Among the multiple challenges facing refugee and rural populations in Lebanon is the high rate of chronic non-communicable diseases (NCDs) such as diabetes and high blood pressure. Widespread NCDs account for more than 80% of deaths, and one out of three refugees suffers from a chronic illness.
This is a particularly troubling problem because the influx of Syrian refugees increased the Lebanese population by 30% between 2011 and 2013. Refugees who fled Palestine after the 1948 war and their descendants make up an additional 10% of the population.
Refugees in Lebanon are unable to access several critical services, including those provided by the national health system. Private sector health services are too expensive for most refugees, so Palestinian refugees rely solely on United Nations Relief and Works Agency (UNRWA) medical centres and hospitals that are contracted by the agency. Rural populations in Lebanon can access the national health system but they often lack transportation and other means to reach services.
Building bridges to healthcare
These conditions make it difficult to manage NCDs, but early screening and detection are vital, particularly for pregnant women. Left undetected and untreated, high blood pressure and diabetes can severely affect both mother and child. Improving NCD detection and treatment relies on health providers, individual patients, and on community health workers. For poor, displaced, or marginalized populations, community health workers are often the only bridge to health providers.
A community-based eHealth system developed by the American University of Beirut and funded by IDRC is showing how NCD care can be effectively delivered to displaced and rural populations. Tested in collaboration with the Ministry of Public Health in rural areas and the UNRWA in Palestinian refugee camps, it has increased diabetes and high blood pressure detection, reduced high blood pressure levels, and improved diabetes control.
In doing so, the eHealth system has shown how digital technologies such as netbooks and mobile phones can help health workers increase their access to health services and improve the quality of service for Palestinians in refugee camps and other hard-to-reach populations. An integrated eHealth system
The e-Sahha project (sahha is an Arabic word meaning “health”) implemented by the university is working to deliver better quality care to underserved populations by using mobile phones to provide useful content, training, and support. All of the eHealth tools and content were created and designed in collaboration with experts at the Ministry of Public Health. Health workers and users of primary care centres were consulted on project design and implementation.
Based on this consultation, tools and content were created to target health providers, patients, and community health workers. Because they were developed with users to meet real needs, it is likely that these tools will continue to be used long after the project ends.
Healthcare providers, most of them nurses, were offered training though online clinical guidelines on diabetes, gestational diabetes, and hypertension. Online platforms helped them feel connected and share information and experiences.
Delivering an integrated tool kit
Some 1,390 patients received weekly educational text messages. To help them improve the management of their diseases, 52 messages were prepared for diabetes, 52 for hypertension, and 36 for gestational diabetes. All messages were written by nutritionists and approved by a physician. Patients received reminders of upcoming appointments via mobile phones.
Two weeks after being referred to a clinic, patients were called to see if they had kept their appointment or why they might have missed it. Determining compliance with treatment and identifying obstacles to accessing care are crucial because NCDs require sustained care.
A new chronic illness screening kit and clinical manual on diabetes and hypertension helps community health workers during their outreach visits. A netbook application makes it easier to enter results and an online system enables them to remotely schedule patient appointments at health centres.
Tested in three of the 28 UNRWA health centres, e-Sahha results show an increased demand for and access to better healthcare services. Equally important, providers, patients, and health workers, as well as health officials, appreciate the services.
Better health and access to healthcare
That appreciation has translated into improvements in patients’ health. After one year, patients receiving text messages had improved their control of blood pressure and blood sugar levels. Many also changed their behaviours based on the messages they received. For instance, they reduced their salt and sugar intake, improved other aspects of their diets, and got more exercise. In the refugee camps, some 33% of patients reported changing aspects of their lifestyle. These and other successes show that text messages can effectively reduce the ravages of chronic diseases and enhance equity in healthcare access.
Healthcare providers also reported that they had changed aspects of their practice after using the eHealth tools. Close to 90% recommended the program to their peers. Accessible at the health centres and through smart phones, the tools enhanced their access to current information about how to treat chronic conditions, thus reducing their professional isolation.
Overall, the project shows how locally-driven innovations with strong community engagement can transform healthcare services among underserved populations. It also shows how eHealth strategies can be easily integrated in the primary healthcare system and adapted to patients’ needs.