Making sure Syrian refugees with non-communicable diseases are not left behind during the COVID-19 pandemic
This blog is adapted from an International Health article titled 'Rapidly adapted community health strategies to prevent treatment interruption and improve COVID-19 detection for Syrian refugees and the host population with hypertension and diabetes in Jordan', by Ruwan Ratnayake, Fatma Rawashdeh, Raeda AbuAlRub, Nahla Al-Ali, Muhammad Fawad, Mohammad Bani Hani, Saleem Zoubi, Ravi Goyal, Khaldoun Al-Amire, Refqi Mahmoud, Rowaida AlMaaitah, Parveen K Parmar (2022).
Read the full article in International Health here.
As researchers of humanitarian health interventions, we are normally very flexible in our approaches to suit the context, but we never expected to bend this far. In this blog, we detail the herculean efforts of community health volunteers and our study team to meet the needs and study the approach in real time to connect Syrian refugee patients with life-saving non-communicable disease care during the COVID-19 pandemic in Jordan.
More than five million Syrian refugees are displaced throughout the Middle East because of the conflict in Syria, with 655,000 displaced in Jordan and most living outside of camps. This is an older population, and a large proportion of these refugees suffer from non-communicable diseases (NCDs) like diabetes and high blood pressure. The International Rescue Committee (IRC) in Jordan has supported Syrian refugees with a community health volunteer (CHVs) program since 2013 which aim to provide a connection between refugee households and IRC health facilities. In 2018, the IRC Jordan partnered with the University of Southern California and the Jordan University of Science and Technology (JUST) Faculty of Nursing to conduct research into how a cadre of CHVs can support Syrian refugees in northern Jordan outside of the clinic with their ongoing management of two primary NCDs, diabetes and high blood pressure. This is a major policy question for both non-communicable care and for alleviating the burden on constrained episodic and constrained primary care in humanitarian settings.
The plan had been to have CHVs conduct an evidence-based package of interventions with high-risk NCD patients based on home visits to monitor blood pressure, blood sugar, and weight, and conduct in-home counseling on medication adherence and disease self-management, and life-style changes utilizing motivational interviewing strategies, and screen for complications and psychosocial problems related to disease management and their vulnerable status.
COVID-19: the disruptor
However, just as this research got started in February 2020, the unexpected happened—the world faced its first pandemic in over 100 years. The patients, including elderly, obese, and chronically ill refugees, who are highly dependent on IRC clinics, found themselves not only dealing with loss of regular work and isolation, but also the daunting task of managing their diseases with their clinics and pharmacies closed. IRC health staff worried that these patients, unable to seek care or get their medications, might face preventable morbidity and mortality from inability to access clinical care—as well as the consequences of a COVID-19 infection.
And this is where the CHVs came in. In a short period of time, IRC health and research staff retrained the CHVs to deliver a fully remote CHV intervention by phone and in collaboration with local pharmacies. Based on widespread needs, this intervention was expanded from our original study population to include all clinic patients with diabetes, hypertension, or both conditions. The goal was primarily to help ensure access and adherence to medications and enable screening for acute complications of disease and immediate referral. This was facilitated by collaboration with local pharmacies to which their medications were delivered to; and with IRC and partner health facilities that could absorb emergency consultations for serious complications. The CHVs also educated patients on self-management, refer psychosocial concerns, and provide health promotion on infection prevention for COVID-19. Patients and their households were screened for COVID-19 symptoms regularly using an algorithm, and those who screened positive for symptoms were referred to testing and instructed on how to prevent secondary infections in the household.
The project ran from July 2020 to March 2021 and the flexible system proved a success. Over 90% of patients were fully adherent to medications. Complications became less common over time, and those that were identified were referred to for care. Detection of COVID-19 was challenging without any face-to-face testing, but thankfully, reports of symptomatic disease remained rare in the cohort and those who screened positive by the algorithm had access to testing and were followed up by the CHVs. And most crucially, disease management remained stable. Despite the pressures of the pandemic, the closure of health facilities, and the financial pressures faced by our population, patients’ blood pressure and blood glucose overall remained stable during the period of the study.
Community connections to prevent health complications.
Even more meaningful to our research and health staff were the ways in which patients and CHVs connected. CHVs provided an avenue of comprehensive support at a challenging and lonely time for many, including referrals to psychosocial care. As one patient said,
“[The CHV) provided me with psychological support and linked me with a counselor, motivated me to care about my health and told me that my life is a priority.”
Many stories emerged of CHVs and the research team identifying needs of vulnerable patients to connect them to secondary care, likely narrowly avoiding poor outcomes.
“At first, I was careless, not interested in what the CHV was telling me, every time they told me about signs of an emergency complication of my disease. Then one day, I got those symptoms and remembered what the CHV told me. Alhamdullah, they rescued me from confirmed death. Since that day I start believe in those CHVs and how much they care about me, and have helped me.”
Our original research focus on the impacts of an in-household visit by CHVs on disease management could not be answered, but our modified program shows promise for the integration of CHVs addressing NCDs within constrained primary care in humanitarian settings. CHVs not only provide essential support to vulnerable patients with complex disease, but they can also do so in a resource-limited setting and pivot quickly in changing circumstances. We believe CHVs provide an innovative way to support individuals with chronic health needs across a variety of conflict and crisis settings where care is disrupted —and to meet changing needs quickly.
Ruwan Ratnayake, Fatma Rawashdeh, Dr. Parveen Parmar