Advertisement

International Journal of Public Health

, Volume 63, Issue 5, pp 577–588 | Cite as

eHealth as a facilitator of equitable access to primary healthcare: the case of caring for non-communicable diseases in rural and refugee settings in Lebanon

  • Shadi Saleh
  • Mohamad Alameddine
  • Angie Farah
  • Nour El Arnaout
  • Hani Dimassi
  • Carles Muntaner
  • Christo El Morr
Original Article

Abstract

Objectives

Assess the effect of selected low-cost eHealth tools on diabetes/hypertension detection and referrals rates in rural settings and refugee camps in Lebanon and explore the barriers to showing-up to scheduled appointments at Primary Healthcare Centers (PHC).

Methods

Community-based screening for diabetes and hypertension was conducted in five rural and three refugee camp PHCs using an eHealth netbook application. Remote referrals were generated based on pre-set criteria. A phone survey was subsequently conducted to assess the rate and causes of no-shows to scheduled appointments. Associations between the independent variables and the outcome of referrals were then tested.

Results

Among 3481 screened individuals, diabetes, hypertension, and comorbidity were detected in 184,356 and 113 per 1000 individuals, respectively. 37.1% of referred individuals reported not showing-up to scheduled appointments, owing to feeling better/symptoms resolved (36.9%) and having another obligation (26.1%). The knowledge of referral reasons and the employment status were significantly associated with appointment show-ups.

Conclusions

Low-cost eHealth netbook application was deemed effective in identifying new cases of NCDs and establishing appropriate referrals in underserved communities.

Keywords

Primary healthcare eHealth Diabetes Hypertension Referrals Appointment no-show 

Abbreviations

NCDs

Non-communicable diseases

PHC

Primary healthcare

LMICs

Low- and middle-income countries

SMS

Short message service

CHWs

Community health workers

PHCCs

Primary healthcare centers

WHO

World Health Organization

CLI

Collaborative for Leadership and Innovations in Health Systems

AUB

American University of Beirut

MOPH

Ministry of Public Health

UNRWA

United Nations Relief and Works Agency

IDRC

International Development Research Center

BMI

Body mass index

DB

Diabetes

FBS

Fasting Blood Sugar

SBP

Systolic Blood Pressure

DBP

Diastolic Blood Pressure

HTN

Hypertension

WC

Waist circumference

DSME

Disease self-management education

OR

Odds ratio

RR

Response rate

US

United States

UK

United Kingdom

Notes

Acknowledgements

Technical support was provided by the Ministry of Public Health (MOPH) and the United Nations Relief and Works Agency (UNRWA) to ensure the commitment of participating centers. The study authors would like to acknowledge all the CHWs and all data collectors for their efforts.

Author contributions

SS and MA have conceptualized the study. MA and HD advised on the study design and data analysis. SS supported the implementation of the study. HD led the data analysis. SS, MA, AF, and NEA contributed significantly to the interpretation and development of the manuscript. AF, NEA, CEM, and CM made significant contributions to the write-up of the manuscript. All authors read and approved the final manuscript.

Funding

The study was funded by the International Development Research Center (IDRC), Canada. The contributions of IDRC staff and the material resources were very supportive to the conduct of this study

Compliance with ethical standards

Ethics approval and consent to participate

Prior to commencing the study, ethical approval was obtained from the Institutional Review Board of AUB. Written informed consent was used at all stages; participation was completely voluntarily and the data collected was completely confidential.

Availability of data and materials

The data sets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Conflict of interest

The authors declare that they have no competing interests.

References

  1. Amara AH, Aljunid SM (2014) Noncommunicable diseases among urban refugees and asylum-seekers in developing countries: a neglected health care need. Global Health 10:1–15.  https://doi.org/10.1186/1744-8603-10-24 CrossRefGoogle Scholar
  2. Ammar W (2009) Health reform in Lebanon key achievements at a glance. Ministry of Public HealthGoogle Scholar
  3. Anderson RM, Funnell MM (2010) Patient empowerment: myths and misconceptions. Patient Educ Couns 79:277–282CrossRefPubMedGoogle Scholar
  4. Balcázar H, Wise S, Rosenthal EL, Ochoa C, Duarte-Gardea M, Rodriguez J, Hastings D, Flores L, Hernandez L (2012) An ecological model using promotores de salud to prevent cardiovascular disease on the US-Mexico border: the HEART project. Prev chRonic Dis 9:110100.  https://doi.org/10.5888/pcd9.110100 PubMedPubMedCentralGoogle Scholar
  5. Beaglehole R, Epping-Jordan J, Patel V, Chopra M, Ebrahim S, Kidd M, Haines A (2008) Improving the prevention and management of chronic disease in low-income and middle-income countries: a priority for primary health care. Lancet 372:940–949.  https://doi.org/10.1016/S0140-6736(08)61404-X CrossRefPubMedGoogle Scholar
  6. Chen B, Cammett M (2012) Informal politics and inequity of access to health care in Lebanon. Int J Equity health 11:1CrossRefGoogle Scholar
  7. Gamm L, Castillo G, Pittman S (2010) Access to quality health services in rural areas—primary care. Nation 2:3Google Scholar
  8. George A, Rubin G (2003) Non-attendance in general practice: a systematic review and its implications for access to primary health care. Fam Pract 20:178–184CrossRefPubMedGoogle Scholar
  9. Gray CS, Miller D, Kuluski K, Cott C (2014) Tying eHealth tools to patient needs: exploring the use of ehealth for community-dwelling patients with complex chronic disease and disability. JMIR Res Protoc 3:e67CrossRefGoogle Scholar
  10. Hogan TP, Wakefield B, Nazi KM, Houston TK, Weaver FM (2011) Promoting access through complementary eHealth technologies: recommendations for VA’s Home Telehealth and personal health record programs. J Gen Intern Med 26:628–635CrossRefPubMedPubMedCentralGoogle Scholar
  11. International Diabetes Federation (2015) IDF Diabetes Atlas. IDF Diabetes Atlas—7th edn. http://www.diabetesatlas.org/. Accessed 20 May 2016
  12. International Diabetes Federation (2017) Middle East and North Africa. http://www.idf-mena.org/about/diabetes-in-the-region. Accessed 20 May 2016
  13. International Society of Hypertension (2015) World Hypertension Day 2015—17 May. http://ish-world.com/new-investigators-news/a/World-Hypertension-Day-2015/. Accessed 20 May 2016
  14. Islam SMS, Tabassum R (2015) Implementation of information and communication technologies for health in Bangladesh. Bull World Health Organ 93:806–809CrossRefPubMedPubMedCentralGoogle Scholar
  15. Islam SMS, Lechner A, Ferrari U, Froeschl G, Alam DS, Holle R, Seissler J, Niessen LW (2014) Mobile phone intervention for increasing adherence to treatment for type 2 diabetes in an urban area of Bangladesh: protocol for a randomized controlled trial. BMC Health Serv Res 14:1CrossRefGoogle Scholar
  16. Katz SJ, Moyer CA (2004) The emerging role of online communication between patients and their providers. J Gen Intern Med 19:978–983CrossRefPubMedPubMedCentralGoogle Scholar
  17. Khader A, Ballout G, Shahin Y, Hababeh M, Farajallah L, Zeidan W, Abu-Zayed I, Kochi A, Harries AD, Zachariah R (2014) Treatment outcomes in a cohort of Palestine refugees with diabetes mellitus followed through use of E-Health over 3 years in Jordan. Tropical Med Int Health 19:219–223CrossRefGoogle Scholar
  18. Lacy NL, Paulman A, Reuter MD, Lovejoy B (2004) Why we don’t come: patient perceptions on no-shows. Ann Fam Med 2:541–545CrossRefPubMedPubMedCentralGoogle Scholar
  19. Maher D, Harries AD, Zachariah R, Enarson D (2009) A global framework for action to improve the primary care response to chronic non-communicable diseases: a solution to a neglected problem. BMC Public Health 9:1CrossRefGoogle Scholar
  20. Maher D, Ford N, Unwin N (2012) Priorities for developing countries in the global response to non-communicable diseases. Global Health 8:1CrossRefGoogle Scholar
  21. Ministry of Public Health (2016) Non communicable diseases prevention and control plan (NCD-PCP) Lebanon 2016. Republic of Lebanon-Ministry of Public HealthGoogle Scholar
  22. Mousa H, Yousef S, Riccardo F, Zeidan W, Sabatinelli G (2010) Hyperglycaemia, hypertension and their risk factors among Palestine refugees served by UNRWAGoogle Scholar
  23. Neal RD, Hussain-Gambles M, Allgar VL, Lawlor DA, Dempsey O (2005) Reasons for and consequences of missed appointments in general practice in the UK: questionnaire survey and prospective review of medical records. BMC Fam Prac 6:1CrossRefGoogle Scholar
  24. Norris SL, Chowdhury FM, Van Le K, Horsley T, Brownstein JN, Zhang X, Jack L, Satterfield DW (2006) Effectiveness of community health workers in the care of persons with diabetes. Diab Med 23:544–556CrossRefGoogle Scholar
  25. Ouma S, Herselman M (2008) E-health in rural areas: case of developing countries. Int J Biol Life Sci 4:194–200Google Scholar
  26. Oyebode O, Pape UJ, Laverty AA, Lee JT, Bhan N, Millett C (2015) Rural, urban and migrant differences in non-communicable disease risk-factors in middle income countries: a cross-sectional study of WHO-SAGE data. PLoS One 10:e0122747CrossRefPubMedPubMedCentralGoogle Scholar
  27. Paré G, Jaana M, Sicotte C (2007) Systematic review of home telemonitoring for chronic diseases: the evidence base. J Am Med Inform Assoc 14:269–277CrossRefPubMedPubMedCentralGoogle Scholar
  28. Sabatinelli G, Pace-Shanklin S, Riccardo F, Shahin Y (2009) Palestinian refugees outside the occupied Palestinian territory. Lancet 373:1063–1065CrossRefPubMedGoogle Scholar
  29. Samb B, Desai N, Nishtar S, Mendis S, Bekedam H, Wright A, Hsu J, Martiniuk A, Celletti F, Patel K, Adshead F, McKee M, Evans T, Alwan A, Etienne C (2010) Prevention and management of chronic disease: a litmus test for health-systems strengthening in low-income and middle-income countries. Lancet 376:1785–1797.  https://doi.org/10.1016/S0140-6736(10)61353-0 CrossRefPubMedGoogle Scholar
  30. Serocca AB (2008) Personal health record use by patients as perceived by ambulatory care physicians in Nebraska and South Dakota: a cross-sectional study. Perspect Health Inform Manag 5:1Google Scholar
  31. Sharp DJ (2001) Non-attendance at general practices and outpatient clinics: local systems are needed to address local problems. BMJ 323:1081–1083CrossRefPubMedPubMedCentralGoogle Scholar
  32. Starfield B, Shi L, Macinko J (2005) Contribution of primary care to health systems and health. Milbank Q 83:457–502CrossRefPubMedPubMedCentralGoogle Scholar
  33. United Nations Relief and Works Agency (2011) Palestine refugees: a special case. UNRWA LebanonGoogle Scholar
  34. Wakerman J, Humphreys JS (2011) Sustainable primary health care services in rural and remote areas: innovation and evidence. Aust J Rural Health 19:118–124CrossRefPubMedGoogle Scholar
  35. Wilson N, Couper I, De Vries E, Reid S, Fish T, Marais B (2009) inequitable distribution of healthcare professionals to rural and remote areas. Rural Remote Health 9:1060PubMedGoogle Scholar
  36. World Health Organization (2005) Preventing chronic diseases: a vital investment, World Health OrganizationGoogle Scholar
  37. World Health Organization (2015) Lebanon: WHO statistical profile, 2015. World Health OrganizationGoogle Scholar
  38. Yamout R, Adib SM, Hamadeh R, Freidi A, Ammar W (2014) Peer reviewed: screening for cardiovascular risk in asymptomatic users of the primary health care network in Lebanon, 2012–2013. Prev Chronic Dis 11:E120CrossRefPubMedPubMedCentralGoogle Scholar
  39. Youssef A (2014) Use of short message service reminders to improve attendance at an internal medicine outpatient clinic in Saudi Arabia: a randomized controlled trial/Utilisation de rappels par minimessages afin d’améliorer l’assiduité des patients dans un service de consultations externes en médecine interne en Arabie saoudite: essai contrôlé randomisé. East Mediterr Health J 20:317CrossRefPubMedGoogle Scholar

Copyright information

© Swiss School of Public Health (SSPH+) 2018

Authors and Affiliations

  1. 1.Department of Health Management and Policy, Faculty of Health SciencesAmerican University of BeirutBeirutLebanon
  2. 2.Global Health InstituteAmerican University of BeirutBeirutLebanon
  3. 3.College of MedicineMohammed Bin Rashid University of Medicine and Health Sciences, Dubai Health Care CityDubaiUAE
  4. 4.School of PharmacyLebanese American UniversityBeirutLebanon
  5. 5.Bloomberg Faculty of Nursing, Dalla Lana School of Public Health and Department of PsychiatrySchool of Medicine University of TorontoTorontoCanada
  6. 6.Health Informatics, School of Health Policy and Management, Faculty of HealthYork UniversityTorontoCanada

Personalised recommendations