GACD Humanitarian Working Group and LSHTM researchers explore strategies for addressing NCD care in humanitarian contexts

The GACD Humanitarian Settings Working Group, in collaboration with implementation science researchers at the London School of Hygiene and Tropical Medicine (LSHTM) and humanitarian actor stakeholders (International Rescue Committee, International Committee for the Red Cross, United Nations High Commission on Refugees, and Medicines sans Frontières), has published a paper examining factors that influence the successful implementation of remote hypertension and/or diabetes care interventions in low- and middle- income countries (LMICs). The full paper is available here.

Study rationale

Humanitarian actors are partnering with researchers in order to better understand how to deliver hypertension and diabetes care in humanitarian settings in LMICs, particularly during periods when patients cannot visit health clinics. During the height of the COVID-19 pandemic, due to their vulnerability to severe disease, NCD patients were discouraged from seeking care in person, and were sometimes unable to visit clinics because of movement restrictions. Humanitarian workers developed reactive, untested strategies for managing patient care remotely. While lockdown restrictions have now eased in many humanitarian settings globally, the delivery of effective remote care strategies for chronic conditions remains highly relevant. In some (typically higher income) contexts, the digital care strategies adapted during the pandemic are becoming routine in the ‘new normal,’ highlighting the need to understand what makes these strategies effective and under what circumstances. In humanitarian settings, evidence-based remote care strategies are necessary given the frequency of disruptions due to civil unrest and/or natural disaster. These periodic disruptions are compounded by chronic access challenges linked to patient frailty, patients living long distances from clinic, language barriers between patients and health care personnel, and under-staffed care facilities.

Methods and findings

In response, implementation scientists from the GACD Humanitarian Settings Working Group and LSHTM conducted a narrative review of studies focusing on remote delivery of hypertension and diabetes care in LMICs (the settings explored were not restricted to humanitarian settings, as there was a shortage of studies conducted in such contexts). Using the Consolidated Framework for Implementation Research, the team identified factors that impacted the effective implementation of e-health and community-based (e.g., task sharing) delivery approaches. Their findings highlighted the impact of internal organisational context on implementation, especially the role of staff and also emphasised the need to examine the external context, such as the policies regarding community health workers for community-based interventions, or the technological environment necessary to facilitate successful e-health programmes. In addition, the study revealed the influence of service users’ socio-demographic characteristics and the need to ensure that interventions were adapted to patients’ needs and resources.

Recommendations for future studies

The team advocates for further operational research that informs the implementation of digital and community-based strategies that can be delivered remotely in humanitarian and other LMIC settings. Ideally, such research will be guided by implementation science methods and frameworks, and results will be reported using the Standards for Reporting Implementation Studies (StaRI). Specific recommendations for future investigations include:

1. Research that investigates the relationships between factors linked to positive health and delivery outcomes, the relative importance of these factors, and the role of the local context.

2. Research documenting strategies for minimising face-to-face contact through simplification of clinical management protocols and/or task-shifting from facility-based to community-level care.

3. Trials that evaluate context-specific interventions to support diabetes and hypertension management that investigate the relationship between the effectiveness of such interventions and the patients’ socioeconomic and cultural circumstances, the health system, and the relevant technological and political context.

More work by this team

The team continues to progress work in this area by surveying and conducting interviews with humanitarian workers supporting NCD patients to understand how they adapted NCD service delivery during the pandemic, what did and did not work, and the factors that influenced success or failure. The results will be published soon.

Please consult the LSHTM NCDs in Humanitarian Settings Knowledge Hub for more resources about managing NCDs in humanitarian settings.