Prevalence and clinical characteristics of diabetes mellitus in Lebanon: a national survey

Ibrahim Bou-Orm - ORCID: 0000-0003-3563-4014 https://orcid.org/0000-0003-3563-4014Background: Diabetes mellitus in all its forms has been rapidly increasing worldwide, especially in the Eastern Mediterranean Region. Aims: This national study aimed to assess the prevalence and clinical aspects of diabetes mellitus in Lebanon with special focus on type 1 (T1DM). Methods: A national multistage, random household sample survey was conducted, using face-to-face interviews with 1 questionnaire per household. A total of 4500 households were selected from all areas based on a pre-existing sampling frame of the Lebanese population. Results: The prevalence of previously diagnosed diabetes mellitus in the surveyed population of 17 832 persons (mean age ~36 years) was 7.95%. The prevalence of T1DM in particular was estimated at 0.1%, or almost 1% of all detected cases of diabetes mellitus. Most persons with diabetes mellitus reported obtaining their usual care from endocrinologists rather than primary healthcare physicians. Delayed performance of haemoglobin A1c test was reported in 25% of 1418 patients. Hypoglycaemic episodes recently occurred in 30% of patients; of whom, at least one third required medical attention, including hospital admission. Diagnosed complications were reported in 22% of cases, with retinopathy being the most common. Conclusions: Prevalence of T1DM in this population was lower than international estimates. Diabetes mellitus management appears to be deficient, based on delays in standard control testing, hypoglycaemic episodes and diabetes mellitus-related complications. Coordination of diabetic care management should be devolved to primary healthcare physicians, who can keep track of the need for referral to various types of diabetes mellitus care.https://doi.org/10.26719/2020.26.2.18226pubpub

Addressing the COVID-19 emergency during the ongoing political and economic crisis in Fragile Lebanon: A call to action

From Springer Nature via Jisc Publications RouterThis Letter to the Editor aims to reflect on the current challenges to increase the coverage of COVID-19 vaccination in the fragile and conflict-affected setting of Lebanon, which is currently experiencing one of the biggest economic crises globally as well as a recent surge in COVID-19 cases. Addressing the supply- and demand-related factors affecting vaccination would increase COVID-19 vaccine coverage and prevent the complete collapse of an already overwhelmed Lebanese health care system.15pubpu

Political Economy of Non-Communicable Disease (NCD) prevention and control in Lebanon: identifying challenges and opportunities for policy change and care provision reforms

From Springer Nature via Jisc Publications RouterHistory: received 2023-07-03, registration 2023-11-28, accepted 2023-11-28, collection 2023-12, epub 2023-12-18, online 2023-12-18Acknowledgements: Not applicable.Publication status: PublishedFunder: National Institute for Health and Care Research; doi: http://dx.doi.org/10.13039/501100000272; Grant(s): NIHR Global Health Research programme 16/136/100, NIHR Global Health Research programme 16/136/100, NIHR Global Health Research programme 16/136/100, NIHR Global Health Research programme 16/136/100Ibrahim Bou-Orm - ORCID: 0000-0003-3563-4014 https://orcid.org/0000-0003-3563-4014Giulia Loffreda - ORCID: 0000-0003-4895-1051 https://orcid.org/0000-0003-4895-1051Karin Diaconu - ORCID: 0000-0002-5810-9725 https://orcid.org/0000-0002-5810-9725Sophie Witter - ORCID: 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Introduction: Lebanon is a middle-income country facing substantial fragility features. Its health profile shows a high burden of NCD morbidity and mortality. This paper intends to analyse the political economy of NCD prevention and control in Lebanon. Methods: This study adopted a literature-based case study research design using a problem-driven political economy analysis framework. A total of 94 peer-reviewed articles and documents from the grey literature published before June 2019 were retrieved and analysed. Results: Lebanon’s political instability and fragile governance negatively affect its capacity to adapt a Health-in-All-Policies approach to NCD prevention and enable the blocking of NCD prevention policies by opposed stakeholders. Recent economic crises limit the fiscal capacity to address health financing issues and resulting health inequities. NCD care provision is twisted by powerful stakeholders towards a hospital-centred model with a powerful private sector. Stakeholders like the MOPH, UN agencies, and NGOs have been pushing towards changing the existing care model towards a primary care model. An incremental reform has been adopted to strengthen a network of primary care centres, support them with health technologies and improve the quality of primary care services. Nevertheless, outpatient services that are covered by other public funds remain specialist-led without much institutional regulation. Conclusion: Our study revealed a locked equilibrium in NCD prevention policymaking in Lebanon, but with an incremental progress in service delivery reforms towards a primary care model. Advocacy and close monitoring by policy entrepreneurs (such as civil society) could initiate and sustain the implementation of policy change and care model reforms.pubpu

Barriers and Opportunities for WHO “Best Buys” Non-communicable Disease Policy Adoption and Implementation From a Political Economy Perspective: A Complexity Systematic Review

Background: Improving the adoption and implementation of policies to curb non-communicable diseases (NCDs) is a major challenge for better global health. The adoption and implementation of such policies remain deficient in various contexts, with limited insights into the facilitating and inhibiting factors. These policies have traditionally been treated as technical solutions, neglecting the critical influence of political economy dynamics. Moreover, the complex nature of these interventions is often not adequately incorporated into evidence for policy-makers. This study aims to systematically review and evaluate the factors affecting NCD policy adoption and implementation.Methods: We conducted a complex systematic review of articles discussing the adoption and implementation of WHO’s “best buys” NCD policies. We identified political economy factors and constructed a causal loop diagram (CLD) program theory to elucidate the interplay between factors influencing NCD policy adoption and implementation. A total of 157 papers met the inclusion criteria.Results: Our CLD highlights a central feedback loop encompassing three vital variables: (1) the ability to define, (re)shape and pass appropriate policy into law; (2) the ability to implement the policy (linked to the enforceability of the policy and to addressing NCD local burden); and (3) ability to monitor progress, evaluate and correct the course. Insufficient context-specific data impedes the formulation and enactment of suitable policies, particularly in areas facing multiple disease burdens. Multisectoral collaboration plays a pivotal role in both policy adoption and implementation. Effective monitoring and accountability systems significantly impact policy implementation. The commercial determinants of health (CDoH) serve as a major barrier to defining, adopting, and implementing tobacco, alcohol, and diet-related policies.Conclusion: To advance global efforts, we recommend focusing on the development of robust accountability, monitoring, and evaluation systems, ensuring transparency in private sector engagement, supporting context-specific data collection, and effectively managing the CDoH. A system thinking approach can enhance the implementation of complex public health interventions

PET/CT Scanner and Bone Marrow Biopsy in Detection of Bone Marrow Involvement in Diffuse Large B-Cell Lymphoma.

Evaluation of bone marrow involvement (BMI) is paramount in diffuse large B-cell lymphoma (DLBCL) for prognostic and therapeutic reasons. PET/CT scanner (PET) is now a routine examination for the staging of DLBCL with prognostic and therapeutic implications. This study evaluates the role of PET for detecting marrow involvement compared to bone marrow biopsy (BMB). This monocentric study included 54 patients diagnosed with DLBCL between 2009 and 2013 and who had FDG PET/CT in a pre-treatment setting. A correlation analysis of the detection of BMI by PET and BMB was performed. A prognostic evaluation of BMI by BMB and/or PET/CT and correlation with an overall 2-year survival were analyzed. PET was more sensitive for the detection of BMI than BMB (92.3% vs. 38.5%). It can be considered a discriminatory Pre-BMB test with a negative predictive value of 97.6%. In addition, BMI by PET had a prognostic value with strong correlation with progression-free survival (PFS) (HR = 3.81; p = 0.013) and overall survival (OS) (HR = 4.12; p = 0.03) while the BMB had not. PET shows superior performance to the BMB for the detection of marrow involvement in DLBCL. It may be considered as the first line examination of bone marrow instead of the biopsy

Dynamics of non-communicable disease prevention, diagnosis and control in Lebanon, a fragile setting

From Springer Nature via Jisc Publications RouterKarin Diaconu - ORCID: 0000-0002-5810-9725 https://orcid.org/0000-0002-5810-9725Abstract: Background: Non-communicable diseases (NCD) present an increasing global health challenge, particularly for settings affected by fragility where access to care may be disrupted, and where high-quality continuous care delivery is difficult to achieve. This study documents the complex dynamics of NCD prevention and management in the fragile setting of rural Beqaa, Lebanon. Methods: Participatory system dynamics methods were used, including 30 semi-structured interviews and three Group Model Building (GMB) workshops. Participants included health care providers offering NCD care, and Lebanese host- and Syrian refugees community members affected by NCDs. Results: Participants across all groups articulated a shared complex understanding of both the structural and direct determinants behind NCD onset. Lebanese and Syrian community members further identified several barriers to health seeking, including restrictions in health coverage, limited availability of services in the Beqaa and perceptions of poor-quality care. Health providers and community members described a health system overtly focused on disease control and overwhelmed by delivery of care to people living with NCD across both communities. Conclusion: Participants across all groups agreed on the need for health promotion and primary prevention activities and identified priority interventions in these areas.This research was funded by the National Institute for Health Research (NIHR) Global Health Research programme 16/136/100.The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health and Social Care.15pubpu

Evaluating the governance and preparedness of the Lebanese health system for the COVID-19 pandemic: a qualitative study

From BMJ via Jisc Publications RouterHistory: received 2021-10-29, accepted 2022-05-16, ppub 2022-06, epub 2022-06-01Publication status: PublishedFunder: World Health Organization; FundRef: http://dx.doi.org/10.13039/100004423; Grant(s): 2002577199Objectives: This study aimed to assess the capacities and governance of Lebanon’s health system throughout the response to the COVID-19 pandemic until August 2020. Design: A qualitative study based on semi-structured interviews. Setting: Lebanon, February–August 2020. Participants: Selected participants were directly or indirectly involved in the national or organisational response to the COVID-19 pandemic in Lebanon. Results: A total of 41 participants were included in the study. ‘Hardware’ capacities of the system were found to be responsive yet deeply influenced by the challenging national context. The health workforce showed high levels of resilience, despite the shortage of medical staff and gaps in training at the early stages of the pandemic. The system infrastructure, medical supplies and testing capacities were sufficient, but the reluctance of the private sector in care provision and gaps in reimbursement of COVID-19 care by many health funding schemes were the main concerns. Moreover, the public health surveillance system was overwhelmed a few months after the start of the pandemic. As for the system ‘software’, there were attempts for a participatory governance mechanism, but the actual decision-making process was challenging with limited cooperation and strategic vision, resulting in decreased trust and increased confusion among communities. Moreover, the power imbalance between health actors and other stakeholders affected decision-making dynamics and the uptake of scientific evidence in policy-making. Conclusions: Interventions adopting a centralised and reactive approach were prominent in Lebanon’s response to the COVID-19 pandemic. Better public governance and different reforms are needed to strengthen the health system preparedness and capacities to face future health security threats

Evolution and lessons from an integrated service delivery network in North West Syria

From Springer Nature via Jisc Publications RouterHistory: received 2022-10-14, registration 2023-03-15, accepted 2023-03-15, epub 2023-03-24, online 2023-03-24, collection 2023-12Acknowledgements: This study is a collaboration between the World Health Organization (WHO) Field Presence in Gaziantep and Queen Margaret University, Edinburgh, with support from Rebuild for Resilience and the Alliance for Health Policy and Systems Research, WHO HQ. We would also like to acknowledge the perspectives of all informants and the work of UDER in data gathering in north west Syria.Publication status: PublishedFunder: WHO Euro/GaziantepSophie Witter - ORCID: 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Karin Diaconu - ORCID: 0000-0002-5810-9725 https://orcid.org/0000-0002-5810-9725Ibrahim Bou-Orm - ORCID: 0000-0003-3563-4014 https://orcid.org/0000-0003-3563-4014Zeina Jamal - ORCID: 0000-0002-5078-3416 https://orcid.org/0000-0002-5078-3416Background: Northwest Syria (NWS) is a complex and extremely fragile operating environment, with more than 2.8 million people needing humanitarian assistance. To support a common standard of care delivery and enable coordination among the multiple providers in NWS, WHO developed an Essential Health Services package (EHSP) in 2016-17 and subsequently supported a facility network model to deliver the EHSP. This article provides an evaluation of the network to date, aiming to inform further development of the network and draw wider lessons for application of similar approaches in complex emergency settings. Methods: This mixed method study included document review, participatory, qualitative and quantitative data, gathered in the first half of 2021. Participatory data came from two group model building workshops with 21 funders and implementers. Semi-structured interviews with 81 funders, health professionals and community members were also conducted. Analyses of the workshops and interviews was inductive, however a deductive approach was used for synthesising insights across this and the document review. The final component was a survey of health providers (59 health care professionals) and service users (233 pregnant women and 214 persons living with NCDs) across network and other comparable facilities, analysed using routine descriptive and inferential statistics. Findings across all methods were triangulated. Results: The study finds that the network and its accompanying essential service package were relevant to the dynamic and challenging context, with high but shifting population needs and multiple uncoordinated providers. Judged in relation to its original goals of comprehensive, coordinated services, equitable access and efficient service delivery, the data indicate that gains have been made in all three areas through the network, although attribution is challenging, given the complex environment. The context remains challenging, with shifting boundaries and populations displaced by conflict, difficulties in retaining staff, the need to import medicines and supplies across borders, and governance gaps. Conclusion: This study adds to a very limited literature on coordinated network approaches used to raise care quality and improve referrals and efficiency in a complex emergency setting. Although areas of ongoing challenge, including for sustainability, are noted, the network demonstrated some resilience strategies and can provide lessons for other similar contexts.pubpu

Understanding fragility: Implications for global health research and practice

Karin Diaconu - ORCID 0000-0002-5810-9725 https://orcid.org/0000-0002-5810-9725Sophie Witter - ORCID 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Advances in population health outcomes risk being slowed—and potentially reversed—by a range of threats increasingly presented as ‘fragility’. Widely used and critiqued within the development arena, the concept is increasingly used in the field of global health, where its relationship to population health, health service delivery, access and utilization is poorly specified. We present the first scoping review seeking to clarify the meaning, definitions and applications of the term in the global health literature. Adopting the theoretical framework of concept analysis, 10 bibliographic and grey literature sources, and five key journals, were searched to retrieve documents relating to fragility and health. Reviewers screened titles and abstracts and retained documents applying the term fragility in relation to health systems, services, health outcomes and population or community health. Data were extracted according to the protocol; all documents underwent bibliometric analysis. Narrative synthesis was then used to identify defining attributes of the concept in the field of global health. A total of 377 documents met inclusion criteria. There has been an exponential increase in applications of the concept in published literature over the last 10 years. Formal definitions of the term continue to be focused on the characteristics of ‘fragile and conflict-affected states’. However, synthesis indicates diverse use of the concept with respect to: level of application (e.g. from state to local community); emphasis on particular antecedent stressors (including factors beyond conflict and weak governance); and focus on health system or community resources (with an increasing tendency to focus on the interface between two). Amongst several themes identified, trust is noted as a key locus of fragility at this interface, with critical implications for health seeking, service utilization and health system and community resilience.This research was funded by the National Institute for Health Research (NIHR) Global Health Research Programme 16/136/100. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health.https://doi.org/10.1093/heapol/czz14235pubpub