Optimising a community-based model for case identification, monitoring, and prevention of hypertension and diabetes among Syrian refugees in Jordan

What did the study set out to achieve?

The study aimed to investigate and improve a community health volunteer (CHV) based model for non-communicable disease (NCD) care in a humanitarian emergency. To do this they set out to:

1. Use a population-based survey to establish the prevalence of hypertension and diabetes, barriers to accessing care, and proportion of cases not under care.
2. Use a causal loop analysis with key stakeholders to identify pathways for service provision, technical gaps, and areas for adaptation. Then modify the CHV-NCD programme accordingly.
3. Implement the re-designed CHV strategy (i.e., training in case identification, referral, prevention, monitoring).
4. Research adherence to care and effects on disease control, implementation feasibility and acceptability, and cost-efficiency.

The population based survey and causal loop analysis took place, but since COVID-19 meant CHVs could not visit patients in their households the planned intervention had to be adapted. A simpler remote CHV intervention focusing on the maintenance of health status, adherence to medications, and early detection of acute complications requiring care, was implemented. This was evaluated through a prospective cohort study, qualitative research and a cost-efficiency study. The study also incorporated detection for COVID-19.

What were the key findings?

• CHVs filled gaps in NCD care that are routinely missed in clinical care (e.g., timely monitoring of complications, self-management, counselling, psychosocial care).
• A tablet-based CommCare programme helped CHVs monitor for stockouts, complications, and needs for referral, psychosocial care, and suspected COVID-19 cases in the household.
• The programme functioned well with >80% monthly uptake of CHV consultations; 87% remaining in care; 90% monthly medication adherence; >50% referred for SARS-CoV-2 testing were positive. Most patients retained stable disease control measures by the end of the study.
• Aligned with WHO guidelines, CHVs were embedded in a supportive and integrated primary care programme that included clinics and pharmacies. However, urgent referrals to secondary care were extremely constrained and handled on an emergency, ad-hoc basis.
• The programme was cost-efficient (INT 218 per patient per year compared with INT 209 for a single primary care consultation).

What does this mean for policy-makers and practitioners?

• CHV programmes must be well-integrated into the health system. For efficiency particularly in humanitarian settings, CHV programmes for NCDs can focus on high-risk patients (e.g., elderly, poor mobility, poor control, co-morbid disease). For more stable patients, CHVs can deliver foundational health education on a less frequent basis.
• Given the relatively small number of urgent referrals to hospitals in this study, it may be cost-efficient to financially support referrals and position CHVs to coordinate referrals.
• Remote CHV strategies are relevant for future COVID-19 waves, as well as any sudden disruptions that cuts off access to services. CHVs provided refugees with a continuous linkage to NCD management, and COVID-19 detection and testing.
• The study produced recommendations for remote CHV programming during a period of instability. The lack of a household visit means that a more comprehensive programme (with in-person counseling, biological monitoring, and visual detection of complications) still requires evaluation among refugees in this context.

The study team have worked closely to share these findings with the Jordan Ministry of Health to inform potential future CHV programmes, and NCD management.