Treating Syrian refugees with diabetes and hypertension in Shatila refugee camp, Lebanon: Médecins Sans Frontières model of care and treatment outcomes

Non-communicable diseases (NCDs) are leading causes of morbidity and mortality globally [1]. Their prevalence and burden are projected to continuously increase, with a more pronounced increase in low to middle-income countries such as Lebanon [2, 3], where an estimated 1.5 million Syrians have been displaced following the onset of the Syrian war in 2011 [4], creating a crisis situation in the country and a huge burden on the Lebanese health care system including that for NCDs [5]. In the refugee population, NCDs can be aggravated by disruption and shortage of medication supplies, lack of access to care and acute exacerbations related to these challenges [6, 7].

In Lebanon, a country characterized by a highly privatized and expensive health care system, there are significant financial barriers to healthcare for the vulnerable refugee population [8], many of whom have pre-existing NCDs [9‐11]. Although health care actors are present in Lebanon to respond to the needs of the refugee population, very little is done for NCDs which is still a high burden within this population. Poverty, often associated with refugee status, can contribute to the worsening of NCDs [12, 13]. Additionally, NCDs often lead to lower earning potential, decreased quality of life, increased morbidity and mortality, and a perpetuation of the poverty cycle [14, 15]. The prevalence of diabetes mellitus (DM) and hypertension (HTN) in the Syrian refugee population living in Lebanon has been recently estimated to be of 9.9 and 20.5%, respectively [9].

In order to meet the needs of the refugee population in the country, Médecins Sans Frontières (MSF) has been providing NCD care since 2013 at the primary healthcare level in the Shatila refugee camp, south of the capital Beirut. The model of care that MSF offers is a comprehensive package adapted to the context of the humanitarian crisis setting. Even though an innovative approach to the model of care was used, it was a significant challenge to successfully reach the target outcome goals for these diseases.

While a few studies and assessments have been published on the prevalence of NCDs among the Syrian refugees in Lebanon [9‐11], to our knowledge, none has described what model of care is used to serve this population, nor the population’s characteristics nor the outcomes of care. Moreover, a recent systematic review looking at the evidence available on the effectiveness of interventions for NCDs in humanitarian contexts highlighted the enormous gap and limited quality of evidence on this topic [16]. These gaps included: the feasibility of NCD interventions in crisis settings, transparency in reporting of follow-up periods, full descriptions of the limitations of the studies as well as inadequacy of outcomes, most of which were self-reported [16]. Additionally, none of the studies included in this analysis were conducted in a refugee setting in Lebanon.

Therefore, the aim of this study was to address these gaps and add to the scarce evidence available by describing the model of care utilized to manage the Syrian refugee population affected by DM and/or HTN followed at the MSF NCD clinic in Shatila, Beirut, Lebanon, as well as to describe patient characteristics and assess treatment outcomes.

To our knowledge, this is the first study describing a program of treatment for DM and HTN among Syrian refugees in Lebanon. It brings new evidence on the effectiveness of the program and treatment of DM and HTN patients in the humanitarian context of the Syrian crisis. Others have looked at the prevalence and access to NCD care in the region and Lebanon [9‐11, 22], but there have been no description of the characteristics of this population, or of treatment outcomes.

This study also described the feasibility of a comprehensive, dynamic and multidisciplinary DM and HTN model operating at a primary care level that was continuously adapted to account for the programmatic and contextual challenges faced by the patients. It attracted many refugees to care, even from outside the catchment area, and demonstrated achievable outcomes deemed successful in a challenging crisis context and over a relatively short period of time (6 months). Additionally, it showed that the use of HbA1C, recommended as the method of choice for monitoring DM as compared to blood glucose measurements [23], is feasible in this context.

The characteristics of the Syrian refugees’ population seen in our clinic are comparable to the profile of patients with DM and/or HTN seen elsewhere in the Middle-East in terms of age and gender [22‐25]. The fact that most of the patients came from outside of the catchment area may be explained by MSF’s successful and attractive comprehensive model of care that allowed patients to see the doctor, get their medications and glucometer if needed, carry out laboratory tests and receive education - all during the same visit and free of charge. This was especially important for patients with significant financial constraints. In that sense and unlike other NCD programs targeting different refugee contexts [24‐26], the MSF model of care was adapted in a way to reduce the burden of visits on the patients. For instance, the model reduced the frequency of the visits to the minimum possible, decreased their length and avoided patients having to move outside of the clinic for tests or drugs, while still achieving high quality care.

While most patients at the MSF clinic had a previously diagnosed disease, which is an indicator of a relatively functional healthcare system in Syria [27], many were found to have uncontrolled DM and/or HTN at baseline. This implies that although aware of their disease, they had challenges accessing health care in Lebanon [5, 9]. For instance, even though all of the patients with Type-1 DM were on insulin when they were seen for their first visit to our program, the mean of their baseline HbA1C was high (9.3%). This is likely because they could not afford to pay for insulin, glucometers or test strips that are needed to monitor blood glucose levels.

The high baseline HbA1C mean of Type-2 DM patients could be an indicator of lack of access to adequate medications, regular medical follow-up and/or poor dietary options. Reasons could be financial barriers, lack of knowledge of the availability of services, or lack of medical awareness of the severity of their disease and the impact of a non-regular follow-up on long term complications. Despite a statistically significant drop in HbA1C in Type-1 DM patients after 6 months of care, they still had, on average, an uncontrolled HbA1C and the magnitude of the drop was still less than what was observed in Type-2 DM patients. This is to be expected given the particular physiological, psychosocial and behavioral challenges [28, 29] related to the Type-1 DM and patients’ specific circumstances, making them more difficult to control. In fact, they require a more frequent insulin regimen, with careful glucose monitoring and represent a younger population with a higher likelihood of non-compliance [30].

Studies looking at DM outcomes in Palestinian refugees have also shown that the proportion of patients with a controlled DM is higher in patients with Type-2 DM or DM and HTN compared to Type-1 DM [26], consistent with our findings. In addition, although there is no convincing evidence supporting improved efficacy with modern insulin [31, 32], if longer acting insulin were available in our clinics, they may have helped in better controlling challenging cases of Type-1 DM by improving compliance.

While it is expected that patients with DM and HTN would have more difficulties in achieving good outcomes, they actually reached a lower target HbA1C compared to the others. In this population, 20% were prescribed three or more drugs for their HTN at their first visit and 13% were already on insulin. These results would suggest that this patient group was more aware of their co-morbidities and had received better management at home and/or more health education over the years. This is the opposite of what one might think of in a crisis context, where polymedicated patients would more likely undergo treatment interruption, and suboptimal compliance. Fortunately, our results showed that these patients arrived better controlled for their DM and HTN and achieved a lower HbA1C target compared to other groups. This finding suggests that aiming for a lower HbA1C target in this population may be possible if clinically indicated. As in our study, another in a Palestinian refugee community showed that the highest proportion of patients with controlled DM was seen in patients with combined DM and HTN [26].

In contrast, Type-2 DM patients almost achieved the HbA1C target at 6 months of care. This raises the question of whether a lower HbA1C target could have been reached had we considered a longer study follow-up period. Yet, a study published in Kibera, Kenya, one of the largest informal settlements in Africa, showed that there was no improvement in DM outcome beyond 6 months of care [33]. However, fasting blood glucose was used in that study as a measure for the outcome and not HbA1C. Also, the context of the Syrian crisis might have prevented patients from following lifestyle changes that are necessary to control their disease, despite education efforts by the PSEC and other health promotion activities.

The protracted Syrian crisis has increased poverty levels and probably contributed to patients’ inability to purchase appropriate food for their conditions [34]. As well, restricted movements due to lack of legal documentation [34] and the living in urban settings may have prevented Syrians from exercising properly and accessing care appropriately contributing to harder control. Increasing psychological distress [35, 36] might also have impacted their motivation to adhere to treatment plans and to follow healthy lifestyle habits.

Although LTFU in patients with DM and/or HTN is a challenge in Shatila, it was only 16%, which is better than expected considering that most of the patients came from outside the catchment area, spent time on the road before getting to the clinic, and are believed to be constantly moving and changing addresses. Retention in care in Shatila seemed less than what was observed previously in the specific context of Palestinian refugees characterized by higher stability [23, 25] but much better than what was reported in other refugee contexts where LTFU in the DM and HTN patients was observed to be as high as 40% [33, 36, 37].

While this study brings new evidence, it also has limitations. It relied on the data collected into a newly implemented, customized DHIS2 software that was somewhat difficult to implement for monitoring and data analysis. Despite the fact that the data management team was thoroughly trained on the software’s use, there was considerable missing data for some variables which prevented their use in the study, body mass index for instance. In addition, although the sample size of the outcome cohort was relatively large, it presented only 9% of the initial outcome sample for DM and 41% for HTN. Reasons were not systematically documented and hence cannot be reported. However, it could partly be due to unrecorded measurements for HbA1C and BP values in the electronic files. It could also be due to missed appointments (anecdotally around 10 NCD patients per day). Although it is possible that this sample was prone to selection bias, we have no reason to believe that it would have led to better outcomes had a different sample been selected. In fact, the characteristics of the patients who were not included in the outcome analysis were similar to the ones who did not end up being part of it on the majority of their characteristics (data not shown). Therefore, we do not believe that selection bias, if present, would have led to an important regard on our results. The use of electronic health records for an efficient disease and programmatic performance follow-up are needed and were previously recommended for such contexts [23]; strengthening routine data systems used for monitoring in the field should be a high priority. Another limitation was the 6 months follow-up for outcome assessment; it might have not been enough time to allow for stabilization of the outcome measures. Our outcome results were compared to targets that had been adapted to the humanitarian context and may not represent ideal targets for best control. In addition, our study lacks specific reporting on the frequency and severity of hypoglycemic episodes by the patients. Although information on hypoglycemia is not systematically documented in our program, patients for whom insulin will be introduced in their treatment plan, those who are on sulfonylureas or those who are in need of medication adjustments, are well educated by their doctors on the management of hypoglycemia and its risks and life threatening consequences. We do recommend for this to be followed-up in future studies specifically for patients with diabetes who are on insulin or on sulfonylureas. In addition to the above mentioned limitations, there is a possibility that our results were affected by regression to the mean. However, simulations applied on patients with more than two repeated measurements, whereby the mean of two baseline measurements was used to compare with a last measurement, did not lead to a significant change in the final conclusion reached. This study, being descriptive in nature, lacks a control group to mitigate possible regression to the mean effect and confirm the true effectiveness of the program. It does however meet the STROBE criteria for cohort studies.

In conclusion, this study showed that a multidisciplinary approach to DM and HTN at the primary care level using contextualized and adapted treatment protocols was feasible in the context of a refugee camp like Shatila and achieved improved quality of care. It also showed that there might be possible to lower the treatment targets in this population to get it closer to the international guidelines. With the increasing burden of NCDs, this study suggests a comprehensive model of care for DM and HTN suitable and possibly replicable in similar contexts throughout the protracted crisis in the Middle-East and elsewhere.