This week in BMC Health Services Research, Ansbro et al. describe their experiences with adapting the RE-AIM framework to assess the Médecins Sans Frontières NCD care program for Syrian refugees and vulnerable Jordanians in Jordan. James Edwards, Senior Assistant Editor, tells us more about the study and what health care researchers working in humanitarian crisis situations can learn from this study for future programs.

Non-communicable diseases (NCDs) like cardiovascular disease and diabetes are the leading cause of death worldwide. Increasing volumes of NCDs in low and middle income countries (LMICs) now account for most of the recent growth in the global NCD burden.

At the same time, increasing humanitarian crises in LMICs have resulted in the global displacement of people reaching record levels, with the average duration of displacement now exceeding 20 years. Until recently, the problem of NCDs in conflict-affected populations was largely neglected. With growing awareness of the challenges that NCDs pose in humanitarian institutions, clinical guidelines for the chronic management of NCDs in LMICs have been developed.

Since 2014 the non-governmental organization (NGO) Médecins Sans Frontières (MSF) has supported the Jordanian health system by providing primary-level multidisciplinary NCD care to Syrian refugees and vulnerable Jordanians living in Irbid, Jordan. This week in BMC Health Services Research, Ansbro et al. Describe your experience with MSF and adapt the RE-AIM framework to evaluate MSF’s NCF nursing program.

RE-AIM is a framework that consists of five elements: Scope, effectiveness, adoption, implementation and maintenance. The framework was originally developed to encourage program planners, evaluators, funders and policymakers to focus more on key program elements, improve sustainable uptake, and promote the implementation of effective, generalizable, evidence-based interventions. In this study, Ansbro used mixed methods et al. The RE-AIM examined five key elements of the MSD Syrian Refugee NCD program.

Image source: Ory et al. (2015)

Reach, Effectiveness, and Adoption

Most areas of the program were deemed acceptable to patients, staff, and stakeholders. Although care was free, patients were burdened with indirect costs such as paying for transportation to visit clinics, which may outweigh the benefits of “free” care.

The program achieved good clinical results in the treatment of patients with high blood pressure and diabetes. However, more research is needed in the future using longer follow-up periods to understand the prevalence or outcomes of serious complications in NCDs.


A central challenge for implementation was the influence of Syrian patients’ experiences of war, loss and social suffering on their commitment to NCD care. Staff also shared concerns that they could not cope with medical problems in isolation from patients ‘psychosocial problems and felt ill-equipped to deal with patients’ war-related trauma.

Patients and staff also reported that referral routes for specialized services were problematic and confusing. Funding for specific referral channels was limited, although MSF was able to raise additional funding. This underscores the need for future programs to securely implement specific remittance routes and ensure they are affordable and accessible from the start.


A key challenge to maintaining the program was cost. High costs were partly responsible for the limited scope and scope of the program. There is room for customization, however. For example, MSF introduced the division of duties for nurses, which could lead to cost savings.

Another challenge is the availability of highly qualified family medicine specialists for the treatment of patients with complex needs. While MSF had access to a large number of highly qualified Jordanian staff on this occasion, this is often not the case in all humanitarian crisis situations. This problem is difficult to solve, but the authors suggest possible workarounds such as telemedicine as a possible solution for future programs.

Research in humanitarian crisis situations is extremely difficult. Governments and humanitarian agencies face major challenges not only in effectively controlling NCDs in LMICs, but also in assessing interventions in humanitarian agencies. However, this study has shown that RE-AIM is a valuable tool for managing complex interventions in humanitarian crisis situations. Ansbro et al. Bridging a knowledge gap in the provision of care in humanitarian institutions. However, more research is urgently needed to strengthen the NCD response in humanitarian crisis situations. Future programs must focus on simplifying models of care, reducing costs, and leveraging telemedicine resources.


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