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Research article
Éimhín Ansbro
London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy
Corresponding Author
ORCiD: https://orcid.org/0000-0002-2291-1652
License:
This work is licensed under a CC BY 4.0 License. Read Full License
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.
Keywords
non communicable disease, diabetes, hypertension, cardiovascular disease, humanitarian, conflict, effectiveness, refugee, Syria, Jordan, programme, RE-AIM, evaluation, implementation
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Peer Review Timeline
CURRENT STATUS: Under Revision
Version 2
Posted 11 Jun, 2020
No community comments so far
Editorial decision: Minor revision
On 23 Aug, 2020
Review #1 received
Received 07 Aug, 2020
Reviewer #2 agreed
On 30 Jul, 2020
Reviewer #1 agreed
On 26 Jun, 2020
Reviewers invited
Invitations sent on 23 Jun, 2020
Editor assigned
On 18 Jun, 2020
Editor invited
On 17 Jun, 2020
Submission checks complete
On 04 Jun, 2020
No comments provided
Editorial decision: Minor revision
On 23 Apr, 2020
Review #2 received
Received 30 Mar, 2020
Review #1 received
Received 30 Mar, 2020
Reviewer #1 agreed
On 26 Mar, 2020
Reviewer #2 agreed
On 26 Mar, 2020
Reviewers invited
Invitations sent on 10 Feb, 2020
Editor assigned
On 07 Feb, 2020
Submission checks complete
On 06 Feb, 2020
Editor invited
On 06 Feb, 2020
First submitted
On 31 Jan, 2020
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
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This preprint is under consideration at BMC Health Services Research. A preprint is a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Learn more about In Review
Research article
Éimhín Ansbro
London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy
Corresponding Author
ORCiD: https://orcid.org/0000-0002-2291-1652
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
Peer Review Timeline
CURRENT STATUS: Under Revision
Version 2
Posted 11 Jun, 2020
No community comments so far
Editorial decision: Minor revision
On 23 Aug, 2020
Review #1 received
Received 07 Aug, 2020
Reviewer #2 agreed
On 30 Jul, 2020
Reviewer #1 agreed
On 26 Jun, 2020
Reviewers invited
Invitations sent on 23 Jun, 2020
Editor assigned
On 18 Jun, 2020
Editor invited
On 17 Jun, 2020
Submission checks complete
On 04 Jun, 2020
No comments provided
Editorial decision: Minor revision
On 23 Apr, 2020
Review #2 received
Received 30 Mar, 2020
Review #1 received
Received 30 Mar, 2020
Reviewer #1 agreed
On 26 Mar, 2020
Reviewer #2 agreed
On 26 Mar, 2020
Reviewers invited
Invitations sent on 10 Feb, 2020
Editor assigned
On 07 Feb, 2020
Submission checks complete
On 06 Feb, 2020
Editor invited
On 06 Feb, 2020
First submitted
On 31 Jan, 2020
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
License:
This work is licensed under a CC BY 4.0 License. Read Full License
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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