Care utilization and adherence to medication for hypertension and diabetes among Syrian refugees and host communities in Lebanon

The influx of over one million Syrian refugees to Lebanon brought enormous demands on the country’s health system. Despite some success in facilitating access to care for highly prevalent non-communicable diseases (NCDs), evidence is needed to tailor interventions to meet chronic health needs of Syrian refugees and host communities in Lebanon. To this end, this dissertation assesses healthcare utilization and medication adherence for hypertension and diabetes among Syrian refugees and host communities in Lebanon. Paper 1 assesses care-seeking, spending, and medication adherence using data from a 2015 household survey of Syrian refugees and Lebanese host communities. Papers 2 and 3 explore care visit frequency and medication adherence, respectively, in greater depth using baseline data from a longitudinal cohort study of care-seekers at primary health facilities in Lebanon. Descriptive analyses reveal material gaps between refugees and host communities in care utilization, out-of-pocket costs, and medication interruption. At the population level, care-seeking and uninterrupted medication adherence for hypertension and diabetes are high. Qualitative findings reveal potentially insufficient GP training and uncertainty about the NCD care quality at primary health facilities. Despite low rates of medication interruption for two weeks or longer in quantitative findings, non-adherence was widely reported during focus group discussions for shorter durations than captured quantitatively and suggest refinements to improve the quantitative measure’s reliability in this context. Few refugee household characteristics were associated with individuals’ care-seeking and medication adherence. Individual level analyses among refugees indicate that for diabetes, older age and housing stability are associated with higher care-seeking and lower odds of medication interruption. For hypertension, housing stability was also associated with higher care-seeking rates and reduced odds of medication interruption. Although care-seeking is high, there are opportunities to improve service utilization and medication adherence by these populations. Current programs may sustain high care-seeking rates; however, continued efforts are needed to inform refugees of available services. Expansion of alternative payment arrangements, increased use of community health workers and refugee outreach volunteers, and quality improvement via large-scale health provider training and collaborative care models could strengthen current initiatives to improve NCD management in Lebanon

Internal displacement and the Syrian crisis: an analysis of trends from 2011–2014

BACKGROUND: Since the start of the Syrian crisis in 2011, civil unrest and armed conflict in the country have resulted in a rapidly increasing number of people displaced both within and outside of Syria. Those displaced face immense challenges in meeting their basic needs. This study sought to characterize internal displacement in Syria, including trends in both time and place, and to provide insights on the association between displacement and selected measures of household well-being and humanitarian needs. METHODS: This study presents findings from two complementary methods: a desk review of displaced population estimates and movements and a needs assessment of 3930 Syrian households affected by the crisis. The first method, a desk review of displaced population estimates and movements, provides a retrospective analysis of national trends in displacement from March 2011 through June 2014. The second method, analysis of findings from a 2014 needs assessment by displacement status, provides insight into the displaced population and the association between displacement and humanitarian needs. RESULTS: Findings indicate that while displacement often corresponds to conflict levels, such trends were not uniformly observed in governorate-level analysis. Governorate level IDP estimates do not provide information on a scale detailed enough to adequately plan humanitarian assistance. Furthermore, such estimates are often influenced by obstructed access to certain areas, unsubstantiated reports, and substantial discrepancies in reporting. Secondary displacement is not consistently reported across sources nor are additional details about displacement, including whether displaced individuals originated within the current governorate or outside of the governorate. More than half (56.4 %) of households reported being displaced more than once, with a majority displaced for more than one year (73.3 %). Some differences between displaced and non-displaced population were observed in residence crowding, food consumption, health access, and education. CONCLUSIONS: Differences in reported living conditions and key health, nutrition, and education indicators between displaced and non-displaced populations indicate a need to better understand migration trends in order to inform planning and provision of live saving humanitarian assistance

Comparison of Heterologous Prime-Boost Strategies against Human Immunodeficiency Virus Type 1 Gag Using Negative Stranded RNA Viruses.

This study analyzed a heterologous prime-boost vaccine approach against HIV-1 using three different antigenically unrelated negative-stranded viruses (NSV) expressing HIV-1 Gag as vaccine vectors: rabies virus (RABV), vesicular stomatitis virus (VSV) and Newcastle disease virus (NDV). We hypothesized that this approach would result in more robust cellular immune responses than those achieved with the use of any of the vaccines alone in a homologous prime-boost regimen. To this end, we primed BALB/c mice with each of the NSV-based vectors. Primed mice were rested for thirty-five days after which we administered a second immunization with the same or heterologous NSV-Gag viruses. The magnitude and quality of the Gag-specific CD8(+) T cells in response to these vectors post boost were measured. In addition, we performed challenge experiments using vaccinia virus expressing HIV-1 Gag (VV-Gag) thirty-three days after the boost inoculation. Our results showed that the choice of the vaccine used for priming was important for the detected Gag-specific CD8(+) T cell recall responses post boost and that NDV-Gag appeared to result in a more robust recall of CD8(+) T cell responses independent of the prime vaccine used. However, the different prime-boost strategies were not distinct for the parameters studied in the challenge experiments using VV-Gag but did indicate some benefits compared to single immunizations. Taken together, our data show that NSV vectors can individually stimulate HIV-Gag specific CD8(+) T cells that are effectively recalled by other NSV vectors in a heterologous prime-boost approach. These results provide evidence that RABV, VSV and NDV can be used in combination to develop vaccines needing prime-boost regimens to stimulate effective immune responses

Concert recording 2019-10-27

[Track 1]. Now sleeps the crimson petal / Roger Quilter -- [Track 2]. Ideale / Paolo Tosti -- [Track 3]. Intorno all\u27idol mio / Anthony Cesti -- [Track 4]. Chanson triste / Henri Duparc -- [Track 5]. Son tutta duolol / Alessandro Scarlatti -- [Track 6]. Aprile / P. Tosti -- [Track 7]. Ah, love, but a day! / Amy Beach -- [Track 8]. So shall the lute and harp awake from An Oratorio-Judas Maccebaeus / George Frideric Handel -- [Track 9]. Come again / John Dowland -- [Track 10]. Der kuss / Ludwig van Beethoven -- [Track 11]. An Chloe / W. A. Mozart -- [Track 12]. Auf dem Wasser zu singen / Franz Schubert --[Track 13]. Allerseelen / Richard Strauss -- [Track 14]. I never saw another butterfly. II. Yes, that\u27s the way things are ; [Track 15]. III. Birdsong / Lori Laitman -- [Track 16]. Je dis que rien m\u27epouvante from Carmen / Georges Bizet -- [Track 17]. Che gelinda manina from La Boheme / Giacomo Puccini -- [Track 18]. Kristine Mezines, piano Granada / Agustin Lara -- [Track 19]. My name from Eve-Song / Jake Heggie -- [Track 20]. Do not go, my love / Richard Hageman

Care utilization and adherence to medication for hypertension and diabetes among Syrian refugees and host communities in Lebanon

The influx of over one million Syrian refugees to Lebanon brought enormous demands on the country’s health system. Despite some success in facilitating access to care for highly prevalent non-communicable diseases (NCDs), evidence is needed to tailor interventions to meet chronic health needs of Syrian refugees and host communities in Lebanon. To this end, this dissertation assesses healthcare utilization and medication adherence for hypertension and diabetes among Syrian refugees and host communities in Lebanon. Paper 1 assesses care-seeking, spending, and medication adherence using data from a 2015 household survey of Syrian refugees and Lebanese host communities. Papers 2 and 3 explore care visit frequency and medication adherence, respectively, in greater depth using baseline data from a longitudinal cohort study of care-seekers at primary health facilities in Lebanon. Descriptive analyses reveal material gaps between refugees and host communities in care utilization, out-of-pocket costs, and medication interruption. At the population level, care-seeking and uninterrupted medication adherence for hypertension and diabetes are high. Qualitative findings reveal potentially insufficient GP training and uncertainty about the NCD care quality at primary health facilities. Despite low rates of medication interruption for two weeks or longer in quantitative findings, non-adherence was widely reported during focus group discussions for shorter durations than captured quantitatively and suggest refinements to improve the quantitative measure’s reliability in this context. Few refugee household characteristics were associated with individuals’ care-seeking and medication adherence. Individual level analyses among refugees indicate that for diabetes, older age and housing stability are associated with higher care-seeking and lower odds of medication interruption. For hypertension, housing stability was also associated with higher care-seeking rates and reduced odds of medication interruption. Although care-seeking is high, there are opportunities to improve service utilization and medication adherence by these populations. Current programs may sustain high care-seeking rates; however, continued efforts are needed to inform refugees of available services. Expansion of alternative payment arrangements, increased use of community health workers and refugee outreach volunteers, and quality improvement via large-scale health provider training and collaborative care models could strengthen current initiatives to improve NCD management in Lebanon

Racial/ethnic workplace discrimination: association with tobacco and alcohol use.

BackgroundExperiences of discrimination are associated with tobacco and alcohol use, and work is a common setting where individuals experience racial/ethnic discrimination. Few studies have evaluated the association between workplace discrimination and these behaviors, and none have described associations across race/ethnicity.PurposeTo examine the association between workplace discrimination and tobacco and alcohol use in a large, multistate sample of U.S. adult respondents to the Behavioral Risk Factor Surveillance System survey Reactions to Race Module (2004-2010).MethodsMultivariable logistic regression analyses evaluated cross-sectional associations between self-reported workplace discrimination and tobacco (current and daily smoking) and alcohol use (any and heavy use, and binge drinking) among all participants and stratified by race/ethnicity, adjusting for relevant covariates. Data were analyzed in 2013.ResultsAmong respondents, 70,080 completed the workplace discrimination measure. Discrimination was more common among black non-Hispanic (21%), Hispanic (12%), and other race respondents (11%) than white non-Hispanics (4%) (p<0.001). In the total sample, discrimination was associated with current smoking (risk ratio [RR]=1.32, 95% CI=1.19, 1.47), daily smoking (RR=1.41, 95% CI=1.24, 1.61), and heavy drinking (RR=1.11, 95% CI=1.01, 1.22), but not binge or any drinking. Among Hispanics, workplace discrimination was associated with increased heavy and binge drinking, but not any alcohol use or smoking. Workplace discrimination among black non-Hispanics and white Non-Hispanics was associated with increased current and daily smoking, but not alcohol outcomes.ConclusionsWorkplace discrimination is common, associated with smoking and alcohol use, and merits further policy attention, given the impact of these behaviors on morbidity and mortality

Racial/ethnic workplace discrimination: association with tobacco and alcohol use.

BackgroundExperiences of discrimination are associated with tobacco and alcohol use, and work is a common setting where individuals experience racial/ethnic discrimination. Few studies have evaluated the association between workplace discrimination and these behaviors, and none have described associations across race/ethnicity.PurposeTo examine the association between workplace discrimination and tobacco and alcohol use in a large, multistate sample of U.S. adult respondents to the Behavioral Risk Factor Surveillance System survey Reactions to Race Module (2004-2010).MethodsMultivariable logistic regression analyses evaluated cross-sectional associations between self-reported workplace discrimination and tobacco (current and daily smoking) and alcohol use (any and heavy use, and binge drinking) among all participants and stratified by race/ethnicity, adjusting for relevant covariates. Data were analyzed in 2013.ResultsAmong respondents, 70,080 completed the workplace discrimination measure. Discrimination was more common among black non-Hispanic (21%), Hispanic (12%), and other race respondents (11%) than white non-Hispanics (4%) (p<0.001). In the total sample, discrimination was associated with current smoking (risk ratio [RR]=1.32, 95% CI=1.19, 1.47), daily smoking (RR=1.41, 95% CI=1.24, 1.61), and heavy drinking (RR=1.11, 95% CI=1.01, 1.22), but not binge or any drinking. Among Hispanics, workplace discrimination was associated with increased heavy and binge drinking, but not any alcohol use or smoking. Workplace discrimination among black non-Hispanics and white Non-Hispanics was associated with increased current and daily smoking, but not alcohol outcomes.ConclusionsWorkplace discrimination is common, associated with smoking and alcohol use, and merits further policy attention, given the impact of these behaviors on morbidity and mortality

Simplified treatment protocols improve recovery of children with severe acute malnutrition in South Sudan: results from a mixed methods study

Abstract Background As part of COVID-19 mitigation strategies, emergency nutrition program adaptations were implemented, but evidence of the effects is limited. Compared to the standard protocol, the full adapted protocol included adapted admissions criteria, simplified dosing, and reduced visit frequency; partially adapted protocols consisting of only some of these modifications were also implemented. To enable evidence-based nutrition program modifications as the context evolved, this study was conducted to characterize how protocol adaptations in South Sudan affected Outpatient Therapeutic Feeding Program outcomes. Methods A mixed methods approach consisting of secondary analysis of individual-level nutrition program data and key informant interviews was used. Analyses focused on program implementation and severe acute malnutrition treatment outcomes under the standard, full COVID-19 adapted, and partially adapted treatment protocols from 2019 through 2021. Analyses compared characteristics and outcomes by different admission types under the standard protocol and across four different treatment protocols. Regression models evaluated the odds of recovery and mean length of stay (LoS) under the four protocols. Results Very few (1.6%; n = 156) children admitted based on low weight-for-height alone under the standard protocol would not have been eligible for admission under the adapted protocol. Compared to the full standard protocol, the partially adapted (admission only) and partially adapted (admission and dosing) protocols had lower LoS of 28.4 days (CI − 30.2, − 26.5) and 5.1 days (CI − 6.2, − 4.0); the full adapted protocol had a decrease of 3.0 (CI − 5.1, − 1.0) days. All adapted protocols had significantly increased adjusted odds ratios (AOR) for recovery compared to the full standard protocol: partially adapted (admission only) AOR = 2.56 (CI 2.18–3.01); partially adapted (admission + dosing) AOR = 1.78 (CI 1.45–2.19); and fully adapted protocol AOR = 2.41 (CI 1.69–3.45). Conclusions This study provides evidence that few children were excluded when weight-for-height criteria were suspended. LoS was shortest when only MUAC was used for entry/exit but dosing and visit frequency were unchanged. Significantly shorter LoS with simplified dosing and visit frequency vs. under the standard protocol indicate that protocol adaptations may lead to shorter recovery and program enrollment times. Findings also suggest that good recovery is achievable with reduced visit frequency and simplified dosing