Integrating community health volunteers into non-communicable disease management among Syrian refugees in Jordan: a causal loop analysis

Abstract

ObjectivesGlobally, there is emerging evidence on the use of community health workers and volunteers in low-income and middle-income settings for the management of non-communicable diseases (NCDs), provision of out-of-clinic screening, linkage with health services, promotion of adherence, and counselling on lifestyle and dietary changes. Little guidance exists on the role of this workforce in supporting NCD care for refugees who lack access to continuous care in their host country. The goals of this work were to evaluate the current roles of community health volunteers (CHVs) in the management of diabetes and hypertension (HTN) among Syrian refugees and to suggest improvements to the current primary care model using community health strategies.Setting and participantsA participatory, multistakeholder causal loop analysis workshop with representatives from the Ministry of Health of Jordan, non-governmental organisations, United Nations agencies, CHVs and refugee patients was conducted in June 2019 in Amman, Jordan.Primary outcomeThis causal loop analysis workshop was used to collaboratively develop a causal loop diagram and CHV strategies designed to improve the health of Syrian refugees with diabetes and HTN living in Jordan.ResultsDuring the causal loop analysis workshop, participants collaboratively identified and mapped how CHVs might improve care among diagnosed patients. Possibilities identified included the following: providing psychosocial support and foundational education on their conditions, strengthening self-management of complications (eg, foot checks), and monitoring patients for adherence to medications and collection of basic health monitoring data. Elderly refugees with restricted mobility and/or uncontrolled disease were identified as a key population where CHVs could provide home-based blood glucose and blood pressure measurement and targeted health education to provide more precise monitoring.ConclusionsCHV programmes were cited as a key strategy to implement secondary prevention of morbidity and mortality among Syrian refugees, particularly those at high risk of decompensation.

Diverse Approaches to Creating and Using Causal Loop Diagrams in Public Health Research: Recommendations From a Scoping Review

“…In terms of research aims found in the 23 articles, four themes emerged: 1) to examine the complexity of a public health topic and illustrate complex systems thinking [26][27][28][29][30][31][32][33][34]; 2) to discuss the complexity of a public health intervention [35][36][37][38][39][40]; 3) to describe study protocol and how CLDs were created [41][42][43][44]; and 4) to illustrate how CLDs can be used to monitor and track initiatives to improve population health or evaluate impact of interventions [45][46][47][48].…”

“…CLDs were mostly seen as a means or a tool to examine feedback at play in public health issues. Some articles were explicit [28,32,33,40,43,44] while others implied this. Both Riley et al [43] and Parmar et al [40] labeled this as "causal loop analysis" and the resulting CLDs were a means to understand systems and potential "programming."…”

“…Both primary and secondary data were used for creating CLDs (Table 3). Most articles reported on primary data collection (18/ 23) and this included interviews [26,27,33,[35][36][37][38][39][40], group model building with stakeholders and/or community members [32,41,43,44,46,48], behavioral data [42,47], fieldnotes [37], and workshops with experts [31]. Twelve articles used primary data only.…”

“…Allender [47] ✓ ✓ Araz [45] ✓ ✓ Bensberg [35] ✓ ✓ Bradley [34] ✓ ✓ Brereton [28] ✓ ✓ Brown [48] ✓ ✓ Burrell [36] ✓ ✓ ✓ Clarke [37] ✓ ✓ ✓ Crielaard [26] ✓ ✓ ✓ Eker [27] ✓ ✓ Gerritsen [41] ✓ ✓ Hassmiller Lich [46] ✓ ✓ Jalali [38] ✓ ✓ ✓ Klement [29] ✓ ✓ Knai [30] ✓ ✓ Maitland [42] ✓ ✓ Osman [31] ✓ ✓ Owen [39] ✓ ✓ Parmar [40] ✓ ✓ ✓ Riley [43] ✓ ✓ Sahin [32] ✓ ✓ ✓ Swierad [44] ✓ ✓ Urwannachotima [33] ✓ ✓…”

“…CLDs created by researchers only was the second most common process (10/23). Two articles reported that CLDs were presented to stakeholders for refinement [39,40]. The range of approaches included:…”