Prevalence of Non-Communicable Diseases and Access to Healthcare Among Internally Displaced People During the Armed Conflict, Northern State (Sudan)

Introduction

Noncommunicable diseases (NCDs) have emerged as a public health challenge. They account for about 74% of deaths globally every year. Approximately 84% of all NCD-related deaths occur in low and middle-income countries. ¹ In Sudan, NCDs account for 53.9% of all deaths, and the most prevalent NCDs are cardiovascular diseases, cancers, respiratory diseases, and diabetes mellitus.² Despite their global burden, NCDs have received little attention in humanitarian settings worldwide, particularly among the displaced population.³

The estimated number of internally displaced people (IDPs) around the world is 75.9 million, and 45% of them are in Sub-Saharan Africa.⁴ Displaced people face many problems including lack of access to healthcare services, and many IDPs suffer from NCDs requiring costly and long-term treatment.⁵

The ongoing armed conflict between the Sudanese Armed Forces (SAF) and the Rapid Support Forces (RSF) has led to the displacement of 6.8 million people within the country, representing the largest number of IDPs internationally.⁶ The number of IDPs in the Northern State is about 2.166 million,⁷ hosted by local communities or allocated in shelters. The substantial influx of IDPs imposed a significant burden across various domains, notably exerting pronounced pressures on the health sector with constrained facilities.

In previous global studies, approximately 8% and 30% of Syrian IDPs and refugees present with complaints related to NCDs, respectively.⁸ In Ukraine about 59.8% of IDPs had at least one NCD.³ In Iraq, about 33% of IDPs had one or more NCDs, and 40% of them were not adhering to their prescribed medication regimen.⁹ In Sudan the ongoing conflict causes a humanitarian crisis and serious impact on the health system. Implications of the war on the health system include the closure of health institutions, cessation of services, shortages of medication supply associated with massive displacement, and increased risk of epidemics, and hunger.^10,11 However, there is a scarcity of studies addressing the health status and needs of IDPs in different regions of Sudan.

The significant and persistent gaps in information and evidence make it challenging to recommend effective strategies to reach satisfactory NCD care among conflict-affected people with special emphasis on children and women.¹² Providing information about the availability of affordable health care services and medications is the first step to establish effective care for IDPs. Unfortunately, there is a lack of such data in Sudan, including Northern state. Bringing these issues into consideration, this study aimed to explore the prevalence of NCDs and access to healthcare services and medications among IDPs in Dongola locality, Northern State, Sudan.

Methodology

Study Design and Setting

A cross-sectional study design was employed, adhering to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The study was conducted in Dongola locality, which accommodates two million IDPs. Dongola is the capital of the Northern State, it is located on the west bank of the River Nile, about 450 km northwest of Khartoum. The study was conducted during the period from 10/09/2023 to 31/12/2023.

Study Population

The study population consisted of Sudanese adults of all ages displaced to the Dongola locality. The study included, males and females who were displaced to Dongola locality due to the armed conflict and living in accommodation shelters during the study period. Individuals who were unconscious, or could not speak were excluded.

Sampling Method and Sample Size Determination

The study participants were recruited by systematic random sampling using a list of IDPs in displacement shelters as a sample frame. Briefly, the sampling interval was calculated by dividing the population size by the sample size. The first was randomly selected using an Excel random number generator. Subsequent participants were then selected at regular intervals until the entire list for was covered.

The sample size was calculated using Raosoft Online Calculator (Raosoft Inc).,¹³ with a margin of error of 5%, and a confidence interval of 95%. Based on the population size of 2054 individuals, the calculated minimum size was 324. By adding 20% to account for potential non-response rates, the study required a minimum sample size of 389 individuals.

Data Collection

The data were collected using a structured questionnaire, and filled by face-to-face interviews. Data collectors were volunteer medical students who were well-trained in sampling procedures and questionnaire administration. The questionnaire was adapted from a similar study conducted in Ukraine,³ and it consisted of two sections (19 items). Section one contained six items about the socio-demographic information of respondents (age, gender, marital status, current source of income, residence before displacement, and duration of displacement). Section two contained 13 items about health information such as if the respondent had been diagnosed with NCD, followed by subsequent questions for each reported diagnosis (type of NCD, date of diagnosis, interruptions in medical care, access to NCD medications, and encountered barriers).

To ensure content validity and clarity, the questionnaire was revised by three experienced researchers and was pretested among 34 individuals with similar characteristics to the participants. The pretest data were not incorporated in the study. The questionnaire was translated into the Arabic language, revised to improve phrasing and clarity, and back-translated to English language by two experts.

Data Analysis

Data were analyzed using statistical software (SPSS version 27, IBM). Descriptive statistics were utilized to summarize sociodemographic characteristics and health information, and presented as frequency and percentage tables. The chi-square test was used to test the association between sociodemographic variables of respondents and health information.

Ethical Considerations

Initially, the research proposal and research procedures including verbal informed consent were approved by the Research Ethics Committee, Ministry of Health, Northern State, Dongola city ((REC-MoH-NS-6-2023). Then verbal Informed consent was obtained from each participant separately, after being fully informed about the study objectives and procedures from data collection to publication. Participation in the study was entirely voluntary, and the participants had the option to withdraw from the study without penalty. The risks involved in the study are minimal, and participants were not compensated, but they could potentially benefit from the study’s findings. The privacy and of participants and confidentiality of data were maintained.

Results

Socio-Demographic Characteristics of Respondents

A total of 374 IDPs participated in the study with a 96.1% response rate. Almost 70% of the respondents were within the age range of 18–49, and 70.9% of them were females. About 66% of respondents were married, and 92.8 of them had no current financial source, about 78.1 of them stated that their original home was Khartoum state, about 80% were displaced for more than 10 weeks. Details of the socio-demographic characteristics of respondents are given in Table 1.

Table 1 Sociodemographic Characteristics of Respondents (N: 374)

Prevalence of Noncommunicable Diseases

As shown in Table 2, the prevalence of NCDs in our study was 42.5%, with a high prevalence of hypertension (44.6%) followed by diabetes mellitus (23.9%) then thyroid disorders (16.3%), with a low prevalence of chronic respiratory disease (11.3%) and chronic kidney disease (3.9%). Furthermore, 62.2% of respondents with NCDs had been diagnosed with more than one NCD.

Table 2 Prevalence and Duration of Non-Communicable Diseases Among Respondents (N: 374)

Interruptions in Medical Care and Access to Medications

As summarized in Table 3, out of the 159 (42.5%) respondents pre-diagnosed with NCDs, 132 (83%) were on long-term medications prescribed by their doctor, but only 54.7% of them used their prescribed medications regularly. Respondents showed that the reasons for interruption in medication use were financial constraints (28.7%), non-availability of their medications in pharmacies (12.5%), lack of motivation to take their medications (3.78%), or difficulty in reaching the pharmacies (1.89%). Furthermore, 61.4% of respondents with NCDs regularly visited a doctor since the displacement. The visits were at the accommodation shelter clinic (29.5%), a governmental public hospital (25.8%), or a private clinic (9.1%). However, 38.6% of respondents were unable to visit a doctor at any point during their stay in the displacement shelter. The reported reasons for not visiting their doctor were financial issues (20%), unavailability of co-patients (10.1%), difficulty in transport (6.9%), or unavailability of their preferred specialist doctor (1.7%).

Table 3 Interruptions in Medical Care and Access to Medications Among Respondents with Non-Communicable Diseases (N: 159)

As shown in Table 4, only 57.2% of respondents received free medical assistance; provided as free examination (25.4%), free investigation (16.8%), or free medication (15.0%).

Table 4 Access to Free Medical Services Among Respondents (=374)

Association between sociodemographic characteristics of respondents and NCDs and access to health care services

Data analysis revealed statistically significant associations of the type of disease with the age (p-value: < 0.001), gender (p-value: < 0.001), residence before displacement (p-value: 0.031), and Length of displacement (p-value: 0.018). (Table 5). On the other hand, there is no significant association between type of disease and doctor visiting (Table 6). Additionally, the chi-square test showed a significant association between the duration of disease and doctor visits (p-value:< 0.001) (Table 7).

Table 5 Association Between Sociodemographic Characteristics of Respondents and Type of Non-Communicable Diseases (N: 159)

Table 6 The Association Between Type of Disease and Doctor Visiting

Table 7 The Association Between the Duration of Disease and Doctor Visits

Discussion

The management of NCDs is a global health challenge, particularly in developing countries with limited resources and populations in armed conflict settings¹² NCDs constitute a major health threat for IDPs, and they are at increasing risk ⁠of deteriorating health status because NCDs require costly and long-term management.⁸

Our study revealed a high prevalence of NCDs among respondents, 42.5% of them had been diagnosed with at least one NCD, with hypertension being the most prevalent condition (44.6%), followed by diabetes mellitus (23.9%) and thyroid disorders (16.3%). Moreover, data showed a high prevalence of NCDs comorbidities among respondents (62.2%), which underscores the compounded health burdens faced by this population. This high prevalence aligns with findings from other conflict-affected regions such as Ukraine³ and Iraq,⁹ where more than one-third of participants reported having at least one NCD⁠⁠. However, in our study, the prevalence of hypertension and diabetes were higher than those reported among Syrian refugees in Jordan,¹⁴ where hypertension was reported among 28.4% of them. This disparity could be attributed to variations in participant characteristics such as genetic factors and socioeconomic status. The high prevalence of NCDs among IDPs could be attributed to the destruction of healthcare facilities in conflict regions. The ongoing war has severely damaged healthcare infrastructure, with 60 attacks on medical facilities reported. Many health facilities have been occupied by warring factions or are facing shortages and safety issues. This has led to the closure of 75% of medical centers and violence against over 200 healthcare workers.¹⁵ Similarly in Syria, the conflict has resulted in the deaths of an estimated 782 healthcare workers, with doctors accounting for a third of the fatalities. Many medical facilities operate critically low, with some functioning at less than 1%.¹⁶ Efforts should be focused on protecting healthcare facilities and workers from humanitarian violations to ensure a safe and effective working environment and minimize displacement and its associated burdens.

Regarding access to health care services, out of 83% of respondents on long-term medications for NCDs, only 54.7% of them adhered to their regimen. Financial constraints, unavailability of medications, lack of motivation, and difficulty accessing pharmacies were the main reported barriers. Moreover, 38.6% of respondents with NCDs reported interruptions in doctor visits due to similar barriers. These findings are consistent with previous studies indicating that financial and logistical challenges are major obstacles to healthcare access among IDPs in Iraq,⁹ Syrian refugees in Jordan^14,17⁠ and Ghanaians.¹⁸ Since healthcare services and medications are crucial to control and prevent complications of NCDs, there is an urgent need for active coordination between the Ministry of Health and non-governmental organizations to overcome barriers to accessing healthcare services. A recent project launched during the Tigray war crisis provided practical evidence for delivering health services to IDPs. In collaboration with community partners, Mekelle University established eleven clinics using local resources. These clinics offered a comprehensive range of healthcare services, including acute care, preventive measures (such as prenatal care and family planning), referrals to specialists, and public health surveillance.¹⁹

The analysis revealed significant associations between the type of NCD and socio-demographic characteristics of respondents (age, gender, and residence before displacement). Older age groups, females, and individuals originally from Khartoum were more likely to report NCDs. Similarly, a recent study reported high prevalence of NCDs among elderly people in Saudi Arabia.^19,20 These findings suggest that tailored evidence based interventions considering these demographic variables are crucial. The chronic disease self-management program has proven effective in many countries, including Saudi Arabia. It empowers individuals to develop essential skills and boost their confidence in managing their NCDs.²⁰

The significant association between disease duration and regular doctor visits further emphasizes the need for continuous and accessible healthcare services for long-term management.

Limitations

The study has some limitations, one of the limitations is that the study was conducted among IDP accommodated in displacement shelters in the Dongola locality, so it may not reflect the status of the displaced individuals who are not living in shelters. Secondly, the prevalence of NCDs was estimated based on self-reported data without further verification of medical records or diagnosis. Thus, undiagnosed patients and new cases are not covered. Additionally, the study was a cross-sectional design conducted at a single point in time, it only identifies associations between variables, not establish causation or the direction of the relationship.

Conclusion and Future Directions

This study is pioneering in its scope within Northern Sudan and provides essential baseline data for future research. About 42.5% of the IDPs in this study suffer from NCDs, with hypertension (44.6%), diabetes mellitus (23.9%), and thyroid disorders (16.3%) predominating. 45.3 and 38.6% of IDPs with NCDs respectively have interrupted their medications and lost regular follow for many reasons including financial constraints, lack of medications lack of access to healthcare services, and lack of motivation.

Our study underscores the urgent need for improved healthcare access and management of NCDs among IDPs. Potential solutions include implementing mobile clinics, establishing primary healthcare centers within accommodation shelters. Addressing the healthcare needs of IDPs with NCDs requires a multifaceted approach, including policy changes, resource allocation, and community-based interventions. Further research should focus on longitudinal studies to monitor health outcomes and the effectiveness of implemented interventions.