The Effectiveness of Interventions for Non-Communicable Diseases in Humanitarian Crises: A Systematic Review

Abstract

Non-communicable diseases (NCDs) are of increasing concern in low- and middle-income countries (LMICs) affected humanitarian crises. Humanitarian agencies and governments are increasingly challenged with how to effectively tackle NCDs. Reviewing the evidence of interventions for NCDs in humanitarian crises can help guide future policies and research by identifying effective interventions and evidence gaps. The aim of this paper is to systematically review evidence on the effectiveness of interventions targeting NCDs during humanitarian crises in LMICs.

A systematic review methodology was followed using PRISMA standards. Studies were selected on NCD interventions with civilian populations affected by humanitarian crises in low- and middle-income countries. Five bibliographic databases and a range of grey literature sources were searched. Descriptive analysis was applied and a quality assessment conducted using the Newcastle-Ottawa Quality Assessment Scale for observational studies and the Cochrane Risk of Bias Tool for experimental studies.

The search yielded 4919 references of which 8 studies met inclusion criteria. Seven of the 8 studies were observational, and one study was a non-blinded randomised-controlled trial. Diseases examined included hypertension, heart failure, diabetes mellitus, chronic kidney disease, thalassaemia, and arthritis. Study settings included locations in the Middle East, Eastern Europe, and South Asia. Interventions featuring disease-management protocols and/or cohort monitoring demonstrated the strongest evidence of effectiveness. No studies examined intervention costs. The quality of studies was limited, with a reliance on observational study designs, limited use of control groups, biases associated with missing data and inadequate patient-follow-up, and confounding was poorly addressed.

The review highlights the extremely limited quantity and quality of evidence on this topic. Interventions that incorporate standardisation and facilitate patient follow-up appear beneficial. However, substantially more research is needed, including data on costs.

Full text

RESEARCH ARTICLE
The Effectiveness of Interventions for Non-
Communicable Diseases in Humanitarian
Crises: A Systematic Review
Alexander Ruby
1
, Abigail Knight
2
, Pablo Perel
3
, Karl Blanchet
2
, Bayard Roberts
1
*
1ECOHOST–The Centre for Health and Social Change, London School of Hygiene and Tropical Medicine,
London, United Kingdom, 2Faculty of Public Health and Policy, London School of Hygiene and Tropical
Medicine, London, United Kingdom, 3Centre for Global Non Communicable Diseases, London School of
Hygiene and Tropical Medicine, London, United Kingdom
*Bayard.Roberts@lshtm.ac.uk
Abstract
Background
Non-communicable diseases (NCDs) are of increasing concern in low- and middle-income
countries (LMICs) affected humanitarian crises. Humanitarian agencies and governments
are increasingly challenged with how to effectively tackle NCDs. Reviewing the evidence of
interventions for NCDs in humanitarian crises can help guide future policies and research
by identifying effective interventions and evidence gaps. The aim of this paper is to system-
atically review evidence on the effectiveness of interventions targeting NCDs during human-
itarian crises in LMICs.
Methods
A systematic review methodology was followed using PRISMA standards. Studies were
selected on NCD interventions with civilian populations affected by humanitarian crises in
low- and middle-income countries. Five bibliographic databases and a range of grey litera-
ture sources were searched. Descriptive analysis was applied and a quality assessment
conducted using the Newcastle-Ottawa Quality Assessment Scale for observational studies
and the Cochrane Risk of Bias Tool for experimental studies.
Results
The search yielded 4919 references of which 8 studies met inclusion criteria. Seven of the
8 studies were observational, and one study was a non-blinded randomised-controlled trial.
Diseases examined included hypertension, heart failure, diabetes mellitus, chronic kidney
disease, thalassaemia, and arthritis. Study settings included locations in the Middle East,
Eastern Europe, and South Asia. Interventions featuring disease-management protocols
and/or cohort monitoring demonstrated the strongest evidence of effectiveness. No
studies examined intervention costs. The quality of studies was limited, with a reliance on
PLOS ONE | DOI:10.1371/journal.pone.0138303 September 25, 2015 1/16
OPEN ACCESS
Citation: Ruby A, Knight A, Perel P, Blanchet K,
Roberts B (2015) The Effectiveness of Interventions
for Non-Communicable Diseases in Humanitarian
Crises: A Systematic Review. PLoS ONE 10(9):
e0138303. doi:10.1371/journal.pone.0138303
Editor: Tatsuo Shimosawa, The University of Tokyo,
JAPAN
Received: June 11, 2015
Accepted: August 28, 2015
Published: September 25, 2015
Copyright: © 2015 Ruby et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are
credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information files.
Funding: The work for this systematic review was
funded by the Research for Health in Humanitarian
Crises (R2HC) Programme. The R2HC programme is
funded equally by the Wellcome Trust and DFID, and
managed by the Enhancing Learning and Research
for Humanitarian Assistance (ELRHA).
Competing Interests: The authors have declared
that no competing interests exist.

observational study designs, limited use of control groups, biases associated with missing
data and inadequate patient-follow-up, and confounding was poorly addressed.
Conclusions
The review highlights the extremely limited quantity and quality of evidence on this topic.
Interventions that incorporate standardisation and facilitate patient follow-up appear benefi-
cial. However, substantially more research is needed, including data on costs.
Introduction
It is estimated that two-thirds of deaths worldwide are attributable to non-communicable dis-
eases (NCDs), with cardiovascular disease, cancer, diabetes mellitus, and chronic lung disease
comprising the largest burden of NCDs.[1] The increasing prevalence of NCDs in low- and
middle-income countries (LMICs) has driven the recent increases in the global NCD burden,
and importantly the probability of premature death due to NCD is higher in LMICs than in
their high-income counterparts.[2] Even in Sub-Saharan Africa—where communicable and
vector-borne diseases are still the largest killers—it is estimated that NCDs will become the
leading cause of death by 2030.[3]
There are around 50 million persons who have been forcibly displaced from their homes as
refugees and internally-displaced persons (IDPs) due to humanitarian crises,[4] defined here
as events stemming from armed conflict, natural disasters, or food insecurity that threaten the
health and safety of a community. There are also many millions more who remain in areas
impacted by humanitarian crises or have recently returned to them after being displaced.
While low-income countries continue to suffer the largest burden of humanitarian crises,
trends have shown an increase in middle-income countries affected by humanitarian crises,
with examples being armed conflicts in Iraq, Libya, Syria, Ukraine, the Balkans, and the Cauca-
sus.[5] These countries have a particularly high burden of NCDs.[6] In addition, humanitarian
crises have become more protracted and so health providers are facing pressure to expand
beyond the immediate basic primary care traditionally provided by relief agencies and address
longer-term health conditions such as NCDs. Moreover, it is known that a number of charac-
teristics related to humanitarian crises such as stress and disrupted access to treatment can
exacerbate NCDs.[7]
The rise of NCDs in LMICs and the recent trends in humanitarian crises mean that the bur-
den of NCDs has likely risen among crisis-affected populations. Governments, humanitarian
organisations, and international agencies are now increasingly challenged with how to effec-
tively tackle NCDs.[8] While there are best clinical practices on key interventions for treating
NCDs in stable settings,[9] there is extremely limited guidance on tackling NCDs in crisis-
affected settings. It is unclear what NCD interventions are effective and feasible in such set-
tings, how best to deliver them, and how well interventions are adhering to clinical best prac-
tice. As a result, there are increasing calls for a better understanding of NCDs and
interventions for NCDs in humanitarian crises.[3,5,8] However, no systematic review has
been published that examines the evidence on effectiveness of interventions targeting NCDs
during humanitarian crises in LMICs. Such a review can help guide future research, policies,
and programming by identifying effective interventions as well as evidence gaps.[10] The aim
of this paper was to systematically review evidence on the effectiveness of interventions target-
ing NCDs during humanitarian crises in LMICs. The specific objectives were to: (i) describe
the study characteristics; (ii) examine evidence on effectiveness of NCDs in humanitarian
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crises; and (iii) assess the quality of the evidence on NCD interventions in humanitarian crises.
The review forms part of a larger review of evidence on health interventions in humanitarian
crises.[11]
Methods
This systematic review followed the reporting items for systematic reviews as described in the
PRISMA statement.[12]
Eligibility Criteria
The populations of interest were civilians in LMICs affected by humanitarian crises, defined
here as events stemming from armed conflicts, natural disasters, or food insecurity that
threaten the health and safety of a community. These included populations remaining in areas
affected by crises and those forcibly displaced from them as refugees and IDPs. Studies that
focused on current or former military populations were excluded. High-income countries were
excluded as the vast majority of humanitarian crises occur in LMICs and the resources avail-
able to tackle NCDs in LMICs are very different to those in high-income countries. The time
periods of humanitarian crises included acute, chronic, and early recovery time periods.
The interventions of interest were health interventions covering health promotion, preven-
tion, treatment, or rehabilitation activities at the individual or population level specifically for
outcomes of NCDs.
The outcomes included morbidity/mortality due to NCDs and surrogate outcomes (e.g.
blood pressure, blood glucose levels) at the individual or population level. In addition, we also
included information on process outcomes (e.g. adherence to clinical treatment) and feasibility
of interventions and measurement methods, if the study included data on changes in health
outcomes. We did not include mental health outcomes as these have been reviewed elsewhere.
[13]
Information Sources and Search Strategy
The following bibliographic databases were searched: MEDLINE, Embase, Global Health, Psy-
chInfo, and IBSS. The search terms were: (i) disaster-related terms; AND (ii) research study-
related terms; AND (iii) geographic terms; AND (iv) NCD terms. A search of the grey literature
was also conducted across a range of humanitarian-related databases and standard search data-
bases such as Google. The full search strategy is provided in S1 File. Studies published in any
language between January 1980 and June 2014 were included.
Study Selection and Data Extraction
Citations from the search results were imported from the bibliographic databases into EndNote
for screening for eligibility based on the eligibility criteria given above. Duplicates were
removed and the remaining citations assessed by title or abstract, and a full text review then
conducted. References of the remaining studies selected after the full text review were examined
for potentially relevant articles based on the eligibility criteria. Analysis of the final selected
studies was then conducted. This involved extracting data from the final selected studies into
an Excel database, with key extraction variables including: author and date of publication, geo-
graphic setting, sample population characteristics, study objectives, NCD condition studied,
intervention characteristics, outcomes measured, results of the intervention, study conclusions,
study design, and quality. The data screening and extraction were conducted independently by
two authors and any variances resolved between them.
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Quality assessment
A quality assessment was conducted, with the Newcastle-Ottawa Quality Assessment Scale
(NOS) version for cohort studies used for the observational studies [14,15]. This was selected
as it is a convenient and widely used tool with proven validity and reliability and has been
endorsed by Cochrane Reviews [15–17]. For the randomised controlled trial (RCT) study we
applied the widely used and validated Cochrane Risk of Bias Tool[18].
The NOS assigns stars for methodological rigour based on three categories: study selection,
comparability of study groups, and outcome assessment. Studies were initially assessed within
each category using the coding manual for cohort studies provided by Wells et al (see [15] and
http://www.ohri.ca/programs/clinical_epidemiology/nosgen.pdf), with letters and descriptions
assigned describing how each study fulfilled each criterion. Stars were then assigned per the
NOS assessment scale when the study achieved high quality within that category. Criteria
which were not applicable to particular studies were listed as not applicable but factored into
overall impressions regarding that study’s conclusions.
The Cochrane Risk of Bias Tool was developed to promote the assessment of quality of trials
based on their risk of biased conclusions rather than focussing on reporting and methodologi-
cal constraints [18]. The RCT was therefore evaluated as being at either high, low, or unclear
risk of bias in several domains (selection, performance, detection, attrition, reporting, and
other bias), and a descriptive justification of each conclusion was provided.
Neither NOS nor the Cochrane Risk of Bias Tool uses an established summary score or
threshold of quality, with the quality assessment primarily used to assess strengths and weak-
nesses of each study rather than to rank studies or to screen them out.
Synthesis of results
As the studies were heterogeneous in setting, intervention, and outcome, single effectiveness
summary statistics across studies were not considered appropriate and were not estimated.
Instead, a descriptive analysis of study results was reported.
Results
Study Selection
The bibliographic databases yielded 4919 citations after duplicates were removed. Of these,
only 8 met the study inclusion criteria (Fig 1).[19–26] The main reasons for excluding the 4879
studies were they were: in high-income countries; not in humanitarian contexts or took place
too long after a humanitarian crises; not intervention studies; did not report changes in health
outcomes; or were not full papers (e.g. conference abstracts only). These reasons applied at
each screening stage. Exploring references from these 8 studies did not reveal any further stud-
ies meeting eligibility criteria. No studies were identified in the grey literature.
Study Characteristics
Key characteristics of the final 8 selected studies are included in Table 1. The studies were pub-
lished between 1997 and 2014, with 6 out of 8 published within the past five years. Seven of the
studies were with populations affected by armed conflict, and the remaining study with a popu-
lation affected by an earthquake.[25] Sample sizes of the study populations ranged from 28
patients included in the RCT [26] to 12,550 patients in a diabetes cohort study.[24] The studies
were conducted in 5 different countries: Afghanistan,[19] Georgia,[21] India,[26] Jordan,[20,
22–24] and Turkey.[25] Four of the studies[20,22–24] came from the same research group
studying Palestinian refugees in Jordan, with their studies covering diabetes and hypertension.
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These four studies and one other[26] took place in long-term, relatively stable refugee settings,
while the remaining studies were in more acute- or early post-crisis settings.
Of the 8 studies, 7 used observational study designs[19–25] and 1 was an RCT.[26] The
observational studies consisted of 5 cohort designs,[20–24,26] 1 case series[19] and 1 inter-
rupted time series.[25] The RCT[26] was the only study to compare outcomes between two
groups. None of the studies examined the cost of implementing the intervention or the cost-
effectiveness of the intervention.
The studies examined a broad range of NCD conditions: arthritis,[26] chronic kidney dis-
ease,[25] diabetes,[22–24] heart failure,[21] hypertension,[20] and thalassaemia.[19] All stud-
ies examined outcomes at the individual patient level and were primarily focused on disease
management rather than prevention or health promotion. Details of each intervention and key
outcome measures, study results, and specific study conclusions are presented in Table 1.
Quality Assessment
The quality assessment identified a number of common weaknesses. The observational studies
(assessed using NOS) were generally adequate in describing the study population and establish-
ing exposure. Deficiencies common to the observational studies were predominantly related
to comparability and follow-up. None had a defined comparison group or unexposed cohort.
Study transparency was also noted to be a weakness common to the observational studies. No
study addressed potential biases, nor did any study discuss how missing data were handled.
Only three of the observational studies adequately reported follow-up periods of participants,
and most studies inadequately described their follow-up procedures. Follow-up periods ranged
from undefined[19] to three years[23], with studies from settings of chronic crisis demonstrat-
ing longer follow-up. Outcome assessment was also problematic. Most studies only provided
self-reported outcomes; the outcomes reported by the Khader et al. papers were of slightly
higher quality in that they were linked to electronic medical records, but those assessments
were not described in a standardised way such as via the International Classification of Disease
(ICD) codes. Only four studies[20–22,24] partially discussed study limitations, and only one
Fig 1. Results of screening process.
doi:10.1371/journal.pone.0138303.g001
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Table 1. Summary of studies examining effectiveness of interventions targeting NCDs during humanitarian crises.
Author,
Date
[Reference]
Setting NCD Type (study
population)
Study Objectives and
Design
Intervention Outcomes Measured Results Study Conclusions
Bolt et al.,
2010 [19]
General conflict-
affected rural
population in
Afghanistan
attending a US
military hospital.
Thalassaemia (45
paediatric patients
aged 13mos-11yrs)
Assess effect of palliative
thalassaemia treatment
in crisis setting. Case-
series design.
Palliative splenectomy
(programme of
undeclared duration).
Change in mean Hgb/Hct;
change in mean blood
transfusion frequency;
complications
encountered.
Hgb: 5.4g/L pre-op to 8.7g/
L post-op; Hct: 16.5% pre-
op to 26.3% post-op;
transfusion every 24 days
pre-op to every~50 days
post-op; complications—2
pre-op deaths, 1 post-op
respiratory distress, 1
transfusion reaction, 1 case
CHF post-transfusion.
Curative options likely
impossible during crisis;
splenectomy may be the
best palliative option.
Khader
et al., 2012
[20]
Camp-based
Palestinian
refugees in
Jordan attending
Nuzha primary
care clinic.
Hypertension
(4130 patients
diagnosed with
HTN).
Assess clinical outcomes
of HTN care using EMR
system. Assess utility of
cohort monitoring using
EMR in refugee context.
Cohort design.
Standardised
hypertension algorithm,
including: diet/lifestyle
management; graduated
anti-hypertensive
medications; referral if
HTN persists; screening
for HTN complications
and associated
conditions (e.g. DM);
quarterly follow-up
appointments. Cohort
monitored via EMR for up
to 2.5-years.
HTN clinical measures:
BP, glucose, cholesterol,
kidney function
(creatinine) testing,
medications used. Cohort
monitoring: incidence/
prevalence of HTN; clinic
attendance (%); missed
appointments; loss to f/u.
4130 patients with HTN
registered in EMR
(cumulative, 2.5 years):
76% remain in care; 74% of
those had BP checked;
74% of those checked had
BP <140/90 mmHg; 15%
had 1+ complications. 226
patients assessed for 12-
15-month outcomes: 62%
remain in care; 76% of
those meeting BP target
(<140/90 mmHg); 3%
glucose (DM) screened;
100% cholesterol
screened; 99% creatinine
screened; 8% had 1
+ complications.
Mixed clinical results:
approx. 3/4 of patients
meeting BP targets;
cholesterol, kidney
function properly
screened; DM poorly
screened; unclear if
clinical practice lacking or
if data recording lacking.
EMR-based cohort
monitoring promising for
assessing programme
implementation and future
needs.
Hebert et al.,
2011 [21]
General conflict-
affected
population in
Georgia (1 urban
hospital and 3
rural districts).
Heart Failure (400
adult heart failure
patients).
Assess clinical outcomes
of a heart failure disease
management programme
(HFDMP). Cohort design.
2-year HFDMP: physician
training; salary support;
equipment supplied;
patient education; free
outpatient care.
Change in: ejection
fraction (EF) (mean); BP
(mean); BMI (mean);
smoking status; health
services and medication
usage; NYHA HF class.
400 patients studied: 337
complete f/u, 51 lost to f/u,
12 died in war. EF increase
4.1±2.6% (p<0.001); BP—
SBP decrease 30.9±20.0
mmHg (p<0.001), DBP
decrease 17.8±13.0 mmHg
(p<0.001); BMI statistically
unchanged; smokers
decrease 18.3% (p<0.001);
ER use decrease 40.7%
(p<0.001); hospital
admission decrease 52.5%
(p<0.001); beta-blocker use
increase 73.3% (p<0.001);
NYHA HF class—increase
in Class I (+13.7%) and
Class II (+19.2%),
decrease in Class III
(-26.0%) and Class IV
(-6.8%); patients lost to f/u
more likely rural.
HFDMP was able to affect
clinical outcomes in a
LMIC experiencing war.
(Continued )
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Table 1. (Continued)
Author,
Date
[Reference]
Setting NCD Type (study
population)
Study Objectives and
Design
Intervention Outcomes Measured Results Study Conclusions
Khader
et al., 2012
[22]
Camp-based
Palestinian
refugees in
Jordan attending
Nuzha primary
care clinic.
Diabetes Mellitus
(2851 patients with
DM).
Assess clinical outcomes
of DM care using EMR
system. Assess utility of
cohort monitoring using
EMR in refugee context.
Cohort design.
Standardised DM
algorithm, including: diet/
lifestyle management;
graduated anti-DM
medications, including
insulin if necessary;
screening for DM
complications and
associated conditions
(e.g.: HTN); quarterly
follow-up appointments.
Cohort monitored via
EMR up to 2.5 years.
DM clinical measures:
2-hr post-prandial blood
glucose; BP, cholesterol,
kidney function
(creatinine) testing; foot
assessment;
ophthalmology referral.
Medications used. Cohort
monitoring: incidence/
prevalence of DM; clinic
attendance (%); missed
appointments; loss to f/u.
2851 patients with DM
registered in EMR
(cumulative, 2.5 years):
70% remain in care; 42% of
those had 2h-PPBG
checked; 50% of those
checked had PPBG 180
mg/dl; 18% had 1
+ complications. 117
patients assessed for 12-
15-month outcomes: 61%
remain in care; 58% of
those meeting DM target
(180 mg/dl); 100%
cholesterol screened; 99%
creatinine screened; 3%
foot checked; no data on
ophthalmology referrals;
10% had 1+ complications.
Mixed clinical results: >half
of patients not receiving
proper PPBG checks; half
of those checked poorly-
controlled; cholesterol,
kidney function properly
screened; DM
complications poorly
screened; unclear if
clinical practice lacking or
if data recording lacking.
EMR-based cohort
monitoring promising for
assessing programme
implementation and future
needs.
Khader
et al., 2014
[23]
Camp-based
Palestinian
refugees in
Jordan attending
Nuzha primary
care clinic.
Diabetes Mellitus
(119 patients with
DM).
Assess 12-, 24-, and
36-month clinical
outcomes and
complications of DM care
using EMR system.
Assess 3-year utility of
cohort monitoring using
EMR in refugee context.
Cohort design.
Standardised DM
algorithm, including: diet/
lifestyle management;
graduated anti-DM
medications, including
insulin if necessary;
screening for DM
complications and
associated conditions
(e.g.: HTN); quarterly
follow-up appointments.
Cohort monitored via
EMR for up to 3 years.
DM clinical measures:
2-hr post-prandial blood
glucose; BP, cholesterol,
kidney function
(creatinine) testing; BMI;
DM complications. Cohort
Monitoring: baseline
prevalence of DM; clinic
attendance (%); missed
appointments; loss to f/u.
119 patients with DM
assessed at 12-, 24-, and
36-months: 72/64/61%
remaining in care at 12-/
24-/36-months (χ2 test-for-
trend = 47.9; p<0.001); 9/
19/29% lost to f/u at 12-/
24-/36-months (χ2 test-for-
trend = 43.5; p<0.001); 71/
78/71% meeting DM goal
(PPBG 180 mg/dl) at 12-/
24-/36-months; 7/14/15%
with 1+ complications at
12-/24-/36-months.
Mixed clinical results:
approx. one-quarter of
patients consistently
missing DM goals; loss to
f/u and complications rise
over time; data indicate
more aggressive treatment
may be necessary. EMR-
based cohort monitoring
useful to highlight
programme effects and
future needs.
Khader
et al., 2014
[24]
Camp-based
Palestinian
refugees in
Jordan attending
6 primary care
clinics.
Diabetes Mellitus
(12550 patients
with DM; focus on
288 newly
registered cases).
Assess new and
cumulative patient
characteristics and
clinical outcomes of DM
care using EMR system.
Assess utility of cohort
monitoring using EMR in
refugee context across
multiple primary care
clinics. Design: cohort
Standardised DM
algorithm, including: diet/
lifestyle management;
graduated anti-DM
medications, including
insulin if necessary;
screening for DM
complications and assoc.
conditions (e.g.: HTN);
quarterly follow-up
appointments. Cohort
monitored via EMR
across 6 clinics (up to 2
years at 5 clinics, 3.5
years at 1 clinic).
DM clinical measures:
2-hr post-prandial blood
glucose; BP, cholesterol,
kidney function
(creatinine) testing; BMI;
foot assessment;
ophthalmology referral;
DM complications and
associated risk factors.
Cohort monitoring:
incidence/prevalence of
DM; clinic attendance (%);
missed appointments;
loss to f/u.
12550 patients with DM
registered in EMR
(cumulative; 2 years at 5
clinics, 3.5 years at 1
clinic): 78% remaining in
care; males more likely to
be smokers (OR M:F = 7.4
(CI 6.6–8.2; p<0.001)) and
inactive (OR M:F = 1.8 (CI
1.6–1.9; p<0.001)) and to
have 1+ complications (OR
M:F = 1.6 (CI 1.4–1.8;
p<0.001)); females more
likely obese (OR M:
F = 0.34 (CI 0.32–0.37;
p<0.001)); 99% had PPBG
measured; 65% at goal
(180 mg/dl); 99% had
cholesterol measured; 63%
at goal (<200 mg/dl); 99%
had BP measured; 87% at
goal (<140/90 mmHg);
100% had BMI measured;
40% non-obese (<30 kg/
m2).
Mixed clinical results:
success testing cohort
widely; clinical goals not
broadly met; high numbers
with associated risk
factors. EMR-based cohort
monitoring useful to
highlight programme
effects and future needs.
(Continued )
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Table 1. (Continued)
Author,
Date
[Reference]
Setting NCD Type (study
population)
Study Objectives and
Design
Intervention Outcomes Measured Results Study Conclusions
Sever et al.,
2004 [25]
General urban
and rural
population
affected by
earthquake in
Marmara region of
Turkey (8 HD
centres).
Chronic Kidney
Disease (8 HD
centres
responsible for 439
patients with
chronic kidney
disease).
Assess clinical outcomes
and infrastructure
changes of
haemodialysis centres
affected by earthquake
damage. Interrupted time
series design.
Haemodialysis Clinical outputs of HD
centres: total number of
HD visits, % patients
receiving weekly HD.
Clinical outcomes: patient
weight, BP. HD
infrastructure: number of
HD centres, machines,
patients served.
8 HD centres assessed:
HD machines: 95 pre-
earthquake; 74 (1mo) and
79 (3mos) post-earthquake;
HD personnel: 112 pre-
earthquake; 86 (1mo) and
94 (3mos) post-earthquake;
HD patients: 439 pre-
earthquake; 175 (1wk), 239
(1mo), and 288 (3mos)
post-earthquake; HD
sessions: 1093/wk pre-
earthquake; 520/wk (1wk),
616/wk (1mo), and 729/wk
(3mos) post-earthquake; %
weekly HD: 2.3% pre- to
7.2% 1wk-post-earthquake.
Interdialytic weight gain: 2.9
±1.1kg pre- to 2.6±1.1kg
1wk-post-earthquake; BP
stable throughout.
Infrastructure damage
significantly impairs HD
treatment during disasters.
Increase in once-weekly
HD but interdialytic weight
gain not increased. Patient
education and disaster
planning may prevent
adverse outcomes.
Ryan, 1997
[26]
Tibetan refugee in
non-formal
refugee
communities in
northern India.
Arthritis (28
patients with
arthritis (24 OA, 4
RA), in 14 matched
pairs).
Compare limb mobility in
matched pairs of Tibetan
refugees with arthritis
after either traditional
Tibetan treatment or
Western medications.
RCT design.
Traditional Tibetan
arthritis treatment (3
months); herbal pills;
dietary restriction;
behavioural advice;
Western arthritis
treatment (3 months);
Ibuprofen or
Indomethacin.
Limb mobility assessed
via praxis-based scale (0–
5) for active movement;
pain assessed via Visual
Analogue Scale.
Limb mobility: Traditional
Tibetan treatment led to
greater improvement in 12/
14 matched pairs; 2 pairs
were a draw; Mean
improvement 1.39 (SD
0.59) points using
traditional Tibetan
treatment; 0.57 (SD 0.33)
points using Western
treatment.) Pain—Western
treatment led to better pain
improvement (data not
given).
Traditional Tibetan
treatment led to better
arthritis improvement
compared to Western
treatment when assessed
via limb mobility. RCTs are
practicable in traditional
settings.
Acronyms: BMI–body mass index; BP–blood pressure; DBP–diastolic blood pressure; DM–diabetes mellitus; EF–ejection fraction; EMR–electronic medical record; ER–emergency
room; f/u–follow-up; Hct–haematocrit; HD–haemodialysis; HFDMP–heart failure disease management programme; Hgb–haemoglobin; HTN–hypertension; LMIC–low/middle-
income country; mmHg–millimetres of mercury; NCD–non-communicable disease; NYHA HF class–New York Heart Association heart failure classification; OA–osteoarthritis; OR–
odds ratio; PPBG–post-prandial blood glucose; RA–rheumatoid arthritis; RCT–randomised controlled trial; Ref#—reference; SBP–systolic blood pressure; SD–standard deviation.
doi:10.1371/journal.pone.0138303.t001
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[23] gave any information on sources of funding, and even then only in the online version of
the article.
The RCT study from India[26] was assessed using the Cochrane Risk of Bias Tool and was
judged to have a high risk of selection, performance, and detection bias, primarily due to the
study’s lack of blinding. The study used an open enrolment process and all members of the
research team appear to have had knowledge of patients’treatment. Although outcome report-
ing was a strength of the study, there was an overall high risk of additional biases given that a
single non-blinded researcher assessed the outcomes. Further deficiencies surrounded the
reporting of the randomisation process, which was not described in any detail. Further details
on the scoring for individual studies are given in S2 File and S3 File.
Synthesis of results
Cardiovascular diseases were assessed via two cohort studies–one in Georgia examining a heart
failure disease management programme[21] and one in Jordan examining hypertension care
among Palestinian refugees.[20] The contexts of these two studies differed in the sense that the
study in Georgia was examining the effectiveness of a health programme that then experienced
the outbreak of war during the intervention, while the study in Jordan took place in a long-
term refugee setting that was relatively stable during the study period. Both studies focused on
the implementation of disease management algorithms in settings of humanitarian crisis and
attempted to highlight both the feasibility and challenges of such programmes.
In the study in Georgia by Hebert et al.,[21] the heart failure disease management pro-
gramme saw some success among its 400 patients by demonstrating a statistically significant
increase in ejection fraction—the fraction of blood volume exiting the heart’s ventricles with
each heartbeat, which tends to decrease in the most common types of heart failure—and a sta-
tistically significant decrease in blood pressure over the course of the 2-year programme. Ejec-
tion fraction improved by 4.1±2.6% (p<0.001) and systolic and diastolic blood pressures
decreased by 30.9±20.0 mmHg and 17.8±13.0 mmHg, respectively (p<0.001 for both). The
intervention also demonstrated a decrease in smoking rates and in emergency room visits and
hospitalisations. Heart failure classification also improved.
The study by Khader et al. on a hypertension management programme in Jordan had
mixed clinical results, with approximately three quarters of patients meeting blood pressure
targets.[20] The intervention focused on the method of cohort monitoring by using an elec-
tronic medical record system to enrol patients in a cohort that could be studied over time. The
monitoring allowed researchers to also assess if goals of care were being met, both with respect
to hypertension care goals such as blood pressure monitoring and with respect to associated
diseases such as hypercholesterolaemia and diabetes. Results were mixed; among a sub-cohort
of 226 patients assessed for 12–15 months, 100% were screened for high cholesterol but only
3% were screened for diabetes using a glucose blood test. The study authors concluded that the
interventions were an improvement on baseline care in both settings. However, no comparison
group was included.
Three cohort studies, all by Khader et al., focused on diabetes care among Palestinian refu-
gees in long-term refugee settings in Jordan.[22–24] All three studies conducted very similar
interventions consisting of a standardised diabetes protocol and assessment of patient out-
comes and programme outputs via electronic medical records-based cohort monitoring. The
concept was very similar as well to the aforementioned study targeting hypertension in a simi-
lar patient population with the initial DM study essentially mirroring that design.[20] The sub-
sequent two diabetes studies differed in terms of follow-up and scope, with one study[23]
focusing on 12-, 24-, and 36-month outcomes, and the other on the expansion of the
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PLOS ONE | DOI:10.1371/journal.pone.0138303 September 25, 2015 9/16

programme from one clinic to six.[24] While the Khader et al. studies had similar designs and
settings, it was confirmed via correspondence with the studies’authors that the populations of
each study differed. For this reason—and because this review featured descriptive analysis
rather than meta-analysis—it was felt that inclusion of each study for analysis was appropriate.
In general, the diabetes studies claimed an improvement in the programme over time. Ear-
lier assessment of the programme [22] found that over half of patients were not receiving post-
prandial blood glucose checks and that those checked only demonstrated proper diabetes con-
trol (</ = 180mg/dl) half of the time. Subsequent assessment described in 2014[24] found that
most programme outputs had improved, with nearly all patients attending clinic meeting the
blood testing goals. However, other treatment goals, specifically foot examination and ophthal-
mology referral, that were problematic during the earlier study did not continue to be assessed
in the subsequent studies. These studies also found that loss to follow-up rose over time (Γ
2
test-for-trend = 43.5; p<0.001). Nevertheless, the study authors contend that having a moni-
tored cohort using an electronic medical record-based system could allow for improved reten-
tion of patients through more proactive patient monitoring.
Chronic kidney disease was assessed by one retrospective study from Sever et al. in the Mar-
mara region of Turkey in the aftermath of an earthquake.[25] This study focused on both the
infrastructure changes and clinical patient outcomes of providing haemodialysis to patients
with severe chronic kidney disease. The study found that infrastructure for providing haemo-
dialysis was affected by the earthquake, with an acute decrease in haemodialysis centres,
machines available, personnel, and subsequently numbers of haemodialysis treatments pro-
vided. Gradually these numbers improved during follow-up. The initial earthquake also led to
an increase in the number of patients receiving once-weekly (i.e., less frequent) haemodialysis.
Despite the infrastructure challenges, the authors found that mean interdialytic weight
gain—the amount of weight patients gain between treatments, typically fluid weight due
to poor blood filtration and urine production—actually decreased from a pre-earthquake
2.9±1.1 kg to 2.6±1.1 kg 1-week post-earthquake, despite the increased numbers of patients
receiving haemodialysis less frequently. Moreover, the blood pressures of patients studied
remained stable throughout the study period. The authors contend that adequate patient edu-
cation regarding disaster preparedness and fluid restriction likely helped mitigate poor patient
outcomes, although no comparison between the baseline health status of patients able to seek
care after the earthquake and the status of the larger number of patients receiving haemodialy-
sis before the earthquake was conducted.
The only RCT eligible for inclusion in this systematic review studied changes in limb mobil-
ity among 14 matched pairs of arthritis patients living in a stable Tibetan refugee setting in
northern India.[26] In this open, non-blinded RCT, patients were randomised to receive three
months of either traditional Tibetan arthritis treatments (herbal pills, dietary restriction, and
behavioural advice) or Western medication (ibuprofen or indomethacin). In 12 of 14 pairs, the
traditional Tibetan treatment led to greater improvement in limb mobility, and in the remain-
ing 2 pairs the treatments performed equally well. Although they have not presented the data,
the authors do suggest that pain control was better with the Western treatment than the tradi-
tional treatment. The authors state that a secondary objective of the study was to examine the
process of conducting an RCT on traditional treatment options, although the authors do not
comment specifically on the nuances of conducting an RCT in unstable settings.
One case series study by Bolt et al. examined thalassaemia among 45 paediatric Afghan
patients seeking care at a United States-managed military hospital in a chronic crisis setting in
Afghanistan.[19] The research team provided the intervention—palliative splenectomy—with
the rationale that more curative treatment (e.g. stem-cell transplantation) would not be feasible
in the Afghan context. The study reported an improvement in anaemia with mean
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haemoglobin levels rising from 5.4g/L pre-operatively to 8.7g/L post-operatively. Furthermore,
frequency of blood transfusion decreased from every 24 days to approximately every 50 days
before and after surgery. The authors state that families were pleased with the improvements
during follow-up, although patient-specific data, confidence intervals, and specifics regarding
follow-up were not provided.
Discussion
To the best of our knowledge, this is the first systematic review to examine the evidence of
effectiveness of interventions targeting NCDs in humanitarian crises. It highlights major gaps
in evidence on NCD interventions in humanitarian crises, with only eight studies meeting
inclusion criteria. While the selected studies addressed a range of NCDs, there were some nota-
ble absences—particularly studies for cancer treatment and respiratory diseases. In the case of
cancer, the challenges of financing and sustaining cancer care for Syrian refugees have been
highlighted and further research is required on these issues.[27] In addition, none of the studies
examined the effectiveness of NCD prevention activities despite prevention being central to
global efforts to tackle NCDs,[9] the potential risk-factors for NCDs in crisis and fragile set-
tings,[28] and humanitarian agencies noting the importance of NCD prevention activities.[29]
Nor did any study prioritise preparedness for crises in relation to NCD management. Geo-
graphically, the studies predominantly focused on the Middle East (which is understandable
given the greater burden of NCDs in the region), and studies in more resource poor settings
with weaker health systems are required. There was also a high risk of bias in the identified
studies.
While it is unwise to draw any definitive conclusions from such a small body of evidence,
there were a number of findings that warrant further discussion. First is the apparent success of
algorithm-based interventions. In Georgia, the improved clinical outcomes and use of appro-
priate medication showed the effectiveness of the heart failure disease management pro-
gramme there.[21] Diabetes care was also implemented using an algorithm in Palestinian
refugee clinics in Jordan.[22–24] Here too, the advantage of specific clinical measures led to
improvement in programmatic outputs over the years of follow-up. Alongside streamlined
clinical measures, it may be beneficial to include certain NCD medications on essential medica-
tion lists to facilitate their accessibility and use during a crisis. Second, the benefit of cohort
monitoring using electronic medical records was highlighted.[20,22–24] These studies were
originally derived from similar cohort monitoring research conducted with other chronic dis-
eases such as tuberculosis and HIV,[30–33] and it has been suggested links between NCDs and
other chronic disease programmes such as tuberculosis and HIV could facilitate this monitor-
ing as well as hasten implementation of NCD-focussed programmes.[34] The systematic col-
lection of baseline and routine NCD data over time should be strongly supported, and agencies
such as UNHCR have now begun implementing a standardised health information system for
refugees.[35] Ideally, this monitoring should be done electronically, and given the trend toward
cheaper and more mobile electronic options, the incorporation of electronic medical record
technology appears to hold promise for the rapid implementation of cohort monitoring during
crisis. Third, the studies also highlight the importance of capacity-building and preparation of
local health staff and patients in effecting good clinical practice,[21] monitoring processes,[24]
and supporting medication adherence and adaptability among patients.
In addition to the limited number of studies, the strength and quality of the existing evi-
dence was also generally quite limited. Most of the studies used cohort study designs and while
some were able to consistently follow-up over time in order to measure changes in NCD out-
comes, none included a comparison group not receiving the tested intervention. This omission
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therefore limits conclusions on the effectiveness of the intervention. Where logistically and eth-
ically appropriate, it would be of considerable value to include some form of comparison group
in order to formulate a more robust assessment of the intervention effectiveness. The use of
stepped wedge designs may be a useful approach to follow in such settings.[36] Where the use
of controls is not possible, statistical methods such as interrupted time-series analysis could
prove useful.[37]
Other common weaknesses include lack of discussion on how missing data were addressed,
and also on other potential biases in study designs and analyses. For example, the haemodialy-
sis study in Turkey[25] was prone to recall bias as each time point analysed was based on ques-
tionnaires sent six months after the earthquake. The RCT examining arthritis[26] was
weakened in its claims by a lack of blinding. Adequate patient follow-up was another area of
weakness. While loss to follow-up may be expected in the volatile and transient settings of
humanitarian crisis, the lack of analysis to address it is problematic. Adjusting for potential
cofounding was also not conducted (and this was further undermined by the lack of control
groups).
There are also issues regarding the appropriateness and generalisability of some of the stud-
ies for other humanitarian contexts. For example, while the thalassaemia study for civilians in
Afghanistan provided an intervention that was tailored toward the resources and context of
Afghanistan, it nevertheless took place in a well-resourced US military hospital.[19] A number
of the studies[20,22–24,26] were conducted in long-term refugee settlements that were rela-
tively stable and so there is little evidence from more insecure and volatile settings.
The lack of cost considerations across all studies further limits the generalisability of the evi-
dence. While cost-effective interventions targeting NCDs in LMICs have been developed,[9,
38] further work needs to be done to better understand the feasibility and cost of NCD inter-
ventions in humanitarian crises given their different resources and the inherent security and
logistical constraints in such settings. Such information on costs and financing of NCDs is cru-
cial to address operational and ethical issues relating to the sustainability of providing NCD
care in such settings—particularly in relation to tension between commencing long-term NCD
care and the shorter-term mandates of many humanitarian agencies.
Most of the evidence identified in this review is from relatively stable settings. This high-
lights the challenges to implementing rigorous research during an acute crisis giving the secu-
rity and resource constraints and rapid population movement. However, previous longitudinal
research with conflict-affected populations in volatile contexts on treatment for chronic condi-
tions such as HIV has shown that such research is possible.[39] Given the time constraints in
such settings, planning research designs in advance, pre-approving protocols, and using inno-
vative designs that can also be rapidly implemented is recommended (e.g. using routine NCD
data for cohort designs or stepped wedge designs as services are rolled out). Ethical concerns
regarding intervening on conditions that require long-term care when the humanitarian
response may be brief must be considered within the humanitarian and research communities,
but the ethical implications of withholding an intervention or researching its effectiveness
must also be strongly considered. Humanitarian donor agencies should also consider longer-
term funding cycles and greater financial support for impact evaluation in order to understand
the actual effectiveness of the health interventions they fund. Operational humanitarian agen-
cies should also give greater priority to research and impact evaluation for NCDs, following the
example of agencies such as Médecins Sans Frontières who have placed a relatively strong
emphasis on rigorous operational research. Stronger links should also be fostered between
humanitarian agencies and academia to strengthen NCD research in humanitarian contexts,
and recent initiatives on this such as R2HC are to be welcomed.[40]
Interventions for NCDs in Humanitarian Crises
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Limitations
Only descriptive analysis was used, but alternative methods such as meta-analysis were not
appropriate because of the multiple outcomes, interventions, study types, and the limited num-
ber of studies. The review searched only quantitative studies as the focus was on the effective-
ness of interventions, and only studies from 1980 onward were included. Analysis of
qualitative research examining aspects such as health care provider and user perspectives on
NCD interventions in humanitarian crises would be extremely valuable. There is also the possi-
bility that humanitarian agencies may not have published all their existing research (either as
published or grey literature), and it is difficult to ascertain the potential levels of such non-pub-
lication. We could have tried hand searching humanitarian agency reports to attempt to find
additional studies. However, our prior experience and discussions with humanitarian agency
staff suggest it would be extremely unlikely to yield any further studies that would not have
been published in scientific journals. The NOS tool used for the quality assessment in this
review has been criticized for limited inter-rater reliability.[41] We did not observe any sub-
stantial discrepancies between quality assessors for this review but did not calculate inter-rater
reliability.
Conclusions
Research during humanitarian crises is inherently difficult. Researching NCDs is arguably
even harder as their chronic nature tends to demand more substantial follow-up. Neverthe-
less, this review has highlighted an urgent need to substantially expand research on NCD
interventions in humanitarian crises given their growing disease burden. Currently available
studies represent an attempt to rectify this knowledge gap but are few in number and of rela-
tively limited quality. The findings point toward the success of standardised algorithms that
can be implemented consistently and monitored via patient tracking using electronic medical
records. Key research needs include: a better understanding of NCD delivery models in more
acute and early recovery settings; using comparison groups (where appropriate); analysing
the costs and sustainability of interventions; and developing methods to minimize bias in set-
ting where standard randomised control studies are not feasible. Such work would support
the generalisability of NCD intervention findings and provide much needed guidance in this
neglected field.
Supporting Information
S1 File. Table. Search terms.
(DOCX)
S2 File. Table. Quality assessment of observational studies using NOS criteria.
(DOCX)
S3 File. Table. Quality assessment of RCT study using Cochrane Risk of Bias Assessment Tool.
(DOCX)
S4 File. Table. PRISMA Checklist.
(DOC)
S5 File. Original dataset.
(XLSX)
Interventions for NCDs in Humanitarian Crises
PLOS ONE | DOI:10.1371/journal.pone.0138303 September 25, 2015 13 / 16

Author Contributions
Conceived and designed the experiments: AR AK PP KB BR. Performed the experiments: AR
AK PP BR. Analyzed the data: AR AK PP BR. Contributed reagents/materials/analysis tools:
AR AK PP BR. Wrote the paper: AR AK PP KB BR.
References
1. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality
from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Bur-
den of Disease Study 2010. The Lancet. 2013; 380(9859):2095–128.
2. Kontis V, Mathers CD, Rehm J, Stevens GA, Shield KD, Bonita R, et al. Contribution of six risk factors
to achieving the 25x25 non-communicable disease mortality reduction target: a modelling study. Lan-
cet. 2014; 384(9941):427–37. doi: 10.1016/S0140-6736(14)60616-4 PMID: 24797573.
3. Holmes MD, Dalal S, Volmink J, Adebamowo CA, Njelekela M, Fawzi WW, et al. Non-communicable
diseases in sub-Saharan Africa: the case for cohort studies. PLoS medicine. 2010; 7(5):e1000244. doi:
10.1371/journal.pmed.1000244 PMID: 20485489
4. United Nations High Commissioner for Refugees. UNHCR Global Trends 2013. 2014.
5. Spiegel PB, Checchi F, Colombo S, Paik E. Health-care needs of people affected by conflict: future
trends and changing frameworks. The Lancet. 2010; 375(9711):341–5.
6. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality
from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Bur-
den of Disease Study 2010. Lancet. 2012; 380(9859):2095–128. doi: 10.1016/S0140-6736(12)61728-
0PMID: 23245604.
7. Demaio A, Jamieson J, Horn R, de Courten M, Tellier S. Non-communicable diseases in emergencies:
a call to action. PLoS currents. 2013; 5. doi: 10.1371/currents.dis.
53e08b951d59ff913ab8b9bb51c4d0de PMID: 24056956; PubMed Central PMCID: PMC3775888.
8. Amara AH, Aljunid SM. Noncommunicable diseases among urban refugees and asylum-seekers in
developing countries: A neglected health care need. Globalization and Health. 2014; 10(1). doi: http://
dx.doi.org/10.1186/1744-8603-10-24. PMID: 2014240896.
9. World Health Organization. Global action plan for the prevention and control of noncommunicable dis-
eases 2013–2020. 2013.
10. Kayabu B, Clarke M. The use of systematic reviews and other research evidence in disasters and
related areas: preliminary report of a needs assessment survey. PLoS currents. 2013; 5. doi: 10.1371/
currents.dis.ed42382881b3bf79478ad503be4693ea PMID: 23378935
11. Blanchet VS K, Ramesh A, Frison S, Warren E, Hossain M, Roberts B. An evidence review of research
on health interventions in humanitarian crises. Cardiff, UK: Enhancing Learning and Research for
Humanitarian Assistance (ELRHA), 2014.
12. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-
analyses: the PRISMA statement. Annals of internal medicine. 2009; 151(4):264–9. PMID: 19622511
13. Tol WA, Barbui C, Galappatti A, Silove D, Betancourt TS, SouzaR, et al. Mental health and psychoso-
cial support in humanitarian settings: linking practice and research. Lancet. 2011; 378(9802):1581–91.
doi: 10.1016/S0140-6736(11)61094-5 PMID: 22008428; PubMed Central PMCID: PMC3985411.
14. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonran-
domized studies in meta-analyses. European journal of epidemiology. 2010; 25(9):603–5. doi: 10.
1007/s10654-010-9491-z PMID: 20652370.
15. Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale
(Nos) For Assessing The Quality Of Nonrandomised Studies In Meta-Analyses 2014 [8 June 2015].
Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.
16. Deeks JJ, Dinnes J, D'Amico R, Sowden AJ, Sakarovitch C, Song F, et al. Evaluating non-randomised
intervention studies. Health technology assessment. 2003; 7(27):iii–x, 1–173. PMID: 14499048.
17. Higgins JP, Green S. Cochrane Handbook For Systematic Reviews OfInterventions Wiley Online
Library, 2008.
18. Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, et al. The Cochrane Collabora-
tion's tool for assessing risk of bias in randomised trials. Bmj. 2011; 343:d5928. doi: 10.1136/bmj.
d5928 PMID: 22008217; PubMed Central PMCID: PMC3196245.
19. Bolt MJD, Schoneboom BA. Operative splenectomy for treatment of homozygous thalassemia major in
afghan children at a US military hospital. AANA Journal. 2010; 78(2):129–33. PMID: 2010245851.
Interventions for NCDs in Humanitarian Crises
PLOS ONE | DOI:10.1371/journal.pone.0138303 September 25, 2015 14 / 16

20. Khader A, Farajallah L, Shahin Y, Hababeh M, Abu-Zayed I, Kochi A, et al. Cohort monitoring of per-
sons with hypertension: An illustrated example from a primary healthcare clinic for Palestine refugees
in Jordan. Tropical Medicine and International Health. 2012; 17(9):1163–70. doi: http://dx.doi.org/10.
1111/j.1365-3156.2012.03048.x PMID: 2012510847.
21. Hebert K, Quevedo HC, Gogichaishvili I, Nozadze N, Sagirashvili E, Trahan P, et al. Feasibility of a
heart failure disease management program in eastern Europe: Tbilisi, Georgia. Circ. 2011; 4(6):763–9.
doi: http://dx.doi.org/10.1161/CIRCHEARTFAILURE.111.962431. PMID: 21900187.
22. Khader A, Farajallah L, Shahin Y, Hababeh M, Abu-Zayed I, Kochi A, et al. Cohort monitoring of per-
sons with diabetes mellitus in a primary healthcare clinic for Palestine refugees in Jordan. Trop Med Int
Health. 2012; 17(12):1569–76. doi: http://dx.doi.org/10.1111/j.1365-3156.2012.03097.x PMID:
23051859.
23. Khader A, Ballout G, Shahin Y, Hababeh M, Farajallah L, Zeidan W, et al. Treatment outcomes in a
cohort of Palestine refugees with diabetes mellitus followed through use of E-Health over 3 years in Jor-
dan. Trop Med Int Health. 2014; 19(2):219–23. doi: http://dx.doi.org/10.1111/tmi.12241 PMID:
24341942.
24. Khader A, Ballout G, Shahin Y, Hababeh M, Farajallah L, Zeidan W, et al. Diabetes mellitus and treat-
ment outcomes in Palestine refugees in UNRWA primary health care clinics in Jordan. Public Health
Action. 2014; 3(4):259–64. doi: http://dx.doi.org/10.5588/pha.13.0083. PMID: 20143022501.
25. Sever MS, Erek E, Vanholder R, Kalkan A, Guney N, Usta N, et al. Features of Chronic Hemodialysis
Practice after the Marmara Earthquake. Journal of the American Society of Nephrology. 2004; 15
(4):1071–6. doi: http://dx.doi.org/10.1097/01.ASN.0000119145.40232.67. PMID: 2004134551.
26. Ryan M. Efficacy of the Tibetan treatment for arthritis. Soc Sci Med. 1997; 44(4):535–9. PMID:
9015888.
27. Spiegel P, Khalifa A, Mateen FJ. Cancer in refugees in Jordan and Syria between 2009 and 2012: Chal-
lenges and the way forward in humanitarian emergencies. The Lancet Oncology. 2014; 15(7):e290–e7.
doi: http://dx.doi.org/10.1016/S1470-2045%2814%2970067-1 PMID: 2014367481.
28. Roberts B, Patel P, McKee M. Noncommunicable diseases and post-conflict countries. Bulletin of the
World Health Organization. 2012; 90(1):2–A. doi: 10.2471/BLT.11.098863 PMID: 22271954
29. United Nations High Commissioner for Refugees. Global Strategy for Public Health. Geneva:
UNHCR, 2014.
30. Allain T, van Oosterhout J, Douglas G, Joukes S, Gadabu O, Darts C, et al. Applying lessons learnt
from the'DOTS'Tuberculosis Model to monitoring and evaluating persons with diabetes mellitus in Blan-
tyre, Malawi. Tropical medicine & international health: TM & IH. 2011; 16(9):1077. doi: 10.1111/j.1365-
3156.2011.02808.x PMID: 21702868
31. Harries A, Zachariah R, Jahn A, Schouten E, Kamoto K. Scaling up antiretroviral therapy in Malawi-
implications for managing other chronic diseases in resource-limited countries. Journal of acquired
immune deficiency syndromes (1999). 2009; 52:S14.
32. Harries A, Zachariah R, Kapur A, Jahn A, Enarson D. The vital signs of chronic disease management.
Transactions of the Royal Society of Tropical Medicine and Hygiene. 2009; 103(6):537. doi: 10.1016/j.
trstmh.2008.12.008 PMID: 19155031
33. Harries AD, Jahn A, Zachariah R, Enarson D. Adapting the DOTS Framework for Tuberculosis Control
to the Management of Non-Communicable Diseases in Sub-Saharan Africa. PLoS Medicine. 2008; 5
(6). doi: 10.1371/journal.pmed.0050124 PMID: 18547138
34. Atun R, Jaffar S, Nishtar S, Knaul FM, Barreto ML, Nyirenda M, et al. Improving responsiveness of
health systems to non-communicable diseases. Lancet. 2013; 381(9867):690–7. doi: 10.1016/S0140-
6736(13)60063-X PMID: 23410609
35. Haskew C, Spiegel P, Tomczyk B, Cornier N, Hering H. A standardized health information system for
refugee settings: rationale, challenges and the way forward. Bull World Health Organ. 2010; 88
(10):792–4. doi: 10.2471/BLT.09.074096 PMID: 20931066; PubMed Central PMCID: PMC2947042.
36. Hussey MA, Hughes JP. Design and analysis of stepped wedge cluster randomized trials. Contempo-
rary clinical trials. 2007; 28(2):182–91. doi: 10.1016/j.cct.2006.05.007 PMID: 16829207.
37. Penfold RB, Zhang F. Use of interrupted time series analysis in evaluating health care quality improve-
ments. Academic pediatrics. 2013; 13(6 Suppl):S38–44. doi: 10.1016/j.acap.2013.08.002 PMID:
24268083.
38. Bonita R, Magnusson R, Bovet P, Zhao D, Malta DC, Geneau R, et al. Country actions to meet UN com-
mitments on non-communicable diseases: a stepwise approach. The Lancet. 2013; 381(9866):575–
84.
Interventions for NCDs in Humanitarian Crises
PLOS ONE | DOI:10.1371/journal.pone.0138303 September 25, 2015 15 / 16

39. Culbert H, Tu D, O'Brien DP, Ellman T, Mills C, Ford N, et al. HIV treatment in a conflict setting: out-
comes and experiences from Bukavu, Democratic Republic of the Congo. PLoS Med. 2007; 4(5):e129.
doi: 10.1371/journal.pmed.0040129 PMID: 17535100; PubMed Central PMCID: PMC1880839.
40. ELHRA. R2HC—Research for Health in Humanitarian Crises 2015 [13 August 2015]. Available from:
http://www.elrha.org/r2hc/home/.
41. Hartling L, Milne A, Hamm MP, Vandermeer B, Ansari M, Tsertsvadze A, et al. Testing the Newcastle
Ottawa Scale showed low reliability between individual reviewers. Journal of clinical epidemiology.
2013; 66(9):982–93. doi: 10.1016/j.jclinepi.2013.03.003 PMID: 23683848.
Interventions for NCDs in Humanitarian Crises
PLOS ONE | DOI:10.1371/journal.pone.0138303 September 25, 2015 16 / 16