Adherence to UNRWA's anaemia treatment guidelines in the Jerash Camp Health Centre, Jordan: a retrospective observational study.

OBJECTIVE: The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) provides primary healthcare to 2.2 million Palestinian refugees in Jordan. This study aimed to measure patient and doctor adherence to the UNRWA guidelines for the prevention and treatment of iron deficiency anaemia in moderate to severe anaemia children, defined as haemoglobin (Hb) level <10.0 g/L. DESIGN, SETTING AND PARTICIPANTS: A retrospective observational study was conducted by analysing the electronic health records of 717 children (353 boys and 364 girls) children aged 12 months old in 2018 in the Jerash Camp Health Centre, Jordan. OUTCOME: Patient adherence to the UNRWA guidelines was calculated by the proportion of health centre visits and doctor adherence by the proportions of Hb tests and iron supplementation among moderate to severe anaemia children at screening, first, second and third follow-up visits, respectively using STATA. RESULTS: The prevalence of moderate to severe anaemia was 15.6% among 12-month-old children. After 1 month of iron supplementation, 83.7% of anaemic children improved their Hb status: mean±SD from 9.1±0.6 g/L to 10.1±1.0 g/L. Patient and doctor adherence to the UNRWA guidelines was above 80% at the screening visit but progressively decreased at follow-up visits, especially patient adherence at the third follow-up visit of 34.4%. The analysis revealed unnecessary health centre visits and iron supplementation being given to mildly anaemic children (Hb level=10.0 g/L-10.9 g/L). Additionally, children visited the health centre at an age significantly later compared with that recommended by the UNRWA guidelines for the screening, first and second follow-up visits (p-value<0.05). CONCLUSION: Adherence to the UNRWA guidelines was above 80% at screening but much lower at follow-up visits. Urgent action is needed to improve adherence at follow-up visits and to minimise any unnecessary health centre visits and iron supplementation to mildly anaemic children.

The impact of e-health system implementation on UNWRA health services: an observational study.

BACKGROUND: The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) provides primary-health-care services to more than 5 million Palestinian refugees in five operational fields (Jordan, Syria, Lebanon, West Bank, and Gaza) through 144 health centres. UNRWA developed its electronic health records (e-Health) system to improve monitoring and facilitation of health services provided to Palestinian refugees. By the end of 2017, the system had been deployed in 129 health centres, included the health files of 3 million patients, and managed more than 8 million visits per year. We assessed whether preventive-health-care services had improved following implementation of the system. METHODS: This observational study used three key performance indicators to assess preventive-health-care services reported in UNRWA's annual reports in 2012-17: the percentage of targeted people aged 40 years and older screened for diabetes; the percentage of pregnant women with a livebirth who attended at least four antenatal visits; and the prevalence of growth problems (underweight, stunting, wasting, and overweight or obesity) in children younger than 5 years. Simple descriptive analysis was conducted with Microsoft Excel 2010. Ethical approval was obtained from the UNRWA Headquarters Department of Health. FINDINGS: Screening for diabetes significantly increased from 13% in 2012 to 21% in 2017 (p<0·0001) since the e-Health system started sending alerts to clerks at health centres. The percentage of pregnant women with a livebirth who attended at least four antenatal visits, increased from 87% in 2012 to 92% in 2017, when the e-Health System allowed health-care providers to log all pregnant women who missed their appointments to enable follow-up. Additionally, an electronic maternal and child health mobile application, sends regular reminders to mothers about appointments for themselves and their children. The percentages of underweight, stunting, wasting, and overweight or obesity among children younger than 5 years increased respectively from 3%, 4%, 2%, and 2% in 2014 to 5%, 7%, 4%, and 5% in 2017, but this was due to the increased detection of growth problems through the e-Health system. INTERPRETATION: The e-Health system improved detection and monitoring by UNRWA health-care providers and access to health services for Palestinian refugees in all three indicator categories. This study has several limitations. It is an observational study based on assessing health records of children rather than a prospective study over time. The focus of the study was to assess the impact of the eHealth system on health-care delivery and not to assess the changes in health-care delivery itself. The electronic health records that were reviewed are for the Palestine refugees who are registered at UNRWA health clinics and not for other refugees or residents of the five countries. Strengths of the study are that it is based on electronic health records which contain data recorded by the treating staff; the e-health system used by UNRWA clinics staff is centralised and the data are aggregated agency wide; and the growth monitoring indicators used by UNRWA were derived from the WHO Multi-center Growth Reference Study to assess the growth of children from birth up to age 5 years. FUNDING: None.

Prevalence and characteristics of Palestine refugee mothers at risk of postpartum depression in Amman, Jordan: a cross-sectional study.

BACKGROUND: Postpartum depression (PPD) is a major public health concern because it adversely affects maternal health and children's physical and mental development. The prevalence of PPD in Arab countries is higher than the worldwide prevalence. Additionally, refugee women are more likely to develop PPD than women in the general population, but little research of refugee women in Arab countries is available. The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) have provided primary health care to Palestine refugees since 1950 and began the Mental Health and Psychosocial (MHPSS) programme in Jordan in 2017 to enhance the psychosocial and social wellbeing of Palestine refugees. We assessed the prevalence of PPD and examined associated factors among Palestine refugee women living in Amman, Jordan. METHODS: This cross-sectional descriptive study was done between April 21 and May 21, 2018. Eligible participants were Palestine refugee mothers who had given birth 3-16 weeks previously and were attending any of five UNRWA health centres in Amman that were launching the MHPSS programme. Data were gathered in face-to-face structured interviews that included the Edinburgh Postpartum Depression Scale (EPDS) to assess PPD, the Maternal Social Support Scale to assess levels of perceived social support, and a structured questionnaire about sociodemographic, obstetric or paediatric, psychological, and social factors. Participants with scores greater than 12 in the EPDS were classified as having depressive symptoms. Logistic regression was used to identify factors associated with depressive symptoms. The study protocol was approved by the Department of Health, UNRWA Headquarters, Amman, Jordan, and Nagasaki University. Each participant provided written informed consent. FINDINGS: 251 women participated in the study, with a mean age of 27·2 years (range 18-42, SD 5·43). 123 (49%) women were classified as having PPD. Logistic regression showed that factors associated with PPD were perceived low levels of social support (adjusted odds ratio 3·76, 95% CI 1·92-10·93) and experiencing stressful life events (one event 3·92, 1·51-9·91; two events 5·77, 2·33-14·27; and three or more events 14·8, 5·23-41·89). INTERPRETATION: The prevalence of PPD among Palestine refugee women in Amman was higher than that reported in a previous study of the general childbearing population (women aged 18-45 years) in Irbid in Jordan (22%, Mohammad et al. Midwifery 2011; 27: e238-45) but similar to findings in the West Bank (47%, Quandil et al. BMC Pregnancy Childbirth 2016; 16: 375) and in Syrian refugee women in Jordan (49·6%, Mohammad et al. Res Nurs Health 2011; 41: 519-245). Our findings highlight the need to address this disorder in Palestine refugee mothers. Periodical PPD screening, raising awareness about PPD, providing information to husbands and families, and building a support system for mothers could alleviate the risk of PPD. Future studies should examine whether factors of antenatal depression, which were not assessed in this study, correlate with having PPD to clarify the need for early intervention in mothers. FUNDING: Nagasaki University.

Anaemia prevalence in children newly registered at UNRWA schools: a cross-sectional study.

OBJECTIVE: Children entering first grade at the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) schools in West Bank, Gaza, Lebanon, Jordan and Syria complete a comprehensive medical examination at UNRWA health centres (HCs) as a requirement for their acceptance. Our study aimed to assess anaemia prevalence and undernutrition indicators among new entrant school children during their preschool medical examination. SETTINGS: In 2017, we conducted a cross-sectional study in 59 UNRWA HCs, targeting children entering first grade at UNRWA schools in four of UNRWA's countries of operation (known as fields), namely Gaza, West Bank, Syria and Lebanon. PARTICIPANTS: 2419 completed the study. Boys and girls living inside or outside Palestine refugee camps were included. Verbal consent was obtained from their parents. PRIMARY AND SECONDARY OUTCOME MEASURES: Sociodemographic and anthropometric data on each child were collected. Underweight (weight-for-age z-score <-2 SD), stunting (height-for-age z-score <-2 SD), thinness (body mass index-for-age z-score <-2 SD) and obesity (body mass index-for-age z-score >+2 SD) were examined according to WHO growth indicators (5-10 years). RESULTS: 2419 students (1278 girls and 1141 boys) aged 6.1±0.4 years were examined. The prevalence of anaemia (haemoglobin (Hb) <11.5 g/L) was 25.0% (Gaza: 29.3%; West Bank: 22.0%; Syria: 30.0%; Lebanon: 18.3%). The mean Hb level was 12.0±0.9 g/L. The overall prevalence of stunting, thinness and underweight was 3.2%, 3.5% and 5.6%, respectively, with the highest levels found in Syria (4.3%, 6.3% and 10.1%, respectively). The highest prevalence of overweight was in Lebanon (8.6%), and the lowest was in Gaza (2.6%). Significant differences were found among fields with regard to undernutrition indicators (p=0.001). Also, children with anaemia had significantly higher prevalence of being underweight (5.2%) in comparison with those without anaemia (p=0.001). CONCLUSIONS: The prevalence of anaemia among the surveyed children increased to 25.0%, compared with the previous study conducted by UNRWA in 2005 (19.5%). Thus, it is recommended that Hb testing be included in the medical examination of new entrant school children attending UNRWA schools.

Assessment of the knowledge, attitudes, and practices (KAP) among UNRWA* health staff in Jordan concerning mental health programme pre-implementation: a cross-sectional study.

BACKGROUND: Mental health is a major public health priority, especially among refugees. The United Nations Relief and Works Agency for Palestine Refugees (UNRWA) started to integrate mental health and psychosocial support (MHPSS) into its primary healthcare services in Jordan in late 2017. In this study, we aimed to assess of the knowledge, attitudes, and practices (KAP) among UNRWA health staff (HS) in Jordan concerning mental health programme pre-implementation, and their perceived barriers about this MHPSS programme. METHODS: A cross-sectional study was conducted among doctors, dentists, nurses, and midwives who work at 16 of the 25 UNRWA health centres in Jordan. The assessment was made using a validated self-administered questionnaire. Data analysis was performed using SPSS (version 22). RESULTS: Of the participants, 73% (161 of 220) believed that their knowledge of MHPSS programmes was insufficient, with no significant difference (p = 0·116) between different categories of staff. Furthermore, 88% (194 of 220) said that they needed more training, 67% (147 of 220) reported that the number of mental health cases is increasing, and 50% (110 of 220) that dealing with these cases is difficult. Reflecting on the past 12 months, 31% of staff (69 out of 220) reported meeting between one and ten children, and 45% (100 out of 220) reported meeting between one and ten adults suspected of having mental illnesses. The most suspected condition was depression (84%; 150 of 220), followed by epilepsy (64%; 140 of 220). The main perceived barriers to implementation included the limited availability of MHPSS policies (87%; 192 of 220), MH professionals (86%; 190 of 220), resources (86%; 189 out of 220), and lack of privacy (14%; 31 out of 220). CONCLUSIONS: Most health staff had positive attitudes towards MHPSS programme implementation but felt they lacked the required knowledge. There is a need for training and clear technical guidelines. Perceived barriers to MHPSS programme implementation were consistent with the previous studies and need to be tackled with a structured plan of action.

Dissemination and implementation of the e-MCHHandbook, UNRWA's newly released maternal and child health mobile application: a cross-sectional study.

OBJECTIVES: In April 2017, the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) released the electronic Maternal andChildHealth Handbook, the e-MCH Handbook application. One of the first mobile health (m-Health) interventions in a refugee setting, the application gives pregnant women and mothers access to educational information and health records on smartphones. This study investigated factors associated with the dissemination and implementation of m-Health in the refugee setting. SETTING AND PARTICIPANTS: A cross-sectional study was conducted in 9 of 25 UNRWA health centres for Palestine refugees in Jordan. Self-administered questionnaires were distributed for 1 week to pregnant women and mothers with children aged 0-5 years. OUTCOME MEASURES: The outcomes were whether participants knew about, downloaded or used the application. Multiple regression analyses were conducted to determine factors associated with application download and usage. RESULTS: 1042 participants were included in the analysis. 979 (95.5%) had a mobile phone and 862 (86.9%) had a smartphone. 499 (51.3%) knew about, 235 (23.8%) downloaded and 172 (17.4%) used the application. Having other mobile applications (OR 6.17, p<0.01), staff knowledge of the application (OR 11.82, p<0.01), using the internet as a source of medical information (OR 1.63, p=0.01) and having internet access at home (OR 1.46, p=0.05) were associated with application download. The age of the husband was associated with application usage (OR 1.04, p=0.11). CONCLUSIONS: Though m-Health may be a promising means of promoting health in refugees, multiple barriers may exist to its dissemination and implementation. Those who regularly use mobile applications and get medical information from the internet are potential targets of m-Health dissemination. For successful implementation of a m-Health intervention, health staff should have thorough knowledge of the application and users should have access to the internet. Husband-related factors may also play a role.

Antenatal care among Palestine refugees in Jordan: factors associated with UNRWA attendance.

BACKGROUND: Maternal and neonatal mortality is a global issue acknowledged by the Sustainable Development Goals (SDGs). Adequate ante-natal care (ANC) is pivotal to reducing these mortality rates, while understanding why women don't attend ANC is crucial to addressing the SDGs. AIMS: Using routine primary health care data to determine the factors associated with inadequate attendance by Palestine refugees (PR) to ANC seeking facilities provided by the United Nations Relief and Works agency for Palestine Refugees in the Near East (UNRWA), Jordan. METHODS: A backwards logistic regression model incorporating non-health system factors and health system factors, was performed using UNRWA data. RESULTS: A younger age of women was associated with inadequate ANC visits (P = 0.0009) in the non-health systems model. For health system factors, pregnancy risk status, having a gynaecologist review and the health centre attended were factors found to be significantly associated with ANC attendance (P < 0.0001). CONCLUSIONS: Understanding the health system factors associated with ANC attendance can lead to changes and improvements in UNRWA's operational policies.

Health and dignity of Palestine refugees at stake: a need for international response to sustain crucial life services at UNRWA.

The UN Sustainable Development Goals affirm equality and dignity as essential to the enjoyment of basic human rights, including the right to the highest attainable standard of physical and mental health, which promotes global solidarity among all people, including refugees. The UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) has provided support to Palestine refugees in Jordan, Lebanon, Syria, the Gaza Strip, and the West Bank since the 1950s. Today, however, conflict and violence, occupation, high levels of poverty, and other social determinants of health jeopardize the wellbeing of Palestine refugees. Health concerns include non-communicable diseases, mental health conditions, and access to hospital care. Additionally, UNRWA is continuing to face a severe funding crisis. Using a historical and health policy perspective, this Health Policy examines UNRWA strategies that facilitate continuous provision of health-care services for Palestine refugees. Given the increasingly volatile environment faced by this population, a multifaceted international response is needed to enable UNRWA to deliver sustainable services to Palestine refugees and avert further loss of life, dignity, and hope, pending a just and lasting solution to their plight in accordance with applicable international law and UN General Assembly resolutions.

Prevalence of functional constipation among Palestinian preschool children and the relation to stressful life events.

AIM: Increasing evidence exists with respect to the relation between stressful life events and functional constipation (FC). We aimed to investigate the prevalence of FC in Palestinian refugee preschool children and to determine if stress and trauma exposure are risk factors of FC in these children. METHODS: From November 2013 until May 2014, a cross-sectional survey was conducted in West Bank, Gaza and Jordan. Mothers of 862 Palestinian refugee children aged 7-48 months were interviewed on defecation pattern, socio-economic factors and the child's exposure to traumatic events. RESULTS: Twelve percent of the Palestinian refugee children fulfilled the criteria for FC. The prevalence of constipation was significantly lower in Gaza compared to Jordan (2% vs. 17%, p <0,001). Living in Gaza was associated with lower odds of FC (OR 0,08, 95% CI 0,03-0,20). Trauma exposure was associated with higher odds of FC (OR 1,19, 95% CI 1,06-1,35), however only a small number of children had been exposed to traumatic events. CONCLUSION: The overall prevalence of FC in Palestinian preschool children is comparable to prevalence rates among older children worldwide. In this age group stressful life events and trauma exposure seem not to play an important role in the development of FC.

Stalled decline in infant mortality among Palestine refugees in the Gaza Strip since 2006.

BACKGROUND: The United Nations Relief and Works Agency for Palestine refugees in the Near East (UNRWA) has periodically estimated infant mortality rates (IMR) among Palestine refugees in the Gaza Strip (Gaza). These surveys have recorded a decline from 127 per 1000 live births in 1960 to 20.2 in 2006. Thereafter, a survey revealed an IMR of 22.4 in 2011. Alerted by these findings, a follow up survey was conducted in 2015 to further assess the trend of IMR. METHODS: We used the same preceding-birth technique as in previous surveys to estimate IMR and neonatal mortality rate (NMR) per 1000 live births. All multiparous mothers who came to the 22 UNRWA health centers to register their last-born child for immunization were asked if their preceding child was alive or dead. We based our target sample size on the previous IMR of 22.4 and we interviewed 3126 mothers from September to November 2015. FINDINGS: The third survey estimated mortality rates in 2013. The IMR was 22.7 (95% CI 17.2-28.1) per 1000 live births. IMR did not decline since the estimated IMR of 20.2 (15.3-25.1) per 1000 live births in 2006 and 22.4 (16.4-28.3) per 1000 live births in 2011. NMR was 16.1 (11.6-20.7) per 1000 live births, which was not statistically significantly different from 2006 (12.1 (8.7-16.4)), and was lower than in 2011 (20.3 (15.3-26.2)). CONCLUSION: The estimated mortality rate in infants of Palestine refugees in Gaza has not declined since 2006. The stagnation of infant mortality rates indicates that further efforts are needed to investigate causes for this stagnation and ways of addressing the potentially preventable causes among Palestine refugee children in Gaza.

Contraceptive use by Palestine refugee mothers of young children attending UNRWA clinics: a cross-sectional follow-up study.

BACKGROUND: UNRWA introduced family planning services in 1994 as an integral part of its expanded maternal and child health-care programme. The main objective of UNRWA's family planning programme is to promote the health of mothers, children, and their families. The aim of this follow-up study was to assess contraceptive practices in the target population 5 years after the 2010 follow-up study and to identify future programme needs. METHODS: This cross-sectional survey was a done by trained nurses from June 1 to Dec 31, 2015. Participants were Palestinian refugee mothers who attended Well Baby Clinics at all UNRWA health centres with their youngest child (aged 2 months to 5 years). A sample size of 10 478 participants was calculated on the basis of contraceptive use in 2010, using Epi Info sample size calculation. Women were interviewed, and retrospective data from health records were used as supplementary data. We did a multiple logistic regression to test if maternal age and parity predicted contraceptive use. We used the χ2 test to analyse the relation between previous contraceptive use and birth interval, birth weight, and gestational age. All participants provided verbal informed consent. The study was approved by the ethical committee in the UNRWA Health Department. FINDINGS: Data were obtained from 9860 mothers (mean age 29·8 years [range 29·4-30·1]). 5849 (59%) women were using modern contraceptives at the time of the survey, 1745 (18%) were using traditional methods, and 2265 (23%) were not using any contraceptive method. The most common modern contraceptive was an intrauterine device (2186 [37%] women), and UNRWA was the main provider for 4827 (83%) women using modern contraceptives. The most common reasons for not using contraceptives were a wish to have a child (873 [22%] women), pregnancy (747 [19%]), and a husband's opposition (775 [20%]). Using women with less than three pregnancies as the reference category, use of contraceptives was most likely in women with three to six pregnancies (adjusted odds ratio 1·58, 95% 1·43-1·73; p<0·0001) and in women with more than six pregnancies (1·6, 1·28-1·99; p<0·0001). Women with at least one male child were more likely to use contraceptives than women with no male child (1·39, 1·24-1·56; p<0·0001). Maternal age over 35 years was not a significant predictor for modern contraceptive use. We found a statistically significant correlation between previous contraceptive use and birthweight [c2=23·88; p<0·0001)] but not with gestational age. INTERPRETATION: It is encouraging that mothers seeking modern contraceptives rely on UNRWA to provide family planning services. We found that mothers with higher parity are more likely to use modern contraceptives that comply with UNRWA recommendations. As expected, modern contraceptives lead to better birth spacing. However, mothers above 35 years of age are not more likely to use modern contraceptives, and these mothers might be at higher risk for negative maternal and infant health outcomes. UNRWA family planning services could focus more on counselling this group of mothers. FUNDING: None.

Development and Deployment of an e-Health System in UNRWA Healthcare Centers (HCs): The Experience and Evidence.

UNRWA recognized the need to develop and introduce eHealth programme based on needs assessment. The web-based e-Health application was developed and deployed in 116 out of 143 HCs in the five fields of operation. Evaluation of the application revealed positive outcomes in terms of reporting requirements, statistics, time saving, efficiency, drug compliance and workflow in general.

Increasing Neonatal Mortality among Palestine Refugees in the Gaza Strip.

BACKGROUND: The United Nations Relief and Works Agency for Palestine refugees in the Near East (UNRWA) has periodically estimated infant mortality rates among Palestine refugees in Gaza. These surveys have recorded a decline from 127 per 1000 live births in 1960 to 20.2 in 2008. METHODS: We used the same preceding-birth technique as in previous surveys. All multiparous mothers who came to the 22 UNRWA health centres to register their last-born child for immunization were asked if their preceding child was alive or dead. We based our target sample size on the infant mortality rate in 2008 and included 3128 mothers from August until October 2013. We used multiple logistic regression analyses to identify predictors of infant mortality. FINDINGS: Infant mortality in 2013 was 22.4 per 1000 live births compared with 20.2 in 2008 (p = 0.61), and this change reflected a statistically significant increase in neonatal mortality (from 12.0 to 20.3 per 1000 live births, p = 0.01). The main causes of the 65 infant deaths were preterm birth (n = 25, 39%), congenital anomalies (n = 19, 29%), and infections (n = 12, 19%). Risk factors for infant death were preterm birth (OR 9.88, 3.98-24.85), consanguinity (2.41, 1.35-4.30) and high-risk pregnancies (3.09, 1.46-6.53). CONCLUSION: For the first time in five decades, mortality rates have increased among Palestine refugee newborns in Gaza. The possible causes of this trend may include inadequate neonatal care. We will estimate infant and neonatal mortality rates again in 2015 to see if this trend continues and, if so, to assess how it can be reversed.

What happens to Palestine refugees with diabetes mellitus in a primary healthcare centre in Jordan who fail to attend a quarterly clinic appointment?

OBJECTIVE: In a primary healthcare clinic in Jordan to determine: (i) treatment outcomes stratified by baseline characteristics of all patients with diabetes mellitus (DM) ever registered as of June 2012 and (ii) in those who failed to attend the clinic in the quarter (April-June 2012), the number who repeatedly did not attend in subsequent quarters up to 1 year later, again stratified by baseline characteristics. METHOD: A retrospective cohort study with treatment outcome data collected and analysed using e-health and the cohort analysis approach in UNRWA Nuzha Primary Health Care Clinic for Palestine refugees, Amman, Jordan. RESULTS: As of June 2012, there were 2974 patients with DM ever registered, of whom 2246 (76%) attended the clinic, 279 (9%) did not attend, 81 (3%) died, 67 (2%) were transferred out and 301 (10%) were lost to follow-up. A higher proportion of males and patients with undetermined or poor disease control failed to attend the clinic compared with those who attended the clinic. Of the 279 patients who did not attend the clinic in quarter 2, 2012, 144 (52%) were never seen for four consecutive quarters and were therefore defined as lost to follow-up. There were a few differences between patients who were lost to follow-up and those who re-attended at another visit that included some variation in age and fewer disease-related complications amongst those who were lost to follow-up. CONCLUSION: This study endorses the value of e-health and cohort analysis for monitoring and managing patients with DM. Just over half of patients who fail to attend a scheduled quarterly appointment are declared lost to follow-up 1 year later, and systems need to be set up to identify and contact such patients so that those who are late for their appointments can be brought back to care and those who might have died or silently transferred out can be correctly recorded.

Treatment outcomes in a cohort of Palestine refugees with diabetes mellitus followed through use of E-Health over 3 years in Jordan.

OBJECTIVE: The aim of this study was to use E-Health to report on 12-month, 24-month and 36-month outcomes and late-stage complications of a cohort of Palestine refugees with diabetes mellitus (DM) registered in the second quarter of 2010 in a primary healthcare clinic in Amman, Jordan. METHOD: Retrospective cohort study with treatment outcomes censored at 12-month time points using E-Health in UNRWA's Nuzha Primary Health Care Clinic. RESULTS: Of 119 newly registered DM patients, 61% were female, 90% were aged ≥40 years, 92% had type 2 DM with 73% of those having hypertension and one-third of patients were newly diagnosed. In the first 3 years of follow-up, the proportion of clinic attendees decreased from 72% to 64% and then to 61%; the proportion lost to-follow-up increased from 9% to 19% and then to 29%. At the three time points of follow-up, 71-78% had blood glucose ≤180 mg/dl; 63-74% had cholesterol <200 mg/dl; and about 90% had blood pressure <140/90 mmHg. Obesity remained constant at 50%. The proportion of patients with late-stage complications increased from 1% at baseline to 7% at 1 year, 14% at 2 years and 15% at 3 years. CONCLUSION: Nuzha PHC Clinic was able to monitor a cohort of DM patients for 3 years using E-Health and the principles of cohort analysis. This further endorses the use of cohort analysis for managing patients with DM and other non-communicable diseases.

Cohort monitoring of persons with diabetes mellitus in a primary healthcare clinic for Palestine refugees in Jordan.

OBJECTIVE: To illustrate the method of cohort reporting of persons with diabetes mellitus (DM) in a primary healthcare clinic in Amman, Jordan, serving Palestine refugees with the aim of improving quality of DM care services. METHOD: A descriptive study using quarterly and cumulative case findings, as well as cumulative and 12-month analyses of cohort outcomes collected through E-Health in UNRWA Nuzha Primary Health Care Clinic. RESULTS: There were 55 newly registered patients with DM in quarter 1, 2012, and a total of 2851 patients with DM ever registered on E-Health because this was established in 2009. By 31 March 2012, 70% of 2851 patients were alive in care, 18% had failed to present to a healthcare worker in the last 3 months and the remainder had died, transferred out or were lost to follow-up. Cumulative and 12-month cohort outcome analysis indicated deficiencies in several components of clinical care: measurement of blood pressure, annual assessments for foot care and blood tests for glucose, cholesterol and renal function. 10-20% of patients with DM in the different cohorts had serious late complications such as blindness, stroke, cardiovascular disease and amputations. CONCLUSION: Cohort analysis provides data about incidence and prevalence of DM at the clinic level, clinical management performance and prevalence of serious morbidity. It needs to be more widely applied for the monitoring and management of non-communicable chronic diseases.

Cohort monitoring of persons with hypertension: an illustrated example from a primary healthcare clinic for Palestine refugees in Jordan.

OBJECTIVE: Recording and reporting systems borrowed from the DOTS framework for tuberculosis control can be used to record, monitor and report on chronic disease. In a primary healthcare clinic run by UNRWA in Amman, Jordan, serving Palestine refugees with hypertension, we set out to illustrate the method of cohort reporting for persons with hypertension by presenting on quarterly and cumulative case finding, cumulative and 12-month analysis of cohort outcomes and to assess how these data may inform and improve the quality of hypertension care services. METHOD: This was a descriptive study using routine programme data collected through E-Health. RESULTS: There were 97 newly registered patients with hypertension in quarter 1, 2012, and a total of 4130 patients with hypertension ever registered since E-Health started in October 2009. By 31 March 2012, 3119 (76%) of 4130 patients were retained in care, 878 (21%) had failed to present to a healthcare worker in the last 3 months and the remainder had died, transferred out or were lost to follow-up. Cumulative and 12-month cohort outcome analysis indicated deficiencies in several components of clinical performance related to blood pressure measurements and fasting blood glucose tests to screen simultaneously for diabetes. Between 8% and 15% of patients with HT had serious complications such as cardiovascular disease and stroke. CONCLUSION: Cohort analysis is a valuable tool for the monitoring and management of non-communicable chronic diseases such as HT.