The authors have declared that no competing interests exist.
Conceived and designed the experiments: AR AK PP KB BR. Performed the experiments: AR AK PP BR. Analyzed the data: AR AK PP BR. Contributed reagents/materials/analysis tools: AR AK PP BR. Wrote the paper: AR AK PP KB BR.
Non-communicable diseases (NCDs) are of increasing concern in low- and middle-income countries (LMICs) affected humanitarian crises. Humanitarian agencies and governments are increasingly challenged with how to effectively tackle NCDs. Reviewing the evidence of interventions for NCDs in humanitarian crises can help guide future policies and research by identifying effective interventions and evidence gaps. The aim of this paper is to systematically review evidence on the effectiveness of interventions targeting NCDs during humanitarian crises in LMICs.
A systematic review methodology was followed using PRISMA standards. Studies were selected on NCD interventions with civilian populations affected by humanitarian crises in low- and middle-income countries. Five bibliographic databases and a range of grey literature sources were searched. Descriptive analysis was applied and a quality assessment conducted using the Newcastle-Ottawa Quality Assessment Scale for observational studies and the Cochrane Risk of Bias Tool for experimental studies.
The search yielded 4919 references of which 8 studies met inclusion criteria. Seven of the 8 studies were observational, and one study was a non-blinded randomised-controlled trial. Diseases examined included hypertension, heart failure, diabetes mellitus, chronic kidney disease, thalassaemia, and arthritis. Study settings included locations in the Middle East, Eastern Europe, and South Asia. Interventions featuring disease-management protocols and/or cohort monitoring demonstrated the strongest evidence of effectiveness. No studies examined intervention costs. The quality of studies was limited, with a reliance on observational study designs, limited use of control groups, biases associated with missing data and inadequate patient-follow-up, and confounding was poorly addressed.
The review highlights the extremely limited quantity and quality of evidence on this topic. Interventions that incorporate standardisation and facilitate patient follow-up appear beneficial. However, substantially more research is needed, including data on costs.
It is estimated that two-thirds of deaths worldwide are attributable to non-communicable diseases (NCDs), with cardiovascular disease, cancer, diabetes mellitus, and chronic lung disease comprising the largest burden of NCDs.[
There are around 50 million persons who have been forcibly displaced from their homes as refugees and internally-displaced persons (IDPs) due to humanitarian crises,[
The rise of NCDs in LMICs and the recent trends in humanitarian crises mean that the burden of NCDs has likely risen among crisis-affected populations. Governments, humanitarian organisations, and international agencies are now increasingly challenged with how to effectively tackle NCDs.[
This systematic review followed the reporting items for systematic reviews as described in the PRISMA statement.[
The populations of interest were civilians in LMICs affected by humanitarian crises, defined here as events stemming from armed conflicts, natural disasters, or food insecurity that threaten the health and safety of a community. These included populations remaining in areas affected by crises and those forcibly displaced from them as refugees and IDPs. Studies that focused on current or former military populations were excluded. High-income countries were excluded as the vast majority of humanitarian crises occur in LMICs and the resources available to tackle NCDs in LMICs are very different to those in high-income countries. The time periods of humanitarian crises included acute, chronic, and early recovery time periods.
The interventions of interest were health interventions covering health promotion, prevention, treatment, or rehabilitation activities at the individual or population level specifically for outcomes of NCDs.
The outcomes included morbidity/mortality due to NCDs and surrogate outcomes (e.g. blood pressure, blood glucose levels) at the individual or population level. In addition, we also included information on process outcomes (e.g. adherence to clinical treatment) and feasibility of interventions and measurement methods, if the study included data on changes in health outcomes. We did not include mental health outcomes as these have been reviewed elsewhere.[
The following bibliographic databases were searched: MEDLINE, Embase, Global Health, PsychInfo, and IBSS. The search terms were: (i) disaster-related terms; AND (ii) research study-related terms; AND (iii) geographic terms; AND (iv) NCD terms. A search of the grey literature was also conducted across a range of humanitarian-related databases and standard search databases such as Google. The full search strategy is provided in
Citations from the search results were imported from the bibliographic databases into EndNote for screening for eligibility based on the eligibility criteria given above. Duplicates were removed and the remaining citations assessed by title or abstract, and a full text review then conducted. References of the remaining studies selected after the full text review were examined for potentially relevant articles based on the eligibility criteria. Analysis of the final selected studies was then conducted. This involved extracting data from the final selected studies into an Excel database, with key extraction variables including: author and date of publication, geographic setting, sample population characteristics, study objectives, NCD condition studied, intervention characteristics, outcomes measured, results of the intervention, study conclusions, study design, and quality. The data screening and extraction were conducted independently by two authors and any variances resolved between them.
A quality assessment was conducted, with the Newcastle-Ottawa Quality Assessment Scale (NOS) version for cohort studies used for the observational studies [
The NOS assigns stars for methodological rigour based on three categories: study selection, comparability of study groups, and outcome assessment. Studies were initially assessed within each category using the coding manual for cohort studies provided by Wells
The Cochrane Risk of Bias Tool was developed to promote the assessment of quality of trials based on their risk of biased conclusions rather than focussing on reporting and methodological constraints [
Neither NOS nor the Cochrane Risk of Bias Tool uses an established summary score or threshold of quality, with the quality assessment primarily used to assess strengths and weaknesses of each study rather than to rank studies or to screen them out.
As the studies were heterogeneous in setting, intervention, and outcome, single effectiveness summary statistics across studies were not considered appropriate and were not estimated. Instead, a descriptive analysis of study results was reported.
The bibliographic databases yielded 4919 citations after duplicates were removed. Of these, only 8 met the study inclusion criteria (
Key characteristics of the final 8 selected studies are included in
Author, Date [Reference] | Setting | NCD Type (study population) | Study Objectives and Design | Intervention | Outcomes Measured | Results | Study Conclusions |
---|---|---|---|---|---|---|---|
Bolt et al., 2010 [ |
General conflict-affected rural population in Afghanistan attending a US military hospital. | Thalassaemia (45 paediatric patients aged 13mos-11yrs) | Assess effect of palliative thalassaemia treatment in crisis setting. Case-series design. | Palliative splenectomy (programme of undeclared duration). | Change in mean Hgb/Hct; change in mean blood transfusion frequency; complications encountered. | Hgb: 5.4g/L pre-op to 8.7g/L post-op; Hct: 16.5% pre-op to 26.3% post-op; transfusion every 24 days pre-op to every~50 days post-op; complications—2 pre-op deaths, 1 post-op respiratory distress, 1 transfusion reaction, 1 case CHF post-transfusion. | Curative options likely impossible during crisis; splenectomy may be the best palliative option. |
Khader et al., 2012 [ |
Camp-based Palestinian refugees in Jordan attending Nuzha primary care clinic. | Hypertension (4130 patients diagnosed with HTN). | Assess clinical outcomes of HTN care using EMR system. Assess utility of cohort monitoring using EMR in refugee context. Cohort design. | Standardised hypertension algorithm, including: diet/lifestyle management; graduated anti-hypertensive medications; referral if HTN persists; screening for HTN complications and associated conditions (e.g. DM); quarterly follow-up appointments. Cohort monitored via EMR for up to 2.5-years. | HTN clinical measures: BP, glucose, cholesterol, kidney function (creatinine) testing, medications used. Cohort monitoring: incidence/prevalence of HTN; clinic attendance (%); missed appointments; loss to f/u. | 4130 patients with HTN registered in EMR (cumulative, 2.5 years): 76% remain in care; 74% of those had BP checked; 74% of those checked had BP <140/90 mmHg; 15% had 1+ complications. 226 patients assessed for 12-15-month outcomes: 62% remain in care; 76% of those meeting BP target (<140/90 mmHg); 3% glucose (DM) screened; 100% cholesterol screened; 99% creatinine screened; 8% had 1+ complications. | Mixed clinical results: approx. 3/4 of patients meeting BP targets; cholesterol, kidney function properly screened; DM poorly screened; unclear if clinical practice lacking or if data recording lacking. EMR-based cohort monitoring promising for assessing programme implementation and future needs. |
Hebert et al., 2011 [ |
General conflict-affected population in Georgia (1 urban hospital and 3 rural districts). | Heart Failure (400 adult heart failure patients). | Assess clinical outcomes of a heart failure disease management programme (HFDMP). Cohort design. | 2-year HFDMP: physician training; salary support; equipment supplied; patient education; free outpatient care. | Change in: ejection fraction (EF) (mean); BP (mean); BMI (mean); smoking status; health services and medication usage; NYHA HF class. | 400 patients studied: 337 complete f/u, 51 lost to f/u, 12 died in war. EF increase 4.1±2.6% (p<0.001); BP—SBP decrease 30.9±20.0 mmHg (p<0.001), DBP decrease 17.8±13.0 mmHg (p<0.001); BMI statistically unchanged; smokers decrease 18.3% (p<0.001); ER use decrease 40.7% (p<0.001); hospital admission decrease 52.5% (p<0.001); beta-blocker use increase 73.3% (p<0.001); NYHA HF class—increase in Class I (+13.7%) and Class II (+19.2%), decrease in Class III (-26.0%) and Class IV (-6.8%); patients lost to f/u more likely rural. | HFDMP was able to affect clinical outcomes in a LMIC experiencing war. |
Khader et al., 2012 [ |
Camp-based Palestinian refugees in Jordan attending Nuzha primary care clinic. | Diabetes Mellitus (2851 patients with DM). | Assess clinical outcomes of DM care using EMR system. Assess utility of cohort monitoring using EMR in refugee context. Cohort design. | Standardised DM algorithm, including: diet/lifestyle management; graduated anti-DM medications, including insulin if necessary; screening for DM complications and associated conditions (e.g.: HTN); quarterly follow-up appointments. Cohort monitored via EMR up to 2.5 years. | DM clinical measures: 2-hr post-prandial blood glucose; BP, cholesterol, kidney function (creatinine) testing; foot assessment; ophthalmology referral. Medications used. Cohort monitoring: incidence/prevalence of DM; clinic attendance (%); missed appointments; loss to f/u. | 2851 patients with DM registered in EMR (cumulative, 2.5 years): 70% remain in care; 42% of those had 2h-PPBG checked; 50% of those checked had PPBG ≤180 mg/dl; 18% had 1+ complications. 117 patients assessed for 12-15-month outcomes: 61% remain in care; 58% of those meeting DM target (≤180 mg/dl); 100% cholesterol screened; 99% creatinine screened; 3% foot checked; no data on ophthalmology referrals; 10% had 1+ complications. | Mixed clinical results: >half of patients not receiving proper PPBG checks; half of those checked poorly-controlled; cholesterol, kidney function properly screened; DM complications poorly screened; unclear if clinical practice lacking or if data recording lacking. EMR-based cohort monitoring promising for assessing programme implementation and future needs. |
Khader et al., 2014 [ |
Camp-based Palestinian refugees in Jordan attending Nuzha primary care clinic. | Diabetes Mellitus (119 patients with DM). | Assess 12-, 24-, and 36-month clinical outcomes and complications of DM care using EMR system. Assess 3-year utility of cohort monitoring using EMR in refugee context. Cohort design. | Standardised DM algorithm, including: diet/lifestyle management; graduated anti-DM medications, including insulin if necessary; screening for DM complications and associated conditions (e.g.: HTN); quarterly follow-up appointments. Cohort monitored via EMR for up to 3 years. | DM clinical measures: 2-hr post-prandial blood glucose; BP, cholesterol, kidney function (creatinine) testing; BMI; DM complications. Cohort Monitoring: baseline prevalence of DM; clinic attendance (%); missed appointments; loss to f/u. | 119 patients with DM assessed at 12-, 24-, and 36-months: 72/64/61% remaining in care at 12-/24-/36-months (χ2 test-for-trend = 47.9; p<0.001); 9/19/29% lost to f/u at 12-/24-/36-months (χ2 test-for-trend = 43.5; p<0.001); 71/78/71% meeting DM goal (PPBG ≤180 mg/dl) at 12-/24-/36-months; 7/14/15% with 1+ complications at 12-/24-/36-months. | Mixed clinical results: approx. one-quarter of patients consistently missing DM goals; loss to f/u and complications rise over time; data indicate more aggressive treatment may be necessary. EMR-based cohort monitoring useful to highlight programme effects and future needs. |
Khader et al., 2014 [ |
Camp-based Palestinian refugees in Jordan attending 6 primary care clinics. | Diabetes Mellitus (12550 patients with DM; focus on 288 newly registered cases). | Assess new and cumulative patient characteristics and clinical outcomes of DM care using EMR system. Assess utility of cohort monitoring using EMR in refugee context across multiple primary care clinics. Design: cohort | Standardised DM algorithm, including: diet/lifestyle management; graduated anti-DM medications, including insulin if necessary; screening for DM complications and assoc. conditions (e.g.: HTN); quarterly follow-up appointments. Cohort monitored via EMR across 6 clinics (up to 2 years at 5 clinics, 3.5 years at 1 clinic). | DM clinical measures: 2-hr post-prandial blood glucose; BP, cholesterol, kidney function (creatinine) testing; BMI; foot assessment; ophthalmology referral; DM complications and associated risk factors. Cohort monitoring: incidence/prevalence of DM; clinic attendance (%); missed appointments; loss to f/u. | 12550 patients with DM registered in EMR (cumulative; 2 years at 5 clinics, 3.5 years at 1 clinic): 78% remaining in care; males more likely to be smokers (OR M:F = 7.4 (CI 6.6–8.2; p<0.001)) and inactive (OR M:F = 1.8 (CI 1.6–1.9; p<0.001)) and to have 1+ complications (OR M:F = 1.6 (CI 1.4–1.8; p<0.001)); females more likely obese (OR M:F = 0.34 (CI 0.32–0.37; p<0.001)); 99% had PPBG measured; 65% at goal (≤180 mg/dl); 99% had cholesterol measured; 63% at goal (<200 mg/dl); 99% had BP measured; 87% at goal (<140/90 mmHg); 100% had BMI measured; 40% non-obese (<30 kg/m2). | Mixed clinical results: success testing cohort widely; clinical goals not broadly met; high numbers with associated risk factors. EMR-based cohort monitoring useful to highlight programme effects and future needs. |
Sever et al., 2004 [ |
General urban and rural population affected by earthquake in Marmara region of Turkey (8 HD centres). | Chronic Kidney Disease (8 HD centres responsible for 439 patients with chronic kidney disease). | Assess clinical outcomes and infrastructure changes of haemodialysis centres affected by earthquake damage. Interrupted time series design. | Haemodialysis | Clinical outputs of HD centres: total number of HD visits, % patients receiving weekly HD. Clinical outcomes: patient weight, BP. HD infrastructure: number of HD centres, machines, patients served. | 8 HD centres assessed: HD machines: 95 pre-earthquake; 74 (1mo) and 79 (3mos) post-earthquake; HD personnel: 112 pre-earthquake; 86 (1mo) and 94 (3mos) post-earthquake; HD patients: 439 pre-earthquake; 175 (1wk), 239 (1mo), and 288 (3mos) post-earthquake; HD sessions: 1093/wk pre-earthquake; 520/wk (1wk), 616/wk (1mo), and 729/wk (3mos) post-earthquake; % weekly HD: 2.3% pre- to 7.2% 1wk-post-earthquake. Interdialytic weight gain: 2.9±1.1kg pre- to 2.6±1.1kg 1wk-post-earthquake; BP stable throughout. | Infrastructure damage significantly impairs HD treatment during disasters. Increase in once-weekly HD but interdialytic weight gain not increased. Patient education and disaster planning may prevent adverse outcomes. |
Ryan, 1997 [ |
Tibetan refugee in non-formal refugee communities in northern India. | Arthritis (28 patients with arthritis (24 OA, 4 RA), in 14 matched pairs). | Compare limb mobility in matched pairs of Tibetan refugees with arthritis after either traditional Tibetan treatment or Western medications. RCT design. | Traditional Tibetan arthritis treatment (3 months); herbal pills; dietary restriction; behavioural advice; Western arthritis treatment (3 months); Ibuprofen or Indomethacin. | Limb mobility assessed via praxis-based scale (0–5) for active movement; pain assessed via Visual Analogue Scale. | Limb mobility: Traditional Tibetan treatment led to greater improvement in 12/14 matched pairs; 2 pairs were a draw; Mean improvement 1.39 (SD 0.59) points using traditional Tibetan treatment; 0.57 (SD 0.33) points using Western treatment.) Pain—Western treatment led to better pain improvement (data not given). | Traditional Tibetan treatment led to better arthritis improvement compared to Western treatment when assessed via limb mobility. RCTs are practicable in traditional settings. |
Acronyms: BMI–body mass index; BP–blood pressure; DBP–diastolic blood pressure; DM–diabetes mellitus; EF–ejection fraction; EMR–electronic medical record; ER–emergency room; f/u–follow-up; Hct–haematocrit; HD–haemodialysis; HFDMP–heart failure disease management programme; Hgb–haemoglobin; HTN–hypertension; LMIC–low/middle-income country; mmHg–millimetres of mercury; NCD–non-communicable disease; NYHA HF class–New York Heart Association heart failure classification; OA–osteoarthritis; OR–odds ratio; PPBG–post-prandial blood glucose; RA–rheumatoid arthritis; RCT–randomised controlled trial; Ref#—reference; SBP–systolic blood pressure; SD–standard deviation.
Of the 8 studies, 7 used observational study designs[
The studies examined a broad range of NCD conditions: arthritis,[
The quality assessment identified a number of common weaknesses. The observational studies (assessed using NOS) were generally adequate in describing the study population and establishing exposure. Deficiencies common to the observational studies were predominantly related to comparability and follow-up. None had a defined comparison group or unexposed cohort. Study transparency was also noted to be a weakness common to the observational studies. No study addressed potential biases, nor did any study discuss how missing data were handled. Only three of the observational studies adequately reported follow-up periods of participants, and most studies inadequately described their follow-up procedures. Follow-up periods ranged from undefined[
The RCT study from India[
Cardiovascular diseases were assessed via two cohort studies–one in Georgia examining a heart failure disease management programme[
In the study in Georgia by Hebert
The study by Khader
Three cohort studies, all by Khader
In general, the diabetes studies claimed an improvement in the programme over time. Earlier assessment of the programme [
Chronic kidney disease was assessed by one retrospective study from Sever
Despite the infrastructure challenges, the authors found that mean interdialytic weight gain—the amount of weight patients gain between treatments, typically fluid weight due to poor blood filtration and urine production—actually decreased from a pre-earthquake 2.9±1.1 kg to 2.6±1.1 kg 1-week post-earthquake, despite the increased numbers of patients receiving haemodialysis less frequently. Moreover, the blood pressures of patients studied remained stable throughout the study period. The authors contend that adequate patient education regarding disaster preparedness and fluid restriction likely helped mitigate poor patient outcomes, although no comparison between the baseline health status of patients able to seek care after the earthquake and the status of the larger number of patients receiving haemodialysis before the earthquake was conducted.
The only RCT eligible for inclusion in this systematic review studied changes in limb mobility among 14 matched pairs of arthritis patients living in a stable Tibetan refugee setting in northern India.[
One case series study by Bolt
To the best of our knowledge, this is the first systematic review to examine the evidence of effectiveness of interventions targeting NCDs in humanitarian crises. It highlights major gaps in evidence on NCD interventions in humanitarian crises, with only eight studies meeting inclusion criteria. While the selected studies addressed a range of NCDs, there were some notable absences—particularly studies for cancer treatment and respiratory diseases. In the case of cancer, the challenges of financing and sustaining cancer care for Syrian refugees have been highlighted and further research is required on these issues.[
While it is unwise to draw any definitive conclusions from such a small body of evidence, there were a number of findings that warrant further discussion. First is the apparent success of algorithm-based interventions. In Georgia, the improved clinical outcomes and use of appropriate medication showed the effectiveness of the heart failure disease management programme there.[
In addition to the limited number of studies, the strength and quality of the existing evidence was also generally quite limited. Most of the studies used cohort study designs and while some were able to consistently follow-up over time in order to measure changes in NCD outcomes, none included a comparison group not receiving the tested intervention. This omission therefore limits conclusions on the effectiveness of the intervention. Where logistically and ethically appropriate, it would be of considerable value to include some form of comparison group in order to formulate a more robust assessment of the intervention effectiveness. The use of stepped wedge designs may be a useful approach to follow in such settings.[
Other common weaknesses include lack of discussion on how missing data were addressed, and also on other potential biases in study designs and analyses. For example, the haemodialysis study in Turkey[
There are also issues regarding the appropriateness and generalisability of some of the studies for other humanitarian contexts. For example, while the thalassaemia study for civilians in Afghanistan provided an intervention that was tailored toward the resources and context of Afghanistan, it nevertheless took place in a well-resourced US military hospital.[
The lack of cost considerations across all studies further limits the generalisability of the evidence. While cost-effective interventions targeting NCDs in LMICs have been developed,[
Most of the evidence identified in this review is from relatively stable settings. This highlights the challenges to implementing rigorous research during an acute crisis giving the security and resource constraints and rapid population movement. However, previous longitudinal research with conflict-affected populations in volatile contexts on treatment for chronic conditions such as HIV has shown that such research is possible.[
Only descriptive analysis was used, but alternative methods such as meta-analysis were not appropriate because of the multiple outcomes, interventions, study types, and the limited number of studies. The review searched only quantitative studies as the focus was on the effectiveness of interventions, and only studies from 1980 onward were included. Analysis of qualitative research examining aspects such as health care provider and user perspectives on NCD interventions in humanitarian crises would be extremely valuable. There is also the possibility that humanitarian agencies may not have published all their existing research (either as published or grey literature), and it is difficult to ascertain the potential levels of such non-publication. We could have tried hand searching humanitarian agency reports to attempt to find additional studies. However, our prior experience and discussions with humanitarian agency staff suggest it would be extremely unlikely to yield any further studies that would not have been published in scientific journals. The NOS tool used for the quality assessment in this review has been criticized for limited inter-rater reliability.[
Research during humanitarian crises is inherently difficult. Researching NCDs is arguably even harder as their chronic nature tends to demand more substantial follow-up. Nevertheless, this review has highlighted an urgent need to substantially expand research on NCD interventions in humanitarian crises given their growing disease burden. Currently available studies represent an attempt to rectify this knowledge gap but are few in number and of relatively limited quality. The findings point toward the success of standardised algorithms that can be implemented consistently and monitored via patient tracking using electronic medical records. Key research needs include: a better understanding of NCD delivery models in more acute and early recovery settings; using comparison groups (where appropriate); analysing the costs and sustainability of interventions; and developing methods to minimize bias in setting where standard randomised control studies are not feasible. Such work would support the generalisability of NCD intervention findings and provide much needed guidance in this neglected field.
Search terms.
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Quality assessment of observational studies using NOS criteria.
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Quality assessment of RCT study using Cochrane Risk of Bias Assessment Tool.
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PRISMA Checklist.
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