MSF experiences of providing multidisciplinary primary level NCD care for Syrian refugees and the host population in Jordan: an implementation study guided by the RE-AIM framework
Background: In response to the rising global NCD burden, humanitarian actors have rapidly scaled-up NCD services in crisis-affected low-and-middle income countries. Using the RE-AIM implementation framework, we evaluated a multidisciplinary, primary-level model of NCD care for Syrian refugees and vulnerable Jordanians in Irbid, Jordan. We examined the programme’s Reach, Effectiveness, Adoption and acceptance; Implementation and Maintenance over time.
Methods: This mixed methods, retrospective evaluation, undertaken in 2017, comprised secondary analysis of pre-existing cross-sectional household survey data; analysis of routine cohort data from December 2014 - December 2017; descriptive costing analysis of total annual, per-patient and per-consultation costs for 2015-2017 from the provider-perspective; clinical audit; medication adherence survey of 300 patients; and qualitative research involving thematic analysis of individual interviews and focus group discussions.
Results: The programme enrolled 23% of Syrian adult refugees with NCDs in Irbid governorate. The cohort mean age was 54.7 years; 71% had multi-morbidity and 9.9% self-reported a disability. The programme was acceptable to patients, staff and stakeholders. Blood pressure and glycaemic control improved as the programme matured and by 7 mmHg and 26 mg/dL respectively within six months of patient enrolment. Total costs increased in parallel with increased service complexity from INT$ 4,206,481 in 2015 to 6,739,438 in 2017. Staff reported that clinical guidelines were usable and patients’ self-reported medication adherence was high. Individual and organisational challenges to programme implementation and maintenance included the impact of war and the refugee experience on Syrian refugees’ ability to engage; inadequate low-cost referral options; and challenges of operating in a regulated, middle-income country. Essential programme adaptations included refinement of health education, development of mental health and psychosocial services and addition of essential referral pathways, home visit, physiotherapy and social worker services.
Conclusion: RE-AIM proved a valuable tool in evaluating a complex intervention in a protracted humanitarian crisis setting. This multidisciplinary programme was highly acceptable. It achieved good clinical outcomes but for a limited number of patients and at relatively high cost. We propose that model simplification, adapted procurement practices and use of technology could improve cost effectiveness without reducing acceptability, and may facilitate replication.
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Posted 11 Jun, 2020
On 23 Aug, 2020
Received 07 Aug, 2020
On 30 Jul, 2020
On 26 Jun, 2020
Invitations sent on 23 Jun, 2020
On 18 Jun, 2020
On 17 Jun, 2020
On 04 Jun, 2020
On 23 Apr, 2020
Received 30 Mar, 2020
Received 30 Mar, 2020
On 26 Mar, 2020
On 26 Mar, 2020
Invitations sent on 10 Feb, 2020
On 07 Feb, 2020
On 06 Feb, 2020
On 06 Feb, 2020
On 31 Jan, 2020
MSF experiences of providing multidisciplinary primary level NCD care for Syrian refugees and the host population in Jordan: an implementation study guided by the RE-AIM framework
Posted 11 Jun, 2020
On 23 Aug, 2020
Received 07 Aug, 2020
On 30 Jul, 2020
On 26 Jun, 2020
Invitations sent on 23 Jun, 2020
On 18 Jun, 2020
On 17 Jun, 2020
On 04 Jun, 2020
On 23 Apr, 2020
Received 30 Mar, 2020
Received 30 Mar, 2020
On 26 Mar, 2020
On 26 Mar, 2020
Invitations sent on 10 Feb, 2020
On 07 Feb, 2020
On 06 Feb, 2020
On 06 Feb, 2020
On 31 Jan, 2020
Background: In response to the rising global NCD burden, humanitarian actors have rapidly scaled-up NCD services in crisis-affected low-and-middle income countries. Using the RE-AIM implementation framework, we evaluated a multidisciplinary, primary-level model of NCD care for Syrian refugees and vulnerable Jordanians in Irbid, Jordan. We examined the programme’s Reach, Effectiveness, Adoption and acceptance; Implementation and Maintenance over time.
Methods: This mixed methods, retrospective evaluation, undertaken in 2017, comprised secondary analysis of pre-existing cross-sectional household survey data; analysis of routine cohort data from December 2014 - December 2017; descriptive costing analysis of total annual, per-patient and per-consultation costs for 2015-2017 from the provider-perspective; clinical audit; medication adherence survey of 300 patients; and qualitative research involving thematic analysis of individual interviews and focus group discussions.
Results: The programme enrolled 23% of Syrian adult refugees with NCDs in Irbid governorate. The cohort mean age was 54.7 years; 71% had multi-morbidity and 9.9% self-reported a disability. The programme was acceptable to patients, staff and stakeholders. Blood pressure and glycaemic control improved as the programme matured and by 7 mmHg and 26 mg/dL respectively within six months of patient enrolment. Total costs increased in parallel with increased service complexity from INT$ 4,206,481 in 2015 to 6,739,438 in 2017. Staff reported that clinical guidelines were usable and patients’ self-reported medication adherence was high. Individual and organisational challenges to programme implementation and maintenance included the impact of war and the refugee experience on Syrian refugees’ ability to engage; inadequate low-cost referral options; and challenges of operating in a regulated, middle-income country. Essential programme adaptations included refinement of health education, development of mental health and psychosocial services and addition of essential referral pathways, home visit, physiotherapy and social worker services.
Conclusion: RE-AIM proved a valuable tool in evaluating a complex intervention in a protracted humanitarian crisis setting. This multidisciplinary programme was highly acceptable. It achieved good clinical outcomes but for a limited number of patients and at relatively high cost. We propose that model simplification, adapted procurement practices and use of technology could improve cost effectiveness without reducing acceptability, and may facilitate replication.