Outpatient use patterns and experiences among diabetic and hypertensive patients in fragile settings: a cross-sectional study from Lebanon

Abstract

ObjectivesAssess and describe the health service use and delivery patterns for non-communicable disease (NCD) services in two contrasting fragility contexts and by other principal equity-related characteristics including gender, nationality and health coverage.SettingPrimary healthcare centres located in the urbanised area of Greater Beirut and the rural area of the Beqaa Valley.DesignThis is a cross-sectional study using a structured survey tool between January and September 2020.Participants1700 Lebanese and Syrian refugee patients seeking primary care for hypertension and diabetes.Primary and secondary outcomesThe main outcome is the comprehensiveness of service delivery comparing differences in use and service delivery patterns by fragility setting, gender, nationality and health coverage.ResultsCompliance with routine NCD care management (eg, counselling, immunisations, diagnostic testing and referral rates) was significantly better in Beirut compared with Beqaa. Women were significantly less likely to be offered lifestyle counselling advice and referral to cardiologists (58.4% vs 68.3% in Beqaa and 58.1% vs 62% in Beirut) and ophthalmologists, compared with men. Across both settings, there was a significant trend for Lebanese patients to receive more services and more advice related to nutrition and diabetes management (89.8% vs 85.2% and 62.4% vs 55.5%, respectively). Similarly, referral rates were higher among Lebanese refugees compared with Syrian refugees. Immunisation and diagnostic testing were significantly higher in Beirut among those who have health coverage compared with Beqaa.ConclusionsThe study discovered significant differences in outpatient service use by setting, nationality and gender to differentials. A rigorous and comprehensive appraisal of NCD programmes and services is imperative for providing policy makers with evidence-based recommendations to guide the design, implementation and evaluation of targeted programmes and services necessary to ensure equity in health services delivery to diabetic and hypertensive patients. Such programmes are an ethical imperative considering the protracted crises and compounded fragility.

Has the COVID-19 pandemic changed the utilization and provision of essential health care services from 2019 to 2020 in the primary health care network in Lebanon? Results from a nationwide representative cross-sectional survey

“…In fact, the vast majority of reported interruptions in the utilization of PHC services was reported by the non-Lebanese population in the country. This finding adds to the body of evidence that compounding shocks often have an inequitable distribution, as they disproportionately affect refugee communities [ 28 , 29 ].…”

“…These findings appear to be confirmed also beyond COVID-19 services: another study conducted in Lebanon among NCD patients highlighted the disparity in access to services and education. When comparing the provision of health services by nationality, Syrian refugees were less likely to receive the necessary services and lacked awareness on the management of their conditions [ 29 ].…”

Implementing and evaluating integrated care models for non-communicable diseases in fragile and humanitarian settings

“…More generally in Lebanon, up to 91 % of deaths are attributed to NCDs ( Zablith et al, 2021 , Mansour et al, 2020 ). The prevalence of NCDs and their risk factors has been higher in Syrian refugees than the host population of Lebanon, while their health-seeking, and access to optimal levels of care is lower ( Zablith et al, 2021 , Mansour et al, 2020 , Saleh et al, 2021 , Saleh et al, 2022 , Lyles et al, 2020 ). Nevertheless, with rising inflation, outgoing migration of the national health workforce, and other cascading effects of the economic and geopolitical crises, such as the lifting of government subsidies for insulin prices in 2021, health-seeking trends for NCD care in the host population have also been affected, with more Lebanese seeking care through the public health system ( Kawa et al, 2022 , Das, 2022 , Hamadeh et al, 2021 ).…”

Patient experiences of diabetes and hypertension care during an evolving humanitarian crisis in Lebanon: A qualitative study

“…In this emerging field, attention at policy and practice levels has been on service provision, positioned from the perspectives of actors who are establishing approaches to embed NCD care in humanitarian models [1,2,7,[11][12][13][14]. There has been less focus on patients' experiences of receiving NCD care during humanitarian crises, with the exception of recent research in Lebanon addressing access to primary health care services [14][15][16]. Our research seeks to address this gap, with a focus on the continuum of care for patients who are accessing services.…”

“…MoPH support to bolster primary care provision has included strengthened procurement, training and guideline development, including for NCDs [31], introduction of an accreditation and national monitoring system [32] and an essential health care benefit package [33]. While NCD service coverage for Syrian refugees has reportedly been high (83%), access for Syrians and vulnerable Lebanese has been limited by cost, availability and legal issues, and services have been fragmented, of variable quality, and poorly coordinated [16,27,[34][35][36].…”