In the Eastern Mediterranean region, the transition from a burden of primarily infectious diseases to noncommunicable diseases (NCDs) has been associated with increased population growth and longevity. Proportional mortality from NCDs has been projected to increase from 62% in 2015 to 70% in 2030. Conflicts in Iraq, Syria, and Yemen have made the inadequate management of NCDs among conflict-affected and displaced populations a major public health issue. NCD management in humanitarian settings is poorly studied, and health responses have been slow to move away from the paradigm of episodic clinical care. Health systems and humanitarian organizations are challenged to provide integrated and cost-effective approaches to stabilize acute presentations, ensure continuous treatment, provide access to medications and insulin, provide patient education, and manage acute complications.
Specifically, the crisis in Syria has greatly impacted regional health trends and national health systems. As of January 2020, 5.6 million refugees were displaced to Turkey, Lebanon, Jordan, and Iraq. In Jordan, 1 in 14 people is a registered refugee, and 79% of refugees live outside camps in urban and periurban areas.8,9 Household surveys have documented that one-half of refugee households have 1 or more adult with an NCD. A 2016 household survey among Syrians in northern Jordan found the most prevalent diagnoses to be hypertension (14.0%) and diabetes (9.2%). A 2015 clinic-based survey among Syrian individuals with diabetes in Bekaa Valley, Lebanon, found that 30% of patients received a diagnosis during displacement, decreasing the likelihood that they had received comprehensive education on disease management. Because Syrian refugees may have developed NCDs after an extended displacement and may lack a diagnosis and awareness of their condition, it follows that neither the disease burden nor health care utilization is well-understood.
Syrian refugees in Jordan access primary care from clinics run by the Jordanian Ministry of Health, nongovernmental organizations (NGOs), and the private sector. In January 2018, facing budget shortfalls, the Ministry of Health reduced subsidies for refugees at public clinics (reinstated in March 2019). Household surveys have cited costs, lack of knowledge of services, and availability of services as primary barriers to NCD care. Interruptions likely affect disease control; in 2016, 25% of surveyed patients with NCDs in northern Jordan reported medication interruptions longer than 2 weeks during the past 6 months, primarily because of costs.
There is emerging evidence that community health worker (CHW) models that focus on NCDs can facilitate linkage and continuity of care. The International Rescue Committee, a humanitarian organization that has provided primary care for Syrian refugees since 2012, has integrated community health into the primary care model. As part of a study to design and evaluate a CHW model for the management of NCDs among refugees, we conducted a household survey among Syrian refugees living outside camps in northern Jordan. The primary objectives were to quantify prevalence using biological measures of hypertension and diabetes, determine the proportion of known and unknown diagnoses, and evaluate access to care for diabetes and hypertension in the catchment area.