poor adherence to guidelines on self-care education. Less than half the patients (40.6%) recalled receiving relevant lifestyle health education sessions (exercise
and diet). Although foot complication (peripheral neuropathy, foot infections) rates are significant, only 16% of patients recalled receiving foot care advice. The same applies for counselling on hypoglycaemia, despite the high rate. Better training, redefining roles and skilful deployment of nonmedical health professionals may help improve self-care education and patient counselling. History of MI or undergoing angioplasty was noted in 9.3% cases and is similar to the 9.7% prevalence of MI among diabetic patients reported earlier in the region [22]. The high rate of MI reflects the need to address underlying risk factors and to strictly follow UNRWA adopted World Health Organization’s (WHO) secondary prevention strategy for people with diabetes and hypertension with stricter monitoring of BP and glycaemia control using HbA1c and introducing the use of statins. A retrospective descriptive study [16] using routine quarterly and cumulative case records, as well as cumulative and 12-month analyses of cohort outcomes collected through E-Health in UNRWA Nuzha Primary Health Care Clinic showed that 70% of the 2851 patients registered during the year 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. 85% of new registrations were 40 years or older, 40% were new diagnoses and more than twothirds of people with diabetes already had hypertension at the time of registration. 42% had post-prandial blood glucose measured and 50% of these had normal blood glucose. Of those diagnosed with hypertension, 63% had blood pressure measured and 75% had a normal reading. Cohort analysis of E health records from centres rolling out the E-Health System shows that almost half of those who miss appointment in one quarter eventually fail to return and end up being classified lost to follow up after a year [23]. These cases are more likely to be males between 40 and 59 years, with no or few complications. Keeping an eye on these patients and encouraging or incentivizing them to re attend may improve long term outcomes.
5. Health care provider training, knowledge, and perceptions The report on the clinical audit of diabetes care within UNRWA system [2] describes health care provider attributes that can have important impact on the quality of care. Amongst the study sample 94% of medical officers (MOs) were males, similar to the predominant male gender distribution of UNRWA MOs (78%). Given the higher female (64%) distribution in both the general and diabetes patient population attending UNRWA clinics, the predominance of male gender amongst MOs may cause challenges in communication and physical examination especially in a conservative Arabic Muslim community and this can have consequences for care and outcomes. 42% of MOs had less than five years’ experience reflecting a high turnover rate. 85% MOs had attended a diabetes related training in the last one year reflecting the importance UNRWA places on training. The MOs generally had good understanding of the UNRWA TIs as well as a fair idea of the characteristics of the patients in their clinics.
diabetes research and clinical practice 108 (2015) 1–6
However, there were some glaring discrepancies. When asked what proportions of their patients are obese, only one third MOs selected the option >50%, whereas 64% of diabetes patients across UNRWA clinics are obese. If MOs do not perceive their patients to be obese they are less likely to initiate actions to address it. When asked what proportion of their insulin treated patients self-inject, only 40% gave the correct answer. In another related question 70% said that their patients depended on paramedics for insulin injection indicating that most MOs underestimate their patients’ ability to self-inject and this perhaps may lead to over reliance on OADs and delay in initiating insulin therapy. In response to the question ‘‘what proportions of your patients are under control?’’ one third of MOs overestimated the proportion of controlled patients. This again has consequences in terms of reviewing treatment options and long term outcome. The findings from the comprehensive clinical audit of diabetes services at UNRWA primary care centres point to the difficulties in diabetes control as also described in studies from tertiary care centres in other developing countries using a similar study protocol [20,21,24–27]. However, in terms of record keeping and monitoring, UNRWA centres fared much better-with data available in over 90% cases on most parameters including records of lab tests and clinical examinations performed in the last one year. In many of these earlier studies proportion of patients undergoing annual lab tests and examinations were much lower indicating poor adherence to protocols; lower level of control for glucose, blood pressure and lipids and higher complication rates. The very high prevalence of overweight and obesity and other risk factors in the UNRWA population points towards a need for a more comprehensive and strategic response that goes beyond the activities of the NCD care programme to address the health burden from diabetes and hypertension. The recently introduced Family Health Team reform [7] offers a framework to address this. While more efforts are required to raise awareness and improve lifestyles through health promotion; the prevailing socioeconomic and psychological stress from spending a lifetime in a refugee camp poses a big challenge. Limited funding and the need to prioritize scarce resources also places constraint on policy recommendations. Addressing the barriers and shortcomings identified through clinical audits and cohort monitoring will further strengthen and improve UNRWA health system’s laudable efforts of providing quality services for diabetes and hypertension at the primary care level.
Conflicts of interest I declare that there is no conflict of interest.
6.
Conclusions
Through a structured process of care delivery the UNRWA health system is making significant strides in addressing diabetes and hypertension and consequently the nine voluntary global targets as envisaged in the WHO Global Action Plan for the Prevention and Control of NCDs 2013–2020. Given that
5
most developing countries either have no or only rudimentary services for diabetes and hypertension at the primary care level and may face similar resource and capacity constraints, UNRWA’s efforts can serve as a model and inspiration to set up similar initiatives.
references
[1] http://www.unrwa.org/. [2] http://www.unrwa.org/sites/default/files/ final_dm_clinical_audit_report_-_small_size.pdf. [3] United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA). The annual report of the Department of Health 2013. Amman, Jordan: United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA); 2014. [4] Giacaman R, Khatib R, Shabaneh L. Health status and health services in the occupied Palestinian territory. Lancet 2009;373:837–49. [5] Husseini A, Abu-Rmeileh NME, Mikki N. Cardiovascular diseases, diabetes mellitus, and cancer in the occupied Palestinian territory. Lancet 2009;373:1041–9. [6] Diabetes Atlas, International Diabetes Federation. http:// www.idf.org/diabetes atlas/5e/Update2012; 2012. [7] Modern and efficient UNRWA Health Services. Family Health Team approach. Available from: http://www.unrwa. org/userfiles/file/publications/ Health%20Reform%20Strategy.pdf; 2011. [8] United Nations Relief and Works Agency Health Department. Technical instructions and management protocols on prevention and control of non-communicable diseases. Technical instruction series: HD/DC/01/1997. Revision no. 4. Amman, Jordan: UNRWA; 2009. [9] World Health Organization. http://www.who.int/nmh/ events/un_ncd_summit2011/political_declaration_en.pdf/; 2011. [10] World Health Organization. Global action plan for the prevention and control of noncommunicable diseases 2013–2020. Geneva, Switzerland: World Health Organization; 2013, http://apps.who.int/iris/bitstream/ 10665/94384/1/9789241506236_eng.pdf?ua=1. [11] MacMahon S, Alderman MH, Lindholm LH, Liu L, Sanchez RA, Seedat YK. Blood-pressure-related disease is a global health priority. Lancet 2008;371:1480–2. [12] Harries AD, Jahn A, Zachariah R, Enarson D. Adapting the DOTS framework for tuberculosis control to the management of non-communicable diseases in subSaharan Africa. PLoS Med 2008;5:e124. [13] Harries AD, Zachariah R, Jahn A, Schouten EJ, Kamoto K. Scaling up antiretroviral therapy in Malawi – implications for managing other chronic diseases in resource-limited countries. J Acquir Immune Defic Syndr 2009;52:S14–6. [14] Allain TJ, van Oosterhout JJ, Douglas GP. Applying lessons learnt from the ‘‘DOTS’’ Tuberculosis Model to monitoring and evaluating persons with diabetes mellitus in Blantyre, Malawi. Trop Med Int Health 2011;16:1077–84. [15] Harries AD, Zachariah R, Kapur A, Jahn A, Enarson DA. The vital signs of chronic disease management. Trans R Soc Trop Med Hyg 2009;103:537–40. [16] Khader A, Farajallah L, Shahin Y, Hababeh M, Abu-Zayed I, Kochi A, et al. Cohort monitoring of persons with diabetes mellitus in a primary health care clinic for Palestine refugees in Jordan. Trop Med Int Health 2012;17:1569–76. [17] Khader A, Farajallah L, Shahin Y, Hababeh M, Abu-Zayed I, Kochi A, et al. Cohort monitoring of persons with hypertension: an illustrative example from a primary
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[23] Khader A, Ballout G, Shahin Y, Hababeh M, Farajallah L, Zeidan W, et al. What happens to Palestine refugees with diabetes mellitus in a primary healthcare centre in Jordan who fail to attend a quarterly clinic appointment? Trop Med Int Health 2014;19:308–12. [24] Mafauzy M, Hussein Z, Chan SP. The status of diabetes control in Malaysia: results of DiabCare 2008. Med J Malays 2011;66:175–81. [25] Soewondo P, Soegondo S, Suastika K, Pranoto A, Soeatmadji DW, Tjokroprawiro A. The DiabCare Asia 2008 study – outcomes on control and complications of type 2 diabetic patients in Indonesia. Med J Indones 2010;19: 235–44. [26] Chinenye S, Uloko AE, Ogbera AO, Ofoegbu EN, Fasanmade OA, Fasanmade AA, et al. Profile of Nigerians with diabetes mellitus – Diabcare Nigeria study group (2008): results of a multicenter study. Indian J Endocr Metab 2012;16:558–64. [27] Sobngwie E, Ndour-Mbayee M, Boateng KF, Ramaiya KL, Njenga EW, Diop SN, et al. Type 2 diabetes control and complications in specialised diabetes care centres of six sub-Saharan African countries: the Diabcare Africa study. Diabetes Res Clin Pract 2012;95:30–6.
Contents available at ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Invited Review
Diabetes care in refugee camps: The experience of UNRWA Yousef Shahin a,*, Anil Kapur b, Akhiro Seita a a b
Department of Health, UNRWA, HQ, Jordan World Diabetes Foundation (WDF), Denmark
article info
abstract
Article history:
United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA)
Received 19 January 2015
was established in 1949 and has delivered health care services for over 65 years. The
Accepted 26 January 2015
epidemiological transition in disease burden is changing the context in which UNRWA’s
Available online 31 January 2015
health programme operates and poses new challenges that require new ways of providing
Keywords:
refugees. UNRWA has been providing diabetes and hypertension care since 1992 in its
UNRWA health system
primary health care centres. Of late, through a structured process of care delivery the
health services. Hypertension and diabetes are two major health problems for Palestine
Diabetes
UNRWA health system is making significant strides in addressing diabetes and hyperten-
Hypertension
sion and consequently the nine voluntary global targets as envisaged in the WHO Global
NCD global targets
Action Plan for the Prevention and Control of NCDs 2013–2020. Given that most developing
Clinical audit
countries either have no or only rudimentary services for diabetes and hypertension at the primary care level and may face similar resource and capacity constraints, UNRWA’s efforts can serve as a model and inspiration to set up similar initiatives. # 2015 Elsevier Ireland Ltd. All rights reserved.
Contents 1. 2. 3. 4. 5. 6.
UNRWA health services – a background . . . . . . . . . . . . . . . . . . . Burden of diabetes and hypertension . . . . . . . . . . . . . . . . . . . . . UNRWA strategy for NCD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diabetes and hypertension care within UNRWA health system Health care provider training, knowledge, and perceptions . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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* Corresponding author at: UNRWA Headquarters, Health Department, P.O. Box 140157, Amman 11814, Jordan. Tel.: +962 5808315; fax: +962 65808318; mobile: +962 791300822. E-mail address: [email protected] (Y. Shahin). http://dx.doi.org/10.1016/j.diabres.2015.01.035 0168-8227/# 2015 Elsevier Ireland Ltd. All rights reserved.
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diabetes research and clinical practice 108 (2015) 1–6
diabetes and hypertension care since 1992 in its primary health care centres. Around 11.0% and 16.2%, of people 40 years attending UNRWA health facilities in 2013 had diabetes and hypertension respectively, with almost 200,000 people with diabetes and/or hypertension being cared for at UNRWA clinics in the region excluding Syria from where accurate statistics were not possible during last 2 years because of ongoing armed conflict [3]. The number of people with diabetes has been steadily increasing (Fig. 1), and 111,562 people with diabetes with or without hypertension were being treated within the UNRWA health system in 2013, almost double of the number in 2004 [3]. The exact prevalence of diabetes and hypertension among Palestine refugees is not known. It is presumed similar to the general population of the countries where they live. The rates of diabetes and hypertension reported by UNRWA are similar to those reported amongst nonrefugee Palestinians living within the occupied Palestinian territory of the West Bank and Gaza [4,5]. Diabetes prevalence among general population (20–79 years) is known to be 10.1% in Jordan, 7.8% in Lebanon, 8.6% in Palestine and 10.8% in Syria [5–7]. Therefore, the prevalence of diabetes among Palestine refugees 20–79 years old is probably between 8 and 11%.
UNRWA health services – a background
United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) was established in 1949 by the United Nations General Assembly resolution to carry out direct relief and works programmes for Palestine refugees. UNRWA provides assistance and protection for 5.3 million Palestine refugees and has contributed to the welfare and human development of four generations of refugees [1]. As part of the mandate UNRWA has delivered comprehensive primary health care services to Palestine refugees in the Gaza Strip, West Bank, Jordan, Lebanon and Syria for over 65 years and has achieved some remarkable health gains, particularly in maternal and child health and communicable diseases. For example, the infant mortality rate among UNRWA beneficiaries has declined from 160 per 1000 live births during the 1950s, to less than 25 in the first decade of the 21st century [2] – a remarkable achievement – better than some large independent countries with better resources. UNRWA currently provides health services from 138 primary healthcare (PHC) centres and one hospital in the West Bank [3]. The epidemiological transition in disease burden is changing the context in which UNRWA’s health programme operates and poses new challenges that require new ways of providing health services. Over the last 65 years, as living conditions have changed with better sanitation and availability of food, life expectancy has risen and the incidence of communicable disease has gradually fallen. While food availability has improved, its quality has deteriorated. Additionally, the unpredictable, ongoing tension and conflict and lack of security, low employment opportunities, reduced physical activity, both, work and leisure related, and boredom, frustration and hopelessness has led to high levels of stress, smoking, obesity and the consequent rise in non-communicable diseases, especially diabetes, hypertension and mental disorders. The main causes of mortality and morbidity among Palestine refugees now, as in most of the world, are non-communicable diseases (NCDs) such as diabetes, cardiovascular diseases and cancer [2].
2.
3.
UNRWA strategy for NCD
The UNRWA NCD strategy is primarily directed at reducing risk factors and providing services for common conditions such as hypertension and diabetes. It has been revised four times since 1992 with the latest change in 2009 [8] and a new revision is under development. The current strategy has three main elements
Healthy life style promotion – emphasizes the importance of weight control and regular exercise; Early detection of diabetes and hypertension – achieved by active screening of at risk individuals; Implementation of treatment protocols and effective case management – emphasizes dietary management and physical exercise and risk assessment and screening for cardiovascular, cerebrovascular and peripheral vascular disease to prevent secondary complications.
Burden of diabetes and hypertension
Among NCDs, hypertension and diabetes are two major health problems for Palestine refugees. UNRWA has been providing
No. of paents (Thousand)
250 200 150 100
85
96
105
112
2002
2003
122
135
150
164
177
188
199
212
193
199
50 0
2000
2001
2004
2005
2006
2007
2008
2009
2010
2011
2012* 2013*
Fig. 1 – Number of diabetes patients under UNRWA care (2006–2013) (Ref. [3]). *Please note that drop in last 2 years is related to non-availability of data from Syria due to ongoing conflict.
diabetes research and clinical practice 108 (2015) 1–6
The overarching theme of the strategy is to improve programme effectiveness and quality of services to prevent, detect and provide care to improve outcomes in a cost effective manner. Given the limited funding, optimal use of resources is very important. The need for urgent action to address NCDs has been recognized and is now acknowledged at the highest level through the UN political declaration [9]. In addition to strengthen national efforts to address the burden of NCDs, the 66th World Health Assembly endorsed the WHO Global Action Plan for the Prevention and Control of NCDs 2013–2020 (resolution WHA66.10). The plan describes 9 voluntary global targets, including that of a 25% relative reduction in premature mortality from NCDs by 2025 and provides a road map and menu of policy options for Member States, WHO, other UN organizations and intergovernmental organizations, NGOs and the private sector [10]. In many parts of the world, a major obstacle to the control of diabetes, blood pressure and other non-communicable diseases is the absence of appropriate primary healthcare services [11]. These services often only provide episodic, unstructured and unmonitored care with limited or no record keeping and no assessment of incidence and prevalence, treatment outcomes, associated morbidity or mortality. Services for chronic care need to evolve and adapt approaches to provide continuing care for long periods and ability to record, retrieve and analyse patient records in a meaningful way to improve individual care delivery as well as to assess programme implementation. Developing guidelines, protocols or technical instructions based on evidence and cost effectiveness and meticulously implementing them and monitoring and evaluating the results are critical for structured chronic care delivery. It has been suggested previously that the ‘cohort’ recording and reporting systems borrowed from the ‘DOTS’ (directly observed therapy, short course) framework for tuberculosis control can be used to record, monitor and report on chronic disease [12], and indeed, this has been performed in Malawi for the management of HIV/AIDS [13] and diabetes mellitus [14]. Just as measuring simple vital signs helps to monitor individual patients and chart their recovery, at the programmatic level similar vital signs (indicators) can be used to monitor the burden and treatment outcome of chronic diseases, as well as assess the impact of interventions [15]. This concept is now being implemented within the UNRWA health system for providing diabetes and hypertension care as reported recently [16,17].
4. Diabetes and hypertension care within UNRWA health system For major disease burdens UNRWA issues guidance to its staff which is called UNRWA Technical Instructions (TI). The staff is trained to implement these TIs and periodic assessment and evaluation of the collected data is done also for resource planning. UNRWA TIs indicate [8] that all Palestine refugees who attend health centres are screened for diabetes and hypertension if they are 40 years or older, if they are judged to be at risk of non-communicable diseases, pregnant or planning to get
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pregnant. Blood sugar test is done by laboratory technicians and diagnosis is confirmed by medical officers if the fasting blood glucose (FBG) is 126 mg/dl on 2 separate occasions [8,18]. If the readings are between 100 and 125 mg/dl, a 75 g oral glucose tolerance test (OGTT) is performed to confirm or exclude diabetes (different criteria is used for pregnant women). If FBG results are 100 mg/dl the person is checked again the following year. Persons diagnosed with diabetes are clinically assessed at baseline for co-morbidities and complications and this data along with demographic and clinical information is recorded in either patient registration files (hard copy) or in E-Health system in health centres implementing electronic medical records. After successfully piloting the programme is six centres in Jordan the E-Health system is being gradually rolled out in all UNRWA centres. Hypertension screening is performed by a trained nurse and the diagnosis confirmed by a medical officer if the blood pressure is 140/90 mmHg on two separate occasions. Those who do not have hypertension are followed up and screened every 6 months [8]. Persons diagnosed with hypertension are clinically assessed for complications and comorbidities such as diabetes mellitus. At registration, information on risk factors such as smoking, physical activity, obesity (defined as body mass index 30 kg/m2) and alcoholic intake are recorded for all patients. Patients are classified as having new or previously diagnosed diabetes/hypertension, the diagnosis made either within or outside of the UNRWA system, and a record is also made about whether the person has been transferred in from another UNRWA health centre. People with diabetes are managed according to standard algorithm defined in the UNRWA TI, with diet and lifestyle advice and different classes of oral anti-diabetic drugs (OADs) namely glibenclamide, gliclazide and metformin and insulin injections. According to UNRWA TI, patients with diabetes and/or hypertension should receive at least four heath education sessions during assessment visits each year. People with uncontrolled diabetes are seen weekly and/or monthly; till their 2 h PPG value is 180 mg/dl and subsequently followed every 3 months. Patients with hypertension are managed according to a standard algorithm which apart from diet and lifestyle advice includes different classes of antihypertensive drugs that include beta-blockers, diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors and methyldopa used in a step care approach. Patients with diabetes and hypertension are primarily treated with diuretics and ACE inhibitors and other drugs added if required. Patients with uncontrolled hypertension are seen weekly or monthly until their blood pressure is <140/90 mmHg, and they are then followed every 3 months. During quarterly visits, weight, blood pressure, PPG value, as well as presence of complications (defined as blindness, end-stage renal failure, myocardial infarction, congestive cardiac failure, stroke, and above-ankle amputation) are recorded. Urine is assessed for glucose and protein every 6 months. Once a year all diabetes and hypertension patients undergo blood tests for total serum cholesterol and creatinine, and urine examination for macroproteinuria every 3 months. Examination and evaluation for diabetic foot and dilated fundoscopic eye exam are recommended annually.
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Recent reports [2,16,17,19,23] provide comprehensive evaluation of the quality of care and challenges faced by UNRWA health system in delivering diabetes and hypertension care at the primary care level. This learning can serve as an inspiration to many developing countries. UNRWA conducted a comprehensive clinical audit on the provision of diabetes care in the primary care setting [19] and found that 95.7% of patients with diabetes had type 2 diabetes and co-morbid hypertension was present in 68.5%. 90.3% people with diabetes were either obese (64.0%) or overweight (26.3%). Clinical management of diabetes was largely in line with UNRWA’s technical instructions for diabetes. Records for 2-h postprandial glucose (2 h PPG), serum cholesterol, serum creatinine, and urine protein analysis were available in 94.7%, 96.4%, 91.4% and 87.5%, cases respectively but records of annual fundoscopic eye exam were available in less than half the cases (47.3%) and foot examinations were even less well documented. Most patients (95.6%) were on anti-diabetic medications – 68.2% on OADs only, 14.4% were receiving combination of OAD and insulin, and 12.9% insulin only. While 44.8% patients had 2 h post-prandial glucose (PPG) 180 mg/dl, only 28.2% had HbA1c 7%; 55.5% and 28.2% had BP 140/90 and 130/80 mm of Hg respectively. Serum cholesterol 200 mg/dl, serum creatinine 1.2 mg/dl and macro albuminuria was noted in 39.8%; 6.4% and 10.3% cases respectively. Peripheral neuropathy (52.6%), foot infections (17%), diabetic retinopathy (11%) and myocardial infarction (MI) (9.6%) were the most common long term complications. While one or more episodes of hypoglycaemia were reported by 25% cases; amongst insulin users it was 48%. The study confirmed that UNRWA doctors and nurses follow TIs for diabetes and hypertension fairly well. Financial constraint and its consequent effect on UNRWA TI and policy related to diabetes care such as reliance on 2 h PPG to measure control, non-availability of routine HbA1c testing, home glucose monitoring and statins within the UNRWA system were important issues in further improving care and are being discussed for the new strategy and TI. High levels of obesity in the community and high patient load in the outpatient clinics with no special day for diabetes services were the other key issues. In terms of record keeping and monitoring, data on most parameters were available in over 90% cases including records of lab tests and clinical examinations performed in the last one year which is better than in similar studies done in other developing countries in tertiary care centres [20,21]. Insufficient focus on lifestyle counselling was another shortcoming identified. More than 90% of people with DM within the UNRWA system are either obese (64%) or overweight (26.3%), around 70% have co existing hypertension and almost 40% have hyperlipidaemia as noted above and all these conditions are amenable to prevention through lifestyle measures; requiring greater attention to lifestyle counselling. According to UNRWA TI, patients should receive at least four heath education sessions during assessment visits each year. The audit revealed that 17.6% patients received no self-care education and 22.6% patients received four or more health education sessions, reflecting poor adherence to guidelines on self-care education. Less than half the patients (40.6%) recalled receiving relevant lifestyle health education sessions (exercise
and diet). Although foot complication (peripheral neuropathy, foot infections) rates are significant, only 16% of patients recalled receiving foot care advice. The same applies for counselling on hypoglycaemia, despite the high rate. Better training, redefining roles and skilful deployment of nonmedical health professionals may help improve self-care education and patient counselling. History of MI or undergoing angioplasty was noted in 9.3% cases and is similar to the 9.7% prevalence of MI among diabetic patients reported earlier in the region [22]. The high rate of MI reflects the need to address underlying risk factors and to strictly follow UNRWA adopted World Health Organization’s (WHO) secondary prevention strategy for people with diabetes and hypertension with stricter monitoring of BP and glycaemia control using HbA1c and introducing the use of statins. A retrospective descriptive study [16] using routine quarterly and cumulative case records, as well as cumulative and 12-month analyses of cohort outcomes collected through E-Health in UNRWA Nuzha Primary Health Care Clinic showed that 70% of the 2851 patients registered during the year 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. 85% of new registrations were 40 years or older, 40% were new diagnoses and more than twothirds of people with diabetes already had hypertension at the time of registration. 42% had post-prandial blood glucose measured and 50% of these had normal blood glucose. Of those diagnosed with hypertension, 63% had blood pressure measured and 75% had a normal reading. Cohort analysis of E health records from centres rolling out the E-Health System shows that almost half of those who miss appointment in one quarter eventually fail to return and end up being classified lost to follow up after a year [23]. These cases are more likely to be males between 40 and 59 years, with no or few complications. Keeping an eye on these patients and encouraging or incentivizing them to re attend may improve long term outcomes.
5. Health care provider training, knowledge, and perceptions The report on the clinical audit of diabetes care within UNRWA system [2] describes health care provider attributes that can have important impact on the quality of care. Amongst the study sample 94% of medical officers (MOs) were males, similar to the predominant male gender distribution of UNRWA MOs (78%). Given the higher female (64%) distribution in both the general and diabetes patient population attending UNRWA clinics, the predominance of male gender amongst MOs may cause challenges in communication and physical examination especially in a conservative Arabic Muslim community and this can have consequences for care and outcomes. 42% of MOs had less than five years’ experience reflecting a high turnover rate. 85% MOs had attended a diabetes related training in the last one year reflecting the importance UNRWA places on training. The MOs generally had good understanding of the UNRWA TIs as well as a fair idea of the characteristics of the patients in their clinics.
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However, there were some glaring discrepancies. When asked what proportions of their patients are obese, only one third MOs selected the option >50%, whereas 64% of diabetes patients across UNRWA clinics are obese. If MOs do not perceive their patients to be obese they are less likely to initiate actions to address it. When asked what proportion of their insulin treated patients self-inject, only 40% gave the correct answer. In another related question 70% said that their patients depended on paramedics for insulin injection indicating that most MOs underestimate their patients’ ability to self-inject and this perhaps may lead to over reliance on OADs and delay in initiating insulin therapy. In response to the question ‘‘what proportions of your patients are under control?’’ one third of MOs overestimated the proportion of controlled patients. This again has consequences in terms of reviewing treatment options and long term outcome. The findings from the comprehensive clinical audit of diabetes services at UNRWA primary care centres point to the difficulties in diabetes control as also described in studies from tertiary care centres in other developing countries using a similar study protocol [20,21,24–27]. However, in terms of record keeping and monitoring, UNRWA centres fared much better-with data available in over 90% cases on most parameters including records of lab tests and clinical examinations performed in the last one year. In many of these earlier studies proportion of patients undergoing annual lab tests and examinations were much lower indicating poor adherence to protocols; lower level of control for glucose, blood pressure and lipids and higher complication rates. The very high prevalence of overweight and obesity and other risk factors in the UNRWA population points towards a need for a more comprehensive and strategic response that goes beyond the activities of the NCD care programme to address the health burden from diabetes and hypertension. The recently introduced Family Health Team reform [7] offers a framework to address this. While more efforts are required to raise awareness and improve lifestyles through health promotion; the prevailing socioeconomic and psychological stress from spending a lifetime in a refugee camp poses a big challenge. Limited funding and the need to prioritize scarce resources also places constraint on policy recommendations. Addressing the barriers and shortcomings identified through clinical audits and cohort monitoring will further strengthen and improve UNRWA health system’s laudable efforts of providing quality services for diabetes and hypertension at the primary care level.
Conflicts of interest I declare that there is no conflict of interest.
6.
Conclusions
Through a structured process of care delivery the UNRWA health system is making significant strides in addressing diabetes and hypertension and consequently the nine voluntary global targets as envisaged in the WHO Global Action Plan for the Prevention and Control of NCDs 2013–2020. Given that
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most developing countries either have no or only rudimentary services for diabetes and hypertension at the primary care level and may face similar resource and capacity constraints, UNRWA’s efforts can serve as a model and inspiration to set up similar initiatives.
references
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