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Abstract
Non-communicable diseases have overtaken communicable diseases as the most common cause of death worldwide, with the majority of these deaths in low-income and middle-income countries. Hypertension alone causes over nine million deaths per year.
Since 2017, around 750 000 Rohingya refugees have fled violence in Myanmar into Cox’s Bazar District in Bangladesh. We describe a quality improvement project focused on the management of hypertension in Rohingya refugees in three primary health facilities within the Rohingya refugee camps. The aim of the project was to create a sustainable hypertension service within existing primary care services.
A number of plan–do–study–act cycles were performed to improve care, with methods including: creating a specialised clinic, writing a treatment algorithm, training of pharmacists, engaging community health workers and educational programmes for staff and patients.
In 2020, 554 patients were engaged in the new hypertension service. Of these, 358 (64.6%) returned for follow-up at least once. Mean systolic blood pressure (BP) was 141.7 (SD 60.0) mm Hg and mean diastolic BP was 88.1 (SD 11.1) mm Hg. Patients engaged in treatment had a significant reduction of BP of 8.2 (95% CI 5.4 to 11.0)/6.0 (95% CI 4.1 to 7.9) mm Hg (p<0.0001).
Our project shows that it is possible to create a hypertension service in a challenging humanitarian crisis, which can successfully improve the control of hypertension, although retention in care can be difficult.
- Quality improvement
- Chronic disease management
- Global Health
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Introduction
Since 2017, around 750 000 Rohingya refugees have fled violence in Myanmar into Cox’s Bazar District in Bangladesh.1 As the humanitarian response has become more established, care has focused more on the management of chronic, non-communicable diseases (NCDs), such as hypertension, alongside traditional objectives such as vaccination and nutrition.
The humanitarian community has recognised the imperative of managing NCDs within the humanitarian setting.2–6 Hypertension is a risk factor for cardiovascular and cerebrovascular disease and reduction in blood pressure (BP) is important in preventing premature mortality and morbidity.7 8 Hypertension affects over a billion people, with around two-thirds living in low-income and middle-income countries (LMICS),9 and caused over 9 million deaths in 2010.7 Other studies of refugee populations have shown a 76% follow-up rate in Palestine10 and another with controlled BP in only 50% after 6 months in Lebanon.11 We designed a quality improvement project (QIP) focused on the management of hypertension.
Project setting
The Rohingya refugee camps in Cox’s Bazar are the largest in the world.12 Healthcare is provided by national facilities, United Nations agencies and non-governmental organisations (NGOs). Challenges facing refugees have included violence, nutrition, sanitation, fires, monsoon, several epidemics13 and the COVID-19 pandemic.
The QIP was designed by a multidisciplinary team of international volunteer healthcare workers in conjunction with Bangladeshi doctors, nurses and pharmacists and Rohingya community health workers (CHWs). The aim of our QIP was to create a sustainable NCD service at the three primary health facilities run by a partnership of two NGOs: Food for the Hungry (FH) and Medical Teams International (MTI).
Design and strategy
A number of plan–do–study–act (PDSA) cycles were performed to improve care. PDSA-1 involved setting up the dedicated hypertension clinic to run within existing primary healthcare services. We believed this was important, rather than treating patients in an ad-hoc fashion with the rest of primary services, so that we could encourage regular follow-up. Waiting times in the facilities were also very long and we aimed to reduce these in a dedicated clinic.
A treatment algorithm, based on the WHO ‘Package of Essential NCD’ guidance14 and adapted for locally available resources, was created (online supplemental appendix 1). The algorithm was introduced via teaching sessions, over WhatsApp and a podcast (available on https://soundcloud.com/user-137083346). Nurses were trained to ensure a consistent approach to BP measurement.
Supplemental material
After the first pilot clinics, it was noted that 12 of 25 patients did not return for follow-up and we addressed this with PDSA-2. There was already a robust system in place of Rohingya CHWs visiting each home regularly and we decided to use them to encourage patients to return regularly for follow-up. They also provided health education and lifestyle management in regards to NCDs.
During the COVID-19 pandemic, patient numbers fell, as seen in figure 1. We addressed this in PDSA-3 and aimed to retain patients in care by giving longer prescriptions without the need to see a healthcare professional between refills. Figure 1 shows the quick return to prepandemic levels with this change.
The number of consultations in the NCD clinic per month for hypertension during 2020. HTN, hypertension; NCD, non-communicable disease.
Throughout the project, we also made improvements in the pharmacy to improve medication supply to avoid stock-outs, which had been a problem in the first clinics. Daily reports of medication use were digitalised to make monthly consumption reports more accurate. This meant that reliable projections could be made quarterly so medications could be ordered. Pharmacists also attended training on medicines management provided by the United Nations High Commissioner for Refugees agency.
Finally, we presented our project to other NGOs so that other groups in the camps could learn from our experience.
Results
In 2020, 554 patients were seen for hypertension in the NCD service of FH/MTI in the Rohingya refugee camps. Of these, 358 (64.6%) returned for follow-up at least once that year. In total, there were 2712 consultations for the 554 patients (4.9 (SD 5.8) consultations per patient). Figure 1 shows the number of consultations per month in the hypertension clinic.
The mean first recorded BP was 145.6 (SD 15.3)/91.6 (SD 11.1) mm Hg. The most recent mean BP while on treatment taken during the study year was 137.4 (SD 15.5)/85.6 (SD 10.3) mm Hg, a significant reduction of 8.2 (95% CI (CI) 5.4 to 11.0)/6.0 (95% CI 4.1 to 7.9) mm Hg (p<0.0001).15
Discussion
Given the burden of NCDs on LMICs, it is essential that NCD services are provided, including in humanitarian crises.2–6 To our knowledge, this is the first study to examine the treatment of hypertension in the Rohingya refugee crisis.
Our project aim was to create a sustainable, specialised hypertension clinic in this humanitarian crisis. We were successful in this as the clinic is still running over 2 years after initiation, providing care for over 200 patients per month.
The difference between mean BP for those who were started on treatment and returned to the clinic was significantly reduced by 8/6 mm Hg, although this includes patients who were on treatment for a different amount of time, which is a limitation of the data.
A strength of our project was its sustainability. It was recognised that the project had to involve national staff, local champions and refugee volunteers from the outset for effective change. After the initial joint setup phase, the operation of the clinic was almost entirely continued by national staff. Integrating the clinic within existing primary care services was also a key strength.
Our results demonstrate the difficulty in retaining patients in care with 35.4% not returning after the first visit, possibly because of the prevalent cultural misunderstanding about the chronic nature of the illness, its asymptomatic nature, dependency on traditional medications or competing priorities for refugees. Another challenge was the COVID-19 pandemic, which affected service utilisation. To encourage return to clinic, we found it useful to use CHWs. A future change will hopefully be to provide several postdated prescriptions to allow patients to collect medication without needing to be seen by a doctor every time.
In conclusion, our project shows that it is possible to create a hypertension clinic integrated into a primary care service in a challenging humanitarian crisis which could lead to significant improvement in the control of hypertension although retention in care remains an issue.
Ethics statements
Patient consent for publication
Acknowledgments
We thank Mahmuda Sarwar, Md. Jihan Sheikh, Saiful Islam and Kaitlin Mason for their assistance in organising data collection.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors DH, MS, LLH and MA designed the study. DH, MS, LLH, EB and RL collected data for the study. DH, MA, AGKM, MK and JW wrote the manuscript. All authors gave final approval of the manuscript. DH is responsible for the overall content as guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.