MSF experiences of providing multidisciplinary primary level NCD care for Syrian refugees and the host population in Jordan: an implementation study guided by the RE-AIM framework.

BACKGROUND: In response to the rising global NCD burden, humanitarian actors have rapidly scaled-up NCD services in crisis-affected low-and-middle income countries. Using the RE-AIM implementation framework, we evaluated a multidisciplinary, primary level model of NCD care for Syrian refugees and vulnerable Jordanians delivered by MSF in Irbid, Jordan. We examined the programme's Reach, Effectiveness, Adoption and acceptance, Implementation and Maintenance over time. METHODS: This mixed methods retrospective evaluation, undertaken in 2017, comprised secondary analysis of pre-existing cross-sectional household survey data; analysis of routine cohort data from 2014 to 2017; descriptive costing analysis of total annual, per-patient and per-consultation costs for 2015-2017 from the provider-perspective; a clinical audit; a medication adherence survey; and qualitative research involving thematic analysis of individual interviews and focus group discussions. RESULTS: The programme enrolled 23% of Syrian adult refugees with NCDs in Irbid governorate. The cohort mean age was 54.7 years; 71% had multi-morbidity and 9.9% self-reported a disability. The programme was acceptable to patients, staff and stakeholders. Blood pressure and glycaemic control improved as the programme matured and by 6.6 mmHg and 1.12 mmol/l respectively within 6 months of patient enrolment. Per patient per year cost increased 23% from INT$ 1424 (2015) to 1751 (2016), and by 9% to 1904 (2017). Cost per consultation increased from INT$ 209 to 253 (2015-2017). Staff reported that clinical guidelines were usable and patients' self-reported medication adherence was high. Individual, programmatic and organisational challenges to programme implementation and maintenance included the impact of war and the refugee experience on Syrian refugees' ability to engage; inadequate low-cost referral options; and challenges for MSF to rapidly adapt to operating in a highly regulated and complex health system. Essential programme adaptations included refinement of health education, development of mental health and psychosocial services and addition of essential referral pathways, home visit, physiotherapy and social worker services. CONCLUSION: RE-AIM proved a valuable tool in evaluating a complex intervention in a protracted humanitarian crisis setting. This multidisciplinary programme was largely acceptable, achieving good clinical outcomes, but for a limited number of patients and at relatively high cost. We propose that model simplification, adapted procurement practices and use of technology could improve cost effectiveness without reducing acceptability, and may facilitate replication.

Knowledge, attitudes and practices of breast cancer screening among women in Jordan.

Enhancing breast cancer screening in developing countries is pivotal in improving women's health. We aimed at describing knowledge of and perceived reasons for performing breast cancer screening. We interviewed 1,549 population-based randomly selected women. We found that women share limited knowledge about breast cancer screening. Few women performed screening for early detection purposes. The influence of physicians was the main reason for performing mammography. Prevalence of breast cancer screening might be enhanced by integrating screening into other medical services. Health agencies need to invite women for screening and educate them regarding the importance of screening in the absence of symptoms.

Diabetes mellitus impact on left ventricular assist device outcomes in heart failure patients: National Inpatient Sample study.

Aim: Diabetes mellitus (DM) is a recognized risk factor for heart failure (HF), increasing the likelihood of requiring left ventricular assist device (LVAD) therapy. Objective: This retrospective cohort study aims to assess the impact of DM on LVAD patients, focusing on in-hospital mortality as the primary outcome. Methods: Utilizing the National Inpatient Sample administrative database, data from 11,506 adult HF patients who underwent LVAD implantation were analyzed. Results: Of the patients, 44.28% had diabetes. Adjusting for various factors, diabetic patients exhibited shorter hospital stays, lower admission costs and similar in-hospital mortality rates compared with non-diabetic patients. Conclusion: These findings enhance our understanding of the risks and benefits of LVAD therapy in patients with refractory HF and DM.

Can we overcome the effect of conflicts in rendering palliative care? An introduction to the Middle Eastern Cancer Consortium (MECC).

The Middle East has been experiencing an ongoing political conflict for the past several decades. This situation has been characterized by hostility often leading to violence of all sources. At times, such a conflict led to the outbreak of a military war, which was followed by an enmity between religious, ethnic, cultural, and national populations. In such environmental situations, palliative care professionals often confront major challenges including bias, mistrust, and mutual suspicion between patients and their treating clinicians. In order to overcome such obstacles, while rendering palliative care services, all professionals involved need careful planning and execution of their treatment plans. The latter is however possible, and sometimes successful even across lines of conflict, thereby promoting understanding, mutual respect, and tolerance between the involved communities and individuals.

Implementation Road Map of Health Technology Assessment in Middle-Income Countries: The Case of Jordan.

OBJECTIVES: Health technology assessment (HTA) can increase the appropriateness and transparency of pricing and reimbursement decisions. Jordan is still in the early phase of its HTA implementation, although the country has very limited public resources for the coverage of healthcare technologies. The study objective was to explore and validate priorities in the HTA road map for Jordan and propose to facilitate the preferred HTA status. METHODS: Health policy experts from the public and private sectors were asked to participate in a survey to explore the current and future status of HTA implementation in Jordan. Semistructured interviews with senior policy makers supported by literature review were conducted to validate survey results and make recommendations for specific actions. RESULTS: Survey and interview results indicated a need for increased HTA training, including both short courses and academic programs and gradually increasing public funding for technology assessment and appraisal. Multiple HTA bodies with central coordination can be the most feasible format of HTA institutionalization. The weight of cost-effectiveness criterion based on local data with published reports and explicit decision thresholds should be increased in policy decisions of pharmaceutical and nonpharmaceutical technologies. CONCLUSION: Currently, HTA has limited impact on health policy decisions in Jordan, and when it is used to support pharmaceutical reimbursement decisions, it is mainly based on results from other countries without considering transferability of international evidence. Policy makers should facilitate HTA institutionalization and use in policy decisions by increasing the weight of local evidence in HTA recommendations.

COVID-19 Crisis in Jordan: Response, Scenarios, Strategies, and Recommendations.

As of April 12, 2020, a total of 389 cases of coronavirus disease were confirmed in Jordan. To control this imminent threat, Jordan has enforced public health infection prevention and control measures, called for social distancing, seized all forms of inbound and outbound movement and international travel, and enacted the Defence Law that transferred the authority to the Minister of Defence to work and formulate orders according to the situation. In an effort to support the government in anticipating the requirements of the health system in the upcoming period, an in-depth reflection and examination of different scenarios of the disease spread were developed. This viewpoint suggests different strategies and measures for case detection and contact tracing, clinical management of cases, public health system functioning, and civil society organizations' contribution. It is necessary to accelerate containment of the disease to protect the economy and to maintain the continuity of some activities to mitigate the subsequent social, economic, and financial impacts. This requires finding a coping mechanism for a period that may be prolonged until laboratories develop a vaccine. Specifically, it is strongly recommended to promote community health awareness toward public health prevention and control measures, increase the efficiency and comprehensiveness of the epidemiological investigation and active and passive surveillance, and employ technology and digital health solutions to track cases and contacts. It is also recommended to increase and expand resources of intensive care units including respirators, increase the capacity and the number of trained health staff in the area of public health and epidemiology, ensure continued provision of essential public health programs, and mobilize the resources of nongovernmental sectors and donors to provide services for refugees and vulnerable populations.

Primary care healthcare policy implementation in the Eastern Mediterranean region; experiences of six countries: Part II.

Background: Primary healthcare (PHC) is essential for equitable access and cost-effective healthcare. This makes PHC a key factor in the global strategy for universal health coverage (UHC). Implementing PHC requires an understanding of the health system under prevailing circumstances, but for most countries, no data are available.Objectives: This paper describes and analyses the health systems of Algeria, Kuwait, Morocco, Saudi Arabia, Jordan and Iraq to PHC.Methods: Data were collected during a workshop at the Wonca East Mediterranean Regional Conference in 2018. Academic family physicians (FP) presented their country; using the Wonca framework of 11 PowerPoint slides, with queries of the country demographics, main health challenges, and the position of PHC in the health system.Results: The six countries had achieved a significant improvement in populations' health but currently face challenges of health financing, a small number of certified FPs, difficulties in accessing services and bureaucratic procedures. Primary concerns were the absence of a family practice model, brain drain and immigration of FPs. Countries differed in building a coherent policy.Conclusion: Priorities should be focused on: developing PHC model in Eastern Mediterranean region with advocacy for community-based PHC to policymakers; capacity building for strengthening PHC-oriented health systems with FP specialty training and restrict practising to fully trained FPs; engage communities to improve understanding of PHC; adopt quality and accreditation policies for better services; validation of the referral and follow-up process; and, develop public-private partnership mechanisms to enhance PHC for UHC.

Jordan Field Epidemiology Training Program: Critical Role in National and Regional Capacity Building.

Field Epidemiology Training Programs (FETPs) are 2-year training programs in applied epidemiology, established with the purpose of increasing a country's capacity within the public health workforce to detect and respond to health threats and develop internal expertise in field epidemiology. The Jordan Ministry of Health, in partnership with the US Centers for Disease Control and Prevention, started the Jordan FETP (J-FETP) in 1998. Since then, it has achieved a high standard of success and has been established as a model for FETPs in the Eastern Mediterranean Region. Here we describe the J-FETP, its role in building the epidemiologic capacity of Jordan's public health workforce, and its activities and achievements, which have grown the program to be self-sustaining within the Jordan Ministry of Health. Since its inception, the program's residents and graduates have assisted the country to improve its surveillance systems, including revising the mortality surveillance policy, implementing the use of electronic data reporting, investigating outbreaks at national and regional levels, contributing to noncommunicable disease research and surveillance, and responding to regional emergencies and disasters. J-FETP's structure and systems of support from the Jordan Ministry of Health and local, regional, and international partners have contributed to the success and sustainability of the J-FETP. The J-FETP has contributed significantly to improvements in surveillance systems, control of infectious diseases, outbreak investigations, and availability of reliable morbidity and mortality data in Jordan. Moreover, the program has supported public health and epidemiology in the Eastern Mediterranean Region. Best practices of the J-FETP can be applied to FETPs throughout the world.

Primary healthcare policy implementation in the Eastern Mediterranean region: Experiences of six countries.

BACKGROUND: Primary healthcare (PHC) is essential for equitable access and cost-effective healthcare. This makes PHC a key factor in the global strategy for universal health coverage (UHC). Implementing PHC requires an understanding of the health system under prevailing circumstances, but for most countries, no data are available. OBJECTIVES: This paper describes and analyses the health systems of Bahrain, Egypt, Lebanon, Qatar, Sudan and the United Arab Emirates, in relation to PHC. METHODS: Data were collected during a workshop at the WONCA East Mediterranean Regional Conference in 2017. Academic family physicians (FP) presented their country, using the WONCA framework of 11 PowerPoint slides with queries of the country demographics, main health challenges, and the position of PHC in the health system. RESULTS: All six countries have improved the health of their populations, but currently face challenges of non-communicable diseases, aging populations and increasing costs. Main concerns were a lack of trained FPs in community settings, underuse of prevention and of equitable access to care. Countries differed in the extent to which this had resulted in coherent policy. CONCLUSION: Priorities were (i) advocacy for community-based PHC to policymakers, including the importance of coordination of healthcare at the community level, and UHC to respond to the needs of populations; (ii) collaboration with universities to include PHC as a core component of every medical curriculum; (iii) collaboration with communities to improve public understanding of PHC; (iv) engagement with the private sector to focus on PHC and UHC.

Development of family medicine in the middle East.

This paper outlines the development of family medicine in seven Middle Eastern countries. Some of the first family medicine activity occurred in Turkey in 1961, in Bahrain in 1978, in Lebanon in 1979, in Jordan in 1981, and in Kuwait in 1983. Family medicine programs have also been established in Qatar, the United Arab Emirates, Libya, and Iraq. In most programs, family medicine training occurs largely in hospitals, even though few Middle Eastern family physicians practice in hospitals after completion of residency training. Thus, there is a need for better outpatient training, but resistance from those responsible for traditional medical education makes it difficult to change the current model of family medicine education. There is also need for better opportunities for professional development after graduation and for establishing research activity in family medicine.

Review of Prosthetic Joint Infection from Listeria monocytogenes.

BACKGROUND: Prosthetic joint infection from Listeria monocytogenes is rare. We decided to shed light on this illness and review the reported cases to better understand its characteristics. PATIENTS AND METHODS: We conducted a comprehensive review of the English literature using PubMed. We also included one case that we had managed. RESULTS: We found 25 cases of prosthetic joint infection from L. monocytogenes reported individually and a retrospective study of 43 cases of joint and bone listerial infection, including 34 with prosthetic joint infection, conducted in France. We have described their clinical and para-clinical features and tried to elaborate on the pathophysiology, treatment, and prevention. CONCLUSION: Prosthetic joint infection from L. monocytogenes is mainly late. Systemic inflammation may be absent. Although rare, it must be suspected in patients at high risk for both prosthetic joint and listerial infections. In addition, those patients must be instructed on appropriate preventive measures.