This week in BMC Health Services Research, Ansbro et al. describe their experiences of adapting the RE-AIM framework to assess Doctors Without Borders NCD care program for Syrian refugees and vulnerable Jordanians in Jordan. James Edwards, Senior Associate Editor, tells us more about the study and what health services researchers working in humanitarian crisis situations can learn from the study for future programs.
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Noncommunicable diseases (NCDs), such as cardiovascular disease and diabetes, are the leading cause of death worldwide. A growing volume of NCDs in low- and middle-income countries (LMICs) now accounts for the majority of recent surges in the global burden of NCDs.
At the same time, growing humanitarian crises in LMICs have resulted in the forced displacement of people around the world at record levels, with the average duration of displacement now over 20 years. Until recently, the issue of NCDs in conflict-affected populations was largely overlooked. However, with growing awareness of the challenges of NCDs in humanitarian settings, clinical guidance has been developed for chronic NCD care in LMICs.
Since 2014, the non-governmental organization (NGO) Doctors Without Borders (MSF) supported the Jordanian health system by providing first-level multidisciplinary care against noncommunicable diseases to Syrian refugees and vulnerable Jordanians living in Irbid, Jordan. This week in BMC Health Services Research, Ansbro et al. describe their experiences with MSF, adapting the RE-AIM framework evaluate the MSF NCD care program.
RE-AIM is a framework made up of five elements, Scope, effectiveness, adoption, implementation and maintenance. The framework was originally developed to encourage program planners, evaluators, funders and policy makers to pay more attention to program essentials, improve sustainable adoption, and promote the implementation of effective, generalizable and evidence-based interventions. In this study, through the use of mixed methods, Ansbro et al. reviewed the five key elements of RE-AIM of the MSF NCD program for Syrian refugees.
Scope, Effectiveness and Adoption
Most areas of the program were found to be acceptable to patients, staff and stakeholders. Although the care was free, patients had to incur indirect costs, such as paying for transportation, to get to clinics, potentially outweighing the benefits of “free” care.
The program has achieved good clinical results for the treatment of patients with hypertension and diabetes. However, more research in the future using longer follow-up periods is needed to understand the prevalence or outcome of major complications of NCDs.
A major challenge for the implementation was the impact of Syrian patients’ experiences of war, loss and social suffering on their engagement in the care of NCDs. Staff also expressed concerns that they could not deal with medical issues independently of the psychosocial issues patients were facing and that they felt ill-equipped to deal with patients’ war-related trauma.
Patients and staff also reported that referral routes to specialist services were awkward and confusing. Funding for specialist referrals was limited, although MSF was successful in securing additional funding. This highlights the need for future programs to safely implement specialized referral pathways, ensuring that they are designed to be affordable and accessible from the start.
A major challenge in maintaining the program was the cost. The high costs were partly responsible for the limited coverage and reach of the program. However, there is room for adaptations. For example, MSF has introduced job sharing for nurses, which could lead to cost savings.
Another challenge here is the availability of highly qualified family medicine specialists, for the management of patients with complex needs. While MSF has had access to a large number of highly qualified Jordanian staff on this occasion, this is often not the case in all humanitarian crisis contexts. This problem is difficult to solve, but the authors offer potential workarounds, such as telemedicine, as a possible solution for future programs.
Research in humanitarian crisis situations is extremely difficult. Not only do governments and humanitarian organizations face significant challenges in effectively addressing NCDs in LMICs, evaluating responses in humanitarian contexts is equally difficult. Yet this study has demonstrated that RE-AIM is a valuable tool for guiding complex interventions in humanitarian crisis situations. Ansbro et al. Filling a knowledge gap in the provision of care in humanitarian settings, however, more research is urgently needed to strengthen responses to NCDs in humanitarian crisis situations. Future programs must focus on simplifying models of care, reducing costs and leveraging telehealth resources.