Introduction
Mandated by the United Nations (UN) General Assembly, the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) started its operations in 1950. It provides humanitarian assistance and protection to the registered Palestine refugees in the five fields, including West Bank, Jordan, Lebanon, the Gaza Strip and Syria. Funded entirely by voluntary contributions by different donors, UNRWA’s humanitarian services and human development encompass education, primary healthcare, relief and social services, camp improvement and emergency response in situations of armed conflict. It is the main primary healthcare provider for Palestine refugees.1 2 Palestine refugees represent the largest refugee population in the world.2
UNRWA has been providing healthcare for patients with diabetes mellitus and hypertension (DM&HTN) in its health centers (HC) since 1992. UNRWA’s diabetes care includes screening of high-risk groups, diagnosis and treatment. In 2014, UNRWA had more than 231 000 registered Palestine refugee patients with non-communicable disease (NCD). The increased burden of NCDs presents a tremendous challenge for the agency accounting for 41% of its total budget spent on medications. With an ageing population, the primary challenge is no longer communicable diseases; rather, it is actually in dealing with comorbidities associated with NCDs.DM, cardiovascular diseases and other NCDs are now responsible for 70.0% of deaths in UNRWA’s population.2
Heart diseases, cerebrovascular diseases, and cancers are the major causes of morbidity and mortality for the population in occupied Palestinian territory and some of the neighborhood countires.3 According to UNRWA’s 2014 records, the prevalence of diabetes among the general population where Palestine refugees live is known to be 10.1% in Jordan; 7.8% in Lebanon; 8.6% in Palestine; and 10.8% in Syria.4 The urbanization and continuing nutritional change from a healthy Mediterranean diet to an increasingly Western-style diet are associated with a decrease in physical activity, obesity, and a loss of the traditional diet benefits.4 As seen throughout all of UNRWA’s areas of operation, specifically for Palestine refugees, they experience a high level of stress due to many environmental stressors: the ongoing political tension and conflict, lack of security, high rate of unemployment, and poor infrastructure in refugee camps. Consequently, there has also been a rise in NCDs, especially diabetes, HTN, and mental disorders.3
Obesity is recognized as one of the most important risk factors for DMII, as it induces insulin resistance and pancreatic beta-cell dysfunction.5 Studies have demonstrated that lifestyle interventions are successful in leading to weight loss in patients with diabetes.6 There are different challenges that UNRWA faces when dealing with diabetes care,1 2 therefore, to acquire information on the diabetes care in the UNRWA HC, the agency has performed a clinical audit in 2012. It was revealed from this clinical audit that over 90% of patients with DM are overweight or obese, with the majority (64%) being obese. UNRWA’s clinical audit had recommended many action steps to be taken, such as: developing a comprehensive package of lifestyle support activities that can be implemented in HCs at no additional cost. It also recommended that UNRWA should change the involvement of nurses and paramedical staff in diabetes care delivery to be more proactive, in order to improve health promotion, education and adherence.7
Responding to the above results, in 2013 UNRWA’s health department embarked on a campaign titled ‘Life is Sweeter with Less Sugar’ which aimed to assist both patients and healthcare providers in changing their attitude and behavior to prevent and control diabetes among Palestine refugees attending UNRWA HCs. Additionally, within Palestine refugee camps, it included efforts to raise the local community’s awareness of the risk factors that can lead to one’s development of diabetes and stressed the importance of healthy lifestyle practices. Funded by the World Diabetes Foundation, this campaign consisted of two prongs: first, outreach and screening activities for detecting new cases of diabetes within the local community; and second, conducting educational group sessions for the registered patients with DM at UNRWA HCs in Jordan, West Bank, Gaza and Lebanon. Also, on a weekly basis for 6 months, 30 HCs conducted educational, healthy cooking, and exercise group sessions for its local communities.
Body measurements, blood tests, and patients’ attendance records were collected monthly. There were 1174 (951 females, 223 males) who completed the diabetes campaign (out of 1300 who were recruited). After the campaign, 185 (16%) lost ≥5%, 226 (22%) has lost between 3% and 5% and 377 (33%) has lost between 1% and 3% of their weight. Waist circumference (WC) mean decreased from 108.5±13.1 cm to 106±13.2 cm with (−2.6±4.9 cm) reduction in the total mean. Also, significant improvements were seen in blood glucose and cholesterol (p<0.001).8
Social networks play a strong role in people’s health behavior, especially in a refugee camp setting. Since diabetes management requires behavioral changes and adherence to healthy lifestyle practices, social support is considered to be one of the influential and important factors for performing self-care and for adherence to the treatment and disease control.9 In order to validate this model of care delivery in refugee camps, UNRWA’s health department has expanded this campaign and replicated it in 32 UNRWA HCs, with the objectives of improving the cardiometabolic risk factors, knowledge and lifestyle behaviors of diabetes care management among Palestine refugees with DM, and enhancing the capacity and technical skills of UNRWA’s health staff for better delivery of diabetes care management to the Palestine refugees who attend UNRWA HCs.