Community Health Worker Program Outcomes for Diabetes and Hypertension Control in West Bank Refugee Camps: A Retrospective Matched Cohort Study

Abstract

A community health worker program in urban Palestinian West Bank refugee camps improves diabetes and hypertension control in a setting of chronic violence and extreme adversity.

Abstract

Key Findings

• Health for Palestine (H4P) was established in 2018 as a refugee-run community health worker program in the occupied West Bank to provide social accompaniment, address health barriers, and initiate monitoring and support for chronic disease patients.

• A study from 2 Palestinian refugee camps indicates that accompaniment-based community health worker programs are feasible and effective in improving diabetes and hypertension control in camps experiencing chronic violence under military occupation.

Key Implications

• Stakeholders providing health care to refugees in Palestine and the diaspora can consider expanding an intensive community-run health model to other camps and communities experiencing extreme adversity as a result of occupation, dispossession, and violence.

• Given the rapidly increasing rise in migration globally, community health programs like H4P could play a key role in mitigating health barriers and maximizing community agency in similar contexts of extreme adversity. Policy makers should consider the multimodal benefits of integrating such programs into broader health programming.

ABSTRACT

Introduction:

Community health worker (CHW) programs have proven effective in improving diabetes control in many locations and settings, but data on feasibility and efficacy are lacking in the Middle East and settings of chronic violence. A Palestinian CHW program, Health for Palestine (H4P), addresses chronic diseases in West Bank refugee camps. Our study assesses the feasibility and effectiveness of the program’s diabetes and hypertension interventions.

Methods:

Data on home visits, patient retention, and blood pressure were extracted from the CHW records and analyzed. To assess diabetic patient progress, we conducted a retrospective matched cohort study using data obtained from a United Nations (UN) clinical database to analyze the trajectory of hemoglobin A1c (A1c) values. Thirty of the 47 diabetic patients in the H4P CHW program met study inclusion criteria and were each matched with 3 patients from the Bethlehem UN clinic (n=120). We tested for significance using multivariable linear regression with robust standard errors.

Results:

The average number of home visits per patient per month was 7.3 (standard deviation=4.1), and the patient retention rate was 100% over an average of 11.2 months. For hypertension patients in the CHW program (n=33), mean systolic blood pressure decreased by 7.3 mmHg (95% confidence interval [CI]=1.93, 12.25; P=.009) and mean diastolic blood pressure by 4.3 mmHg (95% CI=0.80, 7.91; P=.018) from March 2018 to November 2019. On average, diabetic patients within the CHW group experienced a 1.4 point greater decline in A1c per year compared to those in the non-CHW group, after adjusting for potential confounders (95% CI=−0.66, −2.1; P<.001).

Discussion:

The results suggest that CHW accompaniment may be an effective model for improving diabetes and hypertension control in refugee camps experiencing direct violence and extreme adversity. A low exclusion cut-off for A1c (≤6.4%) may underestimate the program’s impact.