Monitoring of diabetes and hypertension services provided by the UN Relief and Works Agency for Palestine Refugees in the Near East

Abstract

Background The UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) is the main provider of health services to 5·1 million Palestinian refugees in Jordan, Lebanon, Syria, and the occupied Palestinian territory (West Bank and Gaza Strip). In 1992, UNRWA planned to incorporate services for the treatment of individuals with diabetes and hypertension into its primary health-care programme; integration of the services was completed in 1994. The number of people with diabetes or hypertension attending UNRWA's health centres increased from 14 500 in 1992 to 199 400 in 2010. More women than men attend UNRWA's clinics, not because of reasons related to their diseases but because these clinics are open during the morning (0730 h to 1400 h) when most men are at work. 61% of 199 400 people attending the clinics were women and 39% were men, and 91% were older than 40 years. In 2010, the prevalence of diabetes in the population older than 40 years was 11% and of hypertension was 16% of 1 506 000 individuals. The aim in this study was to assess the control status and prevalence of complications and associated risk factors in patients with diabetes and hypertension attending UNRWA's clinics. Methods All 199 400 registered refugees with diabetes or hypertension in all UNRWA's clinics were eligible for participation in the study. According to expert opinion, the predefined sample size was 19 400 patients and 10% of patients at each health centre were selected. Every tenth patient's file in the clinic's standardised record keeping system was selected for inclusion in the study to achieve the 10% per health centre and thus 10% overall. At the end of 2010, field data were compiled for all patients who had been registered for at least 1 year, and for those whose files showed their blood pressure and 2 h post-prandial blood glucose (PPG) concentration had been measured at least three times during 2010 and that they had a control status according to UNRWA's criteria (guidelines as per WHO's recommendation). Late (irreversible) complications (namely, myocardial infarction, cerebral stroke, end-stage renal failure, blindness, or above-ankle amputation of at least one side) were included in the assessment. The data were analysed with the Management Health Information System (version 3.08) at UNRWA's headquarters in Amman, Jordan, and Microsoft Excel 2007. This study was reviewed and approved by the ethical committee of UNRWA's Health Department. Participants provided verbal informed consent. Findings According to UNRWA's criteria, a patient's diabetes is controlled if two of three readings for post-prandial glucose concentration are less than or equal to 10 mmol/L, and hypertension is controlled if two of three readings are less than 140/90 mm Hg; for patients with both diseases, both criteria need to be met during 1 calendar year. Criteria for control of diabetes were met in 1642 (48%) of 3400 patients with diabetes, 5432 (60%) of 9100 with hypertension, and 2746 (40%) of 6900 individuals with both diabetes and hypertension. Overall, 2445 (13%) of 19 400 patients had late complications: 947 (5%) myocardial infarction, 621 (3%) congestive heart failure, 702 (4%) stroke, 68 ( 2 ), 5917 (31%) had a serum cholesterol concentration greater than 5·17 mmol/L, and 3317 (17%) were smokers. Interpretation The frequency of risk factors and late complications in Palestinian refugees with diabetes and hypertension are a cause for concern. Monitoring of these patients on a yearly basis would improve their management. Also, the quality of monitoring could be improved with the measurement of glycated haemoglobin A 1c , increased staff capacity at UNRWA, and provision of drugs that improve the control status of diabetes or hypertension and reduce the rates of complications in patients. Furthermore, research for evidence-based information and subsequent actions with respect to non-communicable diseases need to be increased by UNRWA. Funding None.