 Our last presentation for this session will be by John Garansson, Swedish nurse currently working with MSF in Erbid, Jordan on a third mission with MSF bachelor's degree in nursing from Red Cross University College of Stockholm. Thank you very much for that introduction. Hello everybody. So what I'm going to say here is much linking on to what Philippa already is talking about. So we're talking about meeting the health needs of syno-refugees in Jordan and the novel model of non-chemical disease care that we have implemented in this setting. So a lot of the background will be a bit addressed. So there's around 600,000 syno-refugees in Jordan and most of them are living in the northern parts and you already addressed for what the impact of NCDs in this group. What we haven't really touched base is that most of these diseases are not infectious. They're caused by mostly lifestyle. They're caused by obesity, smoking and inactive lifestyle. And in Syria, a third of all women are obese and a fifth of all men are obese. 60% of all men is smoking. It's an epidemic. And by actually targeting these areas we can actually prevent stroke, heart disease and diabetes type 2 up to 80%. So the objective of this study is to explore the novel model of NCD care and its early clinical outcomes. We're also exploring the feasibility of using motivational interviewing on lifestyle changes in syno-refugees and also its early outcomes. We've used the retrospective descriptive study to be part of the study. We picked the first 400 diabetes type 2 and hypertension patients. We've also analyzed routinely collected data and analyzed it with the PERT test. So the intervention is of course the most interesting part of this. So since the 15th of December we've been operational not for a long time. We are working together with the Ministry of Health. In addition to diabetes type 2 and hypertension that we're looking at in this study, we're also including COPD, chronic obstructive pulmonary disease, asthma and of course diabetes type 1. Here on the right you have our patient circuit and our model of care is it's nice because we're able to provide a lot of face time with the health care professional. We're actually providing 30 minutes of the first initial doctor visit, 30 minutes with the patient and additional in the health counseling additional 30 minutes. So they see a health care professional for more than one hour. We also have implemented the appointment system because I actually visited Lebanon in November and heard about their problem with defaulters. So we can actually report that we have very low default rates. 2.5 percent of our patients are completely lost to follow-up, an additional 2.5 around or voluntary exiting mostly because of moving back to Syria. But if we're talking about our patient court in total so we're looking at treating currently 1,600 patients after only four and a half months. 50 percent of them have more than one condition, 64 percent of them have diabetes type 2, an additional 54 percent has hypertension and it's really complex cohort. Staggering 60 percent of our patients are obese, 60 percent which means they have a BMI over 30. But this is the comes to the innovating part. I think change is difficult and I think that many people in this room would like to change something in their lives. I know I want to. And a way of approaching ambivalence towards change is motivational interviewing. It's a patient-centered coaching style that instead of imposing change on somebody it looks at ambivalence and let the patients their own examine the individual process. We're working with creating the coaches are creating an environmental mutual trust and trying to support the patient in this process. We're using techniques that call the oars, open questions, affirmations, reflections and helping the patient by summarizing what they've actually said. So it's the patient talking, not the coach. After a while on the left side here we see different stages of change which the patient is constantly moving through. When after a while we always hear the patient starting saying I want, I would like, I should. This is where a patient's moving into a preparation phase from maybe starting pondering over over change and then moving into actually trying to do it. And here we support the patient by creating their own change plan, a concrete smart plan that's supposed to be achievable. So what did we choose this style? We chose it because it's proven to be effective in terms of reducing BMI, body mass index. It's been proven to help with long-term smoking cessation and also increasing physical activity. But here comes how we adapted this to the context. It's not, there's not a lot of research on MI in refugee contexts. And what we have faced that we had to include treatment care supporters and family members a lot more in the sessions. The, for example, an old man wanting to change his dietary habits. We're not going to be able to reach him if he doesn't reach his wife because his wife is the one taking the decisions that are home when it comes to nutrition. So we had to include a lot more. In terms of human resources and training, all our coaches are nurses, trained, have an introduction, basic training and a motivational interviewing and we're focusing most on the spirit of MI. I'm going to address the challenges a bit later. So we come into the results and it's, as I say, very preliminary results, a short time period. I want to look at the upper line, which is systolic blood pressure, which is the most important factor when it comes to reducing mortality and mobility. We've actually had a significant drop from 144 to 136 in systolic blood pressure, which we can easily say we have taken our first 237 hypertensive patients from having uncontrolled hypertension to having controlled hypertension, which is quite an achievement in only four months. Looking at our HPA1C results, once again very preliminary data, so we've seen that we've had a significant drop. So for HPA1C is a long-term blood sugar test in the blood for diabetes patients. The cut-off point we want to be under is seven, quite not year. We'll be going in the right direction and hopefully this is only 84 patients, but we're hoping to provide better data soon. Here, stage of change. We're actually using this as a diagnostic tool. Our coaches are diagnosing the patients and where in this cycle they are. And we can see that we're looking from the slide from the left to the right, so we're looking at in the beginning 66% of all our patients wasn't even thinking about changing their life. After a couple of months, we see that patients are starting to thinking about it, starting actually preparing to change and actually changing, making changes in their daily life. The tricky part is, of course, maintaining this change in this way too early to come away and there will be conclusions. And I'm saying here, last visit. Last visit is because many of our patients have had different numbers of follow-up visits. Some have had three, some have had five, all depending on the complexity of their disease. Quickly going over lifestyle results. So we have not had any body mass index, significant changes yet. It's way too early and a lot of different confounders. We've looked at the patients that are actually in action phase and the lifestyle change. And we see that 38% of them are decreasing their smoking habit and 6% of them are stopping smoking right now. Comes to the physical level, we see that 28% of our patients are becoming more active and we're using the general practice physical activity questionnaire and diagnosing the different levels. We, of course, face challenges. We saw that with, many of our patients have a lower understanding on their disease process than we thought. And we have to start by talking about disease process, risk and complications before we can move into the actual lifestyle change. We have identified a lot of barriers towards change. Stress and trauma. Many of our patients are coming with better traumatic experience behind them. And many of them have families left in Syria, which is, of course, not a good foundation for change. Many of our patients say, I'm not going to change here. I'm going to change when I come back to Syria. Unemployment is illegal for refugees to work in Jordan, which is, of course, linked to the financial situation. Support from WFP and UNHCR is decreasing. And limited funds is not a good foundation to make, let's say, healthy choices in terms of diet and doesn't help with when nicotine substituted is three times the price than the actual cigarettes. I'm going to go quickly also to culture. So in terms of physical activity, it's not really built into the culture. Most of our patients are coming from southern Syria, Dada region. Women are not always acceptable walking outside. So we're trying to find even innovating ways of addressing this. A lot of limitations to the project also links into limitations to the study. It's a new context in this setting. We're in start-up phase. We're trying to set all the different systems in place. Short-time perspective, we already addressed the non-consistent follow-up duration. Staff has only had basic training, and the more time that goes, the more experience they get, and the higher the quality of motivational interviewing we can provide. We also had some issues in the patient file that could have implicated some of the data collection. Conclusions. So what can we say? We can say that a patient-centered model of care for NCDs appears to be feasible in a refugee context, and its early clinical outcomes looks promising. We can also say that motivational interviewing towards lifetime chains seems to be feasible and actually seems to improve motivation at this early point. We can also say that Syrian refugees are struggling with barriers towards change, and we have to find ways of addressing these barriers and taking them on. Come to the future. So we hope to provide a formal evaluation to be able to inform other NCD projects in similar settings. I'm saying similar settings, because Jordan and Lebanon are quite different settings that we normally work in. Hopefully also to provide outcome indicators and together work for our data tool, I would say for OCA. We're also focusing on trying to get health counseling guidelines for non-chemical disease care, which is not existent right now in our programs. A lot of people, as you can see, has been working together with me. I will now say a special thank you to Dr. Lars Failing, who started this project with me last year. The biggest thank you go to Dr. Rami Sugul, who is the man working on the data, and without him none of this would have been possible. Thank you very much, and let's open up for some questions. Your question, please. The technical questions. I'm Misha, working with the MSF Unitate Pool. I just had a question, because I assume that smoking activity is self-reported. How did you control for the reliability bias? Of course. That bias always exists, because it is self-reported and same with physical activity level. We're trying to develop an environment of trust with our patients in our sessions. They do come back regularly for every follow-up session. It's 15 minutes, so they get to see these patients through a long period of time and develop a relationship. Of course, that bias always exists when it comes to self-reported tools. I wish I could say that we had a magical way of not having that bias. Daniel O'Brien, just wondering in your smoking cessation, do you use nicotine replacement like patches? Because it would be quite, I haven't seen that used in MSF before. Yeah, so nicotine substitute we are not using. MSF is not providing this. Of course, that would be a big debate in MSF. We're starting to do that. But it is proven that 50 to 70% of our patients, all patients are helped with nicotine substitutes. Of course, that would be an added effect. But at this point, we do not do that. It's something that we're trying to discuss, or at least maybe targeting nicotine substitutes to the patients that are in action preparation phase, not to everybody, but to the ones who actually want to change that we can follow-up. Because they are three times more expensive than actual cigarettes. Any other question, please? Yes, please. Hi there. My name is Maverick from New Zealand, Liverpool School of Tropical Medicine. I was just wondering, in terms of the obesity part of your study, did you involve the use of a dietitian at all? Or did you consider that? Because I guess in a lot of other studies like this, there's a lot of intensive kind of dietary change. And I was also wondering, I presume that the Syrian refugee's status makes also maybe food security an issue and accessibility? So our program is set up in that nurses are the coaches, but they are technically supervised by a dietitian who has hired us a health promoter who has given them and me training in how to eat properly. But as you said, there's a lot of barriers. WFP food ratios have been cut by half since November, and that makes it very difficult for patients to have enough money to actually make sound dietary choices. But we have a dietitian involved, yes. Last question, please. Hi, I'm Anna from Institute Pasteur. I'm just wondering, did you do any separation of looking at the time since seeking refuge or the time since arriving in the patients that you're looking at, and what their motivational levels were separating those groups out, stratification type? We have not done that yet. So we are looking at routinely collected data, and we have their, now we don't actually look at their arrival date into Jordan. That would be something interesting looking at, maybe for the future. Okay. Thank you, John. Thank you very much. Please join us here. I would like to invite the panelists to come here.