Care In Humanitarian Settings Research Articles

Implementing and evaluating integrated care models for non-communicable diseases in fragile and humanitarian settings

In this commentary, we advocate for the wider implementation of integrated care models for NCDs within humanitarian preparedness, response, and resilience efforts. Since experience and evidence on integrated NCD care in humanitarian settings is limited, we discuss potential benefits, key lessons learned from other settings, and lessons from the integration of other conditions that may be useful for stakeholders considering an integrated model of NCD care. We also introduce our ongoing project in North Lebanon as a case example currently undergoing parallel tracks of program implementation and process evaluation that aims to strengthen the evidence base on implementing an integrated NCD care model in a crisis setting.

Patient experiences of diabetes and hypertension care during an evolving humanitarian crisis in Lebanon: A qualitative study.

Humanitarian health care models increasingly incorporate care for non-communicable diseases (NCDs). Current research evidence focuses on burden of disease, service provision and access to care, and less is known about patient's experience of the continuum of care in humanitarian settings. To address this gap, this study explored experiences of displaced Syrian and vulnerable Lebanese patients receiving care for hypertension and/or diabetes at four health facilities supported by humanitarian organisations in Lebanon. We conducted in-depth, semi-structured qualitative interviews with a purposive sample of patients (n = 18) and their informal caregivers (n = 10). Data were analysed thematically using both deductive and inductive approaches. Both Syrian and Lebanese patients reported interrupted pathways of care. We identified three typologies of patient experience at the time of interview; (1) managing adequately from the patient's perspective; (2) fragile management and (3) unable to manage their condition(s) adequately, with the majority falling into typologies 2 and 3. Patients and their families recognised the importance of maintaining continuity of care and self-management, but experienced substantial challenges due to changing availability and cost of medications and services, and decreasing economic resources during a period of national crises. Family support underpinned patient's response to challenges. Navigating the changing care landscape was a significant burden for patients and their families. Interactions were identified between mental health and NCD management. This study suggests that patients experienced disrupted, non-linear pathways in maintaining care for hypertension and diabetes in a humanitarian setting, and family support networks were key in absorbing treatment burden and sustaining NCD management. Recommendations are made to reduce treatment burden for patients and their families and to support sustainable condition management.

What drives change in children receiving telephone-delivered Common Elements Treatment Approach (t-CETA)? A multiple n = 1 study with Syrian refugee children and adolescents in Lebanon

BackgroundAlthough the evidence-base for mental health and psychosocial support (MHPSS) interventions in humanitarian settings is growing rapidly, their mechanisms of change remain poorly understood despite the potential to improve the effectiveness and reach of interventions. ObjectiveThis study aimed to explore the mechanisms or factors that drive change in a modular transdiagnostic telephone-delivered mental health intervention, Common Elements Treatment Approach (t-CETA). Participants and settingParticipants were Syrian refugee children and adolescents living in tented settlements in Lebanon. MethodsWe used a multiple n = 1 design, drawing on secondary data from 9 children who completed t-CETA during a pilot randomized controlled trial. ResultsChildren with historical war-related trauma were more likely to show significant improvement across symptom clusters by the end of treatment compared to children presenting with depression related to daily living conditions. Children also showed fluctuating symptoms during the early stages of treatment (engagement and cognitive restructuring) but significant decline in symptoms after the trauma module (prolonged imaginal exposure) and depression module (behavioral activation). Salient external life events identified were starting or dropping out of school, working, change in living conditions, family conflict and the October Revolution; and interpersonal factors of parental engagement (with or without full attendance) and counsellor skills in building rapport were also identified as having an impact on treatment success. ConclusionsImplications of our findings are discussed in terms of integrating active ingredients into MHPSS programming, and building on parental and multi-sector involvement in child and adolescent mental health care in humanitarian settings.

Aid when 'there is nothing left to offer': Experiences of palliative care and palliative care needs in humanitarian crises.

Access to palliative care, and more specifically the alleviation of avoidable physical and psychosocial suffering is increasingly recognized as a necessary component of humanitarian response. Palliative approaches to care can meet the needs of patients for whom curative treatment may not be the aim, not just at the very end of life but alleviation of suffering more broadly. In the past several years many organizations and sectoral initiatives have taken steps to develop guidance and policies to support integration of palliative care. However, it is still regarded by many as unfeasible or aspirational in crisis contexts; particularly where care for persons with life threatening conditions or injuries is logistically, legally, and ethically challenging. This article presents a synthesis of findings from five qualitative sub-studies within a research program on palliative care provision in humanitarian crises that sought to better understand the ethical and practical dimensions of humanitarian organizations integrating palliative care into emergency responses. Our multi-disciplinary, multi-national team held 98 in-depth semi-structured interviews with people with experiences in natural disasters, refugee camps in Rwanda and Jordan, and in Ebola Treatment Centers in Guinea. Participants included patients, family members, health care workers, and other staff of humanitarian agencies. We identified four themes from descriptions of the struggles and successes of applying palliative care in humanitarian settings: justification and integration of palliative care into humanitarian response, contextualizing palliative care approaches to crisis settings, the importance of being attentive to the 'situatedness of dying', and the need for retaining a holistic approach to care. We discuss these findings in relation to the ideals embraced in palliative care and corresponding humanitarian values, concluding that palliative care in humanitarian response is essential for responding to avoidable pain and suffering in humanitarian settings.

Perioperative Risk Assessment in Humanitarian Settings: A Scoping Review.

No validated perioperative risk assessment models currently exist for use in humanitarian settings. To inform the development of a perioperative mortality risk assessment model applicable to humanitarian settings, we conducted a scoping review of the literature to identify reports that described perioperative risk assessment in surgical care in humanitarian settings and LMICs. We conducted a scoping review of the literature to identify records that described perioperative risk assessment in low-resource or humanitarian settings. Searches were conducted in databases including: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science, World Health Organization Catalog, and Google Scholar. Our search identified 1582 records. After title/abstract and full text screening, 50 reports remained eligible for analysis in quantitative and qualitative synthesis. These reports presented data from over 37 countries from public, NGO, and military facilities. Data reporting was highly inconsistent: fewer than half of reports presented the indication for surgery; less than 25% of reports presented data on injury severity or prehospital data. Most elements of perioperative risk models designed for high-resource settings (e.g., vital signs, laboratory data, and medical comorbidities) were unavailable. At present, no perioperative mortality risk assessment model exists for use in humanitarian settings. Limitations in consistency and quality of data reporting are a primary barrier, however, can be addressed through data-driven identification of several key variables encompassed by a minimum dataset. The development of such a score is a critical step toward improving the quality of care provided to populations affected by conflict and protracted humanitarian crises.

A systematic review of newborn health interventions in humanitarian settings

BackgroundAlmost half of the under-5 deaths occur in the neonatal period and most can be prevented with quality newborn care. The already vulnerable state of newborns is exacerbated in humanitarian...

Context matters: a systematic review of neonatal care in humanitarian emergencies

BackgroundOf the 15 countries with the highest neonatal mortality rates, 13 are characterised by conflict and political instability. Despite well-documented evidence of best practice interventions for neonatal survival, it remains less clear on how these practices are implemented in humanitarian emergency settings.ObjectiveTo conduct a systematic review of published and grey literature on the implementation strategies and challenges in addressing neonatal care in humanitarian emergencies.MethodsA systematic literature search was conducted in SCOPUS, MEDLINE, Web of Science, CINHAL and Global Health for studies published between 1 January 2003 and 30 June 2018. Additionally, websites of organisations actively working in humanitarian emergencies were searched. Interventions were reviewed against the existing essential newborn care framework according to the standards outlined in the Newborn Health in Humanitarian Settings Field Guide.ResultsTwenty-one studies were identified: eight reporting on conflict and refugee settings, nine followed natural disasters and four discussed multiple emergency settings. Few studies addressed all the components of essential newborn care outlined in the field guide regardless of the emergency type. The review of literature demonstrated challenges in addressing essential newborn care identified in all humanitarian settings including the lack of adequate equipment, financing, and trained staff. Implementation strategies identified included quality improvement training for staff, the development of evacuation procedures, integrating with local and government resources and generating spaces in health facilities specifically for newborn care.ConclusionsThe requirements and initiatives needed to deliver essential newborn care in humanitarian settings are highly variable and context dependent. Given the diversity of factors needing to be addressed by the field guide, more research should be directed towards the adaptability of the implementation strategies to differing emergency contexts.Trial registrationPROSPERO registration ID: CRD42018098824

Chronic NCD care in crises: A qualitative study of global experts’ perspectives on models of care for hypertension and diabetes in humanitarian settings

BackgroundThe high and rising global burden of non-communicable diseases (NCDs) is reflected among crisis-affected populations. People living with NCDs are especially vulnerable in humanitarian crises. Limited guidance exists to support humanitarian actors in designing effective models of NCD care for crisis-affected populations in low- and middle-income countries (LMICs). We aimed to synthesise expert opinion on current care models for hypertension and diabetes (HTN/DM) in humanitarian settings in LMICs, to examine the gaps in delivering good quality HTN/DM care and to propose solutions to address these gaps. MethodsWe interviewed twenty global experts, purposively selected based on their expertise in provision of NCD care in humanitarian settings. Data were analysed using a combination of inductive and deductive methods. We used a conceptual framework for primary care models for HTN/DM in humanitarian settings, guided by the WHO health systems model, patient-centred care models and literature on NCD care in LMICs. ResultsHTN/DM care model design was highly dependent on the type of humanitarian crisis, the implementing organisation, the target population, the underlying health system readiness to deal with NCDs and its resilience in the face of crisis. Current models were mainly based at primary-care level, in prolonged crisis settings. Participants focussed on the basic building blocks of care, including training the workforce, and strengthening supply chains and information systems. Intermediate health system goals (responsiveness, quality and safety) and final goals received less attention. There were notable gaps in standardisation and continuity of care, integration with host systems, and coordination with other actors. Participants recommended a health system strengthening approach and aspired to providing patient-centred care. However, more evidence on effective integration and on patients’ priorities and experience is needed. More funding is needed for NCD care and related research. ConclusionsComprehensive guidance would foster standardization, continuity, integration and, thus, better quality care. Future models should take a health system strengthening approach, use patient-centred design, and should be co-created with patients and providers. Those designing new models may draw on lessons learned from existing chronic care models in high- and low-income settings.

Preventing avoidable hospital admissions after emergency care in humanitarian settings: a cross-sectional review of Médecins Sans Frontières emergency departments

ObjectivesThe aim of this study was to describe the types of emergency departments (EDs), and the acuity, types and disposition of conditions managed at Médecins Sans Frontières (MSF)-supported EDs in...

Setting research priorities for sexual, reproductive, maternal, newborn, child and adolescent health in humanitarian settings

BackgroundAn estimated 70.8 million people are forcibly displaced worldwide, 75% of whom are women and children. Prioritizing a global research agenda to inform guidance, service delivery, access to and quality of services is essential to improve the survival and health of women, children and adolescents in humanitarian settings.MethodA mixed-methods design was adapted from the Child Health and Nutrition Research Initiative (CHNRI) methodology to solicit priority research questions across the sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) domains in humanitarian settings. The first step (CHNRI) involved data collection and scoring of perceived priority questions, using a web-based survey over two rounds (first, to generate the questions and secondly, to score them). Over 1000 stakeholders from across the globe were approached; 177 took part in the first survey and 69 took part in the second. These research questions were prioritized by generating a research prioritization score (RPP) across four dimensions: answerability, program feasibility, public health relevance and equity. A Delphi process of 29 experts followed, where the 50 scored and prioritized CHRNI research questions were shortlisted. The top five questions from the CHNRI scored list for each SRMNCAH domain were voted on, rendering a final list per domain.ResultsA total of 280 questions were generated. Generated questions covered sexual and reproductive health (SRH) (n = 90, 32.1%), maternal health (n = 75, 26.8%), newborn health (n = 42, 15.0%), child health (n = 43, 15.4%), and non-SRH aspects of adolescent health (n = 31, 11.1%). A shortlist of the top ten prioritized questions for each domain were generated on the basis of the computed RPPs. During the Delphi process, the prioritized questions, based on the CHNRI process, were further refined. Five questions from the shortlist of each of the SRMNCAH domain were formulated, resulting in 25 priority questions across SRMNCAH. For example, one of the prioritized SRH shortlisted and prioritized research question included: “What are effective strategies to implement good quality comprehensive contraceptive services (long-acting, short-acting and EC) for women and girls in humanitarian settings?”ConclusionData needs, effective intervention strategies and approaches, as well as greater efficiency and quality during delivery of care in humanitarian settings were prioritized. The findings from this research provide guidance for researchers, program implementers, as well as donor agencies on SRMNCAH research priorities in humanitarian settings. A global research agenda could save the lives of those who are at greatest risk and vulnerability as well as increase opportunities for translation and innovation for SRMNCAH in humanitarian settings.

Clinical outcomes in a primary-level non-communicable disease programme for Syrian refugees and the host population in Jordan: A cohort analysis using routine data.

BackgroundLittle is known about the content or quality of non-communicable disease (NCD) care in humanitarian settings. Since 2014, Médecins Sans Frontières (MSF) has provided primary-level NCD services in Irbid, Jordan, targeting Syrian refugees and vulnerable Jordanians who struggle to access NCD care through the overburdened national health system. This retrospective cohort study explored programme and patient-level patterns in achievement of blood pressure and glycaemic control, patterns in treatment interruption, and the factors associated with these patterns.Methods and findingsThe MSF multidisciplinary, primary-level NCD programme provided facility-based care for cardiovascular disease, diabetes, and chronic respiratory disease using context-adapted guidelines and generic medications. Generalist physicians managed patients with the support of family medicine specialists, nurses, health educators, pharmacists, and psychosocial and home care teams. Among the 5,045 patients enrolled between December 2014 and December 2017, 4,044 eligible adult patients were included in our analysis, of whom 72% (2,913) had hypertension and 63% (2,546) had type II diabetes. Using visits as the unit of analysis, we plotted the following on a monthly basis: mean blood pressure among hypertensive patients, mean fasting blood glucose and HbA1c among type II diabetic patients, the proportion of each group achieving control, mean days of delayed appointment attendance, and the proportion of patients experiencing a treatment interruption. Results are presented from programmatic and patient perspectives (using months since programme initiation and months since cohort entry/diagnosis, respectively). General linear mixed models explored factors associated with clinical control and with treatment interruption. Mean age was 58.5 years, and 60.1% (2,432) were women. Within the programme’s first 6 months, mean systolic blood pressure decreased by 12.4 mm Hg from 143.9 mm Hg (95% CI 140.9 to 146.9) to 131.5 mm Hg (95% CI 130.2 to 132.9) among hypertensive patients, while fasting glucose improved by 1.12 mmol/l, from 10.75 mmol/l (95% CI 10.04 to 11.47) to 9.63 mmol/l (95% CI 9.22 to 10.04), among type II diabetic patients. The probability of achieving treatment target in a visit was 63%–75% by end of 2017, improving with programme maturation but with notable seasonable variation. The probability of experiencing a treatment interruption declined as the programme matured and with patients’ length of time in the programme. Routine operational data proved useful in evaluating a humanitarian programme in a real-world setting, but were somewhat limited in terms of data quality and completeness. We used intermediate clinical outcomes proven to be strongly associated with hard clinical outcomes (such as death), since we had neither the data nor statistical power to measure hard outcomes.ConclusionsGood treatment outcomes and reasonable rates of treatment interruption were achieved in a multidisciplinary, primary-level NCD programme in Jordan. Our approach to using continuous programmatic data may be a feasible way for humanitarian organisations to account for the complex and dynamic nature of interventions in unstable humanitarian settings when undertaking routine monitoring and evaluation. We suggest that frequency of patient contact could be reduced without negatively impacting patient outcomes and that season should be taken into account in analysing programme performance.

Supporting Maternal Mental Health and Nurturing Care in Humanitarian Settings

Supporting Maternal Mental Health and Nurturing Care in Humanitarian Settings

Community health workers in humanitarian settings: Scoping review.

BackgroundThere is a need for greater understanding of experiences implementing community-based primary health care in humanitarian settings and of the adjustments needed to ensure continuation of essential services and utilization of services by the population, and to contribute to effective emergency response. We reviewed the evidence base on community health workers (CHWs) in humanitarian settings, with the goal of improving delivery of essential services to the most vulnerable populations.MethodsWe conducted a scoping review of published and grey literature related to health and nutrition services provided by CHWs in humanitarian settings. Extracted data from retained documents were analyzed inductively for key themes.ResultsOf 3709 documents screened, 219 were included in the review. Key findings from the literature include: 1) CHWs were often able to continue providing services during acute and protracted crises, including prolonged periods of conflict and insecurity and during population displacement. 2) CHWs carried out critical emergency response activities during acute crises. 3) Flexible funding facilitated transitions between development and humanitarian programming. 4) Communities that did not have a locally-resident CHW experienced reduced access to services when travel was limited. 5) Community selection of CHWs and engagement of respected local leaders were crucial for community trust and acceptance and high utilization of services. 6) Selection of local supervisors and use of mobile phones facilitated continued supervision. 7) Actions taken to maintain supplies included creating parallel supply chains, providing buffer stocks to CHWs, and storing commodities in decentralized locations. 8) When travel was restricted, reporting and data collection were continued using mobile phones and use of local data collectors. 9) CHWs and supervisors faced security threats and psychological trauma as a result of their work.ConclusionsTo achieve impact, policy makers and program implementers will have to address the bottlenecks to CHW service delivery common in stable low-income settings as well as the additional challenges unique to humanitarian settings. Future interventions should take into account the lessons learned from years of experience with implementation of community-based primary health care in humanitarian settings. There is also a need for rigorous assessments of community-based primary health care interventions in humanitarian settings.

Challenges associated with providing diabetes care in humanitarian settings

Summary The humanitarian health landscape is gradually changing, partly as a result of the shift in global epidemiological trends and the rise of non-communicable diseases, including diabetes. Humanitarian actors are progressively incorporating care for diabetes into emergency medical response, but challenges abound. This Series paper discusses contemporary practical challenges associated with diabetes care in humanitarian contexts in low-income and middle-income countries, using the six building blocks of health systems described by WHO (information and research, service delivery, health workforce, medical products and technologies, governance, and financing) as a framework. Challenges include the scarcity of evidence on the management of diabetes and clinical guidelines adapted to humanitarian contexts; unavailability of core indicators for surveillance and monitoring systems; and restricted access to the medicines and diagnostics necessary for adequate clinical care. Policy and system frameworks do not routinely include diabetes and little funding is allocated for diabetes care in humanitarian crises. Humanitarian organisations are increasingly gaining experience delivering diabetes care, and interagency collaboration to coordinate, improve data collection, and analyse available programmes is in progress. However, the needs around all six WHO health system building blocks are immense, and much work needs to be done to improve diabetes care for crisis-affected populations.

Delays in arrival and treatment in emergency departments: Women, children and non-trauma consultations the most at risk in humanitarian settings.

IntroductionDelays in arrival and treatment at health facilities lead to negative health outcomes. Individual and external factors could be associated with these delays. This study aimed to assess common factors associated with arrival and treatment delays in the emergency departments (ED) of three hospitals in humanitarian settings.MethodologyThis was a cross-sectional study based on routine data collected from three MSF-supported hospitals in Afghanistan, Haiti and Sierra Leone. We calculated the proportion of consultations with delay in arrival (>24 hours) and in treatment (based on target time according to triage categories). We used a multinomial logistic regression model (MLR) to analyse the association between age, sex, hospital and diagnosis (trauma and non-trauma) with these delays.ResultsWe included 95,025 consultations. Males represented 65.2%, Delay in arrival was present in 27.8% of cases and delay in treatment in 27.2%. The MLR showed higher risk of delay in arrival for females (OR 1.2, 95% CI 1.2–1.3), children <5 (OR 1.4, 95% CI 1.4–1.5), patients attending to Gondama (OR 30.0, 95% CI 25.6–35.3) and non-trauma cases (OR 4.7, 95% CI 4.4–4.8). A higher risk of delay in treatment was observed for females (OR 1.1, 95% CI 1.0–1.1), children <5 (OR 2.0, 95% CI 1.9–2.1), patients attending to Martissant (OR 14.6, 95% CI 13.9–15.4) and non-trauma cases (OR 1.6, 95% CI 1.5–1.7).ConclusionsWomen, children <5 and non-trauma cases suffered most from delays. These delays could relate to educational and cultural barriers, and severity perception of the disease. Treatment delay could be due to insufficient resources with consequent overcrowding, and severity perception from medical staff for non-trauma patients. Extended community outreach, health promotion and support to community health workers could improve emergency care in humanitarian settings.

Delivering paediatric critical care in humanitarian settings

Delivering paediatric critical care in humanitarian settings

Forced displacements and the environment: Its place in national and international climate agenda

Countries in the East African region have for decades been synonymous with natural disasters, conflicts and severe environmental degradation. About 10 million out of the 65.6 million displaced persons globally are found in this region. This paper presents an empirical analysis of environmental impacts caused by forced displacements in five East African countries. Contrary to a widely-held opinion, there is sufficient anecdotal and empirical evidence depicting environmental damage caused by refugees and/or Internally Displaced Persons (IDPs). A spatial analysis of current and former refugee and/or IDP camps in these five countries suggests the formation of “deforestation clusters” with concentrations of camps that compound environmental impacts. Technological advancements such as remote sensing capabilities can provide the means for assessing and implementing environmental protection measures. This paper recommends environmental care in humanitarian settings be considered an integral part of the Disaster Risk Reduction (DRR) and climate change/variability agenda, based on cost- and responsibility-sharing, employing technology, and incorporating appropriate monitoring tools.

6.10-P26“There is no time for these patients”: ethics, obstacles and palliative care in humanitarian settings

6.10-P26“There is no time for these patients”: ethics, obstacles and palliative care in humanitarian settings

Twelve-month contraceptive continuation among women initiating short- and long-acting reversible contraceptives in North Kivu, Democratic Republic of the Congo.

ContextDespite the inclusion of sexual and reproductive health (SRH) services in the minimum standards of health care in humanitarian settings, access to SRH services, and especially to contraception, is often compromised in war. Very little is known about continuation and switching of contraceptive methods in these settings. An evaluation of a contraceptive services program in North Kivu, Democratic Republic of the Congo (DRC) was conducted to measure 12-month contraceptive continuation by type of contraceptive method (short-acting or long-acting).MethodsA stratified systematic sample of women who initiated a contraceptive method 12–18 months prior to data collection was selected retrospectively from facility registers. A total of 548 women was interviewed about their contraceptive use: 304 who began a short-acting method (pills, injectables) and 244 who began a long-acting method (intra-uterine devices, implants). Key characteristics of short-acting method versus long-acting method acceptors were compared using chi-square statistics for categorical data and t-tests for continuous data. Unadjusted and adjusted Cox proportional hazard ratios were estimated to assess factors associated with discontinuation.ResultsAt 12 months, 81.6% women reported using their baseline contraceptive method continuously, with more long-acting than short-acting contraceptive acceptors (86.1% versus 78.0%, p = .02) continuing contraceptive use. Use of a short-acting method (Hazard ratio (HR) 1.74 [95%CI 1.13–2.67]) and desiring a child within two years (HR 2.58 [95%CI 1.45–4.54]) were associated with discontinuation within the first 12 months of use. The vast majority (88.3%) of women reported no prior contraceptive use.ConclusionThis is the first study of contraceptive continuation in a humanitarian setting. The high percentages of women continuing contraceptive use found here demonstrates that women will choose to initiate and continue use of their desired contraceptive method, even in a difficult, unstable and low contraceptive prevalence setting like North Kivu.

A qualitative evaluation of nursing care in humanitarian settings

A qualitative evaluation of nursing care in humanitarian settings