Clinical outcomes in a primary-level non-communicable disease programme for Syrian refugees and the host population in Jordan: A cohort analysis using routine data.

BACKGROUND: Little is known about the content or quality of non-communicable disease (NCD) care in humanitarian settings. Since 2014, Médecins Sans Frontières (MSF) has provided primary-level NCD services in Irbid, Jordan, targeting Syrian refugees and vulnerable Jordanians who struggle to access NCD care through the overburdened national health system. This retrospective cohort study explored programme and patient-level patterns in achievement of blood pressure and glycaemic control, patterns in treatment interruption, and the factors associated with these patterns. METHODS AND FINDINGS: The MSF multidisciplinary, primary-level NCD programme provided facility-based care for cardiovascular disease, diabetes, and chronic respiratory disease using context-adapted guidelines and generic medications. Generalist physicians managed patients with the support of family medicine specialists, nurses, health educators, pharmacists, and psychosocial and home care teams. Among the 5,045 patients enrolled between December 2014 and December 2017, 4,044 eligible adult patients were included in our analysis, of whom 72% (2,913) had hypertension and 63% (2,546) had type II diabetes. Using visits as the unit of analysis, we plotted the following on a monthly basis: mean blood pressure among hypertensive patients, mean fasting blood glucose and HbA1c among type II diabetic patients, the proportion of each group achieving control, mean days of delayed appointment attendance, and the proportion of patients experiencing a treatment interruption. Results are presented from programmatic and patient perspectives (using months since programme initiation and months since cohort entry/diagnosis, respectively). General linear mixed models explored factors associated with clinical control and with treatment interruption. Mean age was 58.5 years, and 60.1% (2,432) were women. Within the programme's first 6 months, mean systolic blood pressure decreased by 12.4 mm Hg from 143.9 mm Hg (95% CI 140.9 to 146.9) to 131.5 mm Hg (95% CI 130.2 to 132.9) among hypertensive patients, while fasting glucose improved by 1.12 mmol/l, from 10.75 mmol/l (95% CI 10.04 to 11.47) to 9.63 mmol/l (95% CI 9.22 to 10.04), among type II diabetic patients. The probability of achieving treatment target in a visit was 63%-75% by end of 2017, improving with programme maturation but with notable seasonable variation. The probability of experiencing a treatment interruption declined as the programme matured and with patients' length of time in the programme. Routine operational data proved useful in evaluating a humanitarian programme in a real-world setting, but were somewhat limited in terms of data quality and completeness. We used intermediate clinical outcomes proven to be strongly associated with hard clinical outcomes (such as death), since we had neither the data nor statistical power to measure hard outcomes. CONCLUSIONS: Good treatment outcomes and reasonable rates of treatment interruption were achieved in a multidisciplinary, primary-level NCD programme in Jordan. Our approach to using continuous programmatic data may be a feasible way for humanitarian organisations to account for the complex and dynamic nature of interventions in unstable humanitarian settings when undertaking routine monitoring and evaluation. We suggest that frequency of patient contact could be reduced without negatively impacting patient outcomes and that season should be taken into account in analysing programme performance

MSF experiences of providing multidisciplinary primary level NCD care for Syrian refugees and the host population in Jordan: an implementation study guided by the RE-AIM framework.

BACKGROUND: In response to the rising global NCD burden, humanitarian actors have rapidly scaled-up NCD services in crisis-affected low-and-middle income countries. Using the RE-AIM implementation framework, we evaluated a multidisciplinary, primary level model of NCD care for Syrian refugees and vulnerable Jordanians delivered by MSF in Irbid, Jordan. We examined the programme's Reach, Effectiveness, Adoption and acceptance, Implementation and Maintenance over time. METHODS: This mixed methods retrospective evaluation, undertaken in 2017, comprised secondary analysis of pre-existing cross-sectional household survey data; analysis of routine cohort data from 2014 to 2017; descriptive costing analysis of total annual, per-patient and per-consultation costs for 2015-2017 from the provider-perspective; a clinical audit; a medication adherence survey; and qualitative research involving thematic analysis of individual interviews and focus group discussions. RESULTS: The programme enrolled 23% of Syrian adult refugees with NCDs in Irbid governorate. The cohort mean age was 54.7 years; 71% had multi-morbidity and 9.9% self-reported a disability. The programme was acceptable to patients, staff and stakeholders. Blood pressure and glycaemic control improved as the programme matured and by 6.6 mmHg and 1.12 mmol/l respectively within 6 months of patient enrolment. Per patient per year cost increased 23% from INT$1424 (2015) to 1751 (2016), and by 9$ 209 to 253 (2015-2017). Staff reported that clinical guidelines were usable and patients' self-reported medication adherence was high. Individual, programmatic and organisational challenges to programme implementation and maintenance included the impact of war and the refugee experience on Syrian refugees' ability to engage; inadequate low-cost referral options; and challenges for MSF to rapidly adapt to operating in a highly regulated and complex health system. Essential programme adaptations included refinement of health education, development of mental health and psychosocial services and addition of essential referral pathways, home visit, physiotherapy and social worker services. CONCLUSION: RE-AIM proved a valuable tool in evaluating a complex intervention in a protracted humanitarian crisis setting. This multidisciplinary programme was largely acceptable, achieving good clinical outcomes, but for a limited number of patients and at relatively high cost. We propose that model simplification, adapted procurement practices and use of technology could improve cost effectiveness without reducing acceptability, and may facilitate replication

NEWS DISCOURSE ON THE 212 SOCIAL MOVEMENTS: CRITICAL DISCOURSE ANALYSIS ON REPUBLIKA AND MEDIA INDONESIA

The 3rd Defend Islam Action incident on Friday, December 2, 2016, was the biggest rally after the 1998 protest rally. This action created two camps, i.e. supporters of DKI Jakarta Governor, Basuki Tjahaja Purnama, and the camp who demanded his detention. This condition could be seen in mass media news, including in the Media Indonesia newspaper owned by Surya Paloh, Chairman of the National Democratic Party, who supports Basuki Tjahaja Purnama and also in the Republika newspaper which promotes the interests of Muslims. The focus of this study is the existence of different discourses on the news of this 3rd Defend Islam Action. These differences are the result of the interests and ideology of the two media. Media Indonesia’s news discourse did not support the action. On the contrary, Republika pushed for it to be carried out. This study uses the public sphere and hegemony theory which is able to see that in the news text both media have their own interests and ideologies. This study used a critical paradigm with a qualitative descriptive method. Teun Van Dijk's critical discourse analysis model was used in this study. The results of this study indicate that the news coverages of the 3rd Defend Islam Action produced by Media Indonesia and Republika were produced by their editorial staff based on the ideology and hidden interests of the media

A Performance Quality Index to Assess Professional Conduct of Contractors at Sustainable Construction Projects in Saudi Arabia

The quality performance of contractors in sustainable construction projects is a major concern for the industry. Over the past decade, studies on measurements, factors, and indicators for assessment of the professional conduct of construction companies are to be found in the sustainable construction management literature. There is adequate evidence over the last decade that an increasing number of construction professionals have adopted the measurement of the professional conduct of contractors as a tool to support their future decisions. The method of the Analytical Hierarchy (AHP) process has been deployed to identify the major factors and sub-factors involved in sustainable construction in Saudi Arabia. Using several governing factors, including quality of document submittals (QDS), quality system implementation (QSI), and quality of construction works (QCW), a working framework was developed by using the pair-wise comparison method. The results show that proper accountability and keen consideration of factors that could hinder sustainable construction by contractors contribute to the development of a better perspective on quality issues. After a critical analysis, a Performance Quality Index was developed, and a benchmark value was obtained. The benchmark value of PQI will assist project managers and owners in the sustainable construction sector as a reference for future improvement in the quality performance of contractors

Optimum Green Synthesis, Characterization, and Antibacterial Activity of Silver Nanoparticles Prepared from an Extract of Aloe fleurentinorum

The synthesis of metal nanoparticles through the use of plant extract is a process that is not only simple but also inexpensive, quick, and favorable to the environment. As a result, it is utilized in a wide variety of fields. When synthesizing silver nanoparticles (AgNPs), several different kinds of plant extracts were utilized. The manufacture of silver nanoparticles was carried out in this study using an environmentally friendly technique. The aqueous extract of the Aloe fleurentinorum plant was utilized as a stabilizing and reducing agent. To determine the optimal conditions for the synthesis of silver nanoparticles, it was necessary to investigate the impact of several parameters on the process. These parameters included the reactant volume ratio, pH values, temperature, and reaction time. To get crystallite and stable silver nanoparticles, an aqueous solution of AgNO3 (0.01M) was added to an aqueous extract of Aloe fleurentinorum plant at a temperature of 60 degrees Celsius and a pH of 8. The mixture was then stirred with a magnetic stirrer for ninety minutes (90 minutes). Using a variety of methods (UV-vis spectrophotometer, FTIR, XRD, SEM, EDX, and XPS), several approaches were utilized to investigate and describe the green-produced AgNPs. Through the use of the SEM method, it was demonstrated that the morphology of AgNPs is tetrahedral. It was determined using X-ray diffraction that the size of crystalline AgNPs was 26.7 nm. AgNPs that have been optimally synthesized have antibacterial properties that are both significant and effective against various bacterial species that have been tested at varying doses