Increased utilization of health care services for non-communicable diseases during the COVID-19 pandemic among refugees in Jordan: a mixed-methods study

Maintaining routine health services during epidemics and humanitarian crises is instrumental to reduce preventable mortality and morbidity. Given the health service disruptions observed during the COVID-19 pandemic worldwide, we aimed to investigate the evolution of health care service utilization for acute and routine chronic care among refugees in Jordan during distinct phases of the COVID-19 pandemic and discuss the interventions that may have contributed to the observed changes in utilization. We conducted a mixed-methods study with three components: (1) interrupted time-series analysis of routine health data in Azraq and Zaatari camps; (2) a household survey among refugees in and out-of-camps (descriptive statistics and comparisons across pandemic periods using Poisson models with household-correlated robust variance estimation); 3) focus group discussions among refugees in and out-of-camps (inductive and deductive thematic content analysis). The analyses compared outcomes across four study periods: (1) Pre-COVID-19 (January 2018–March 2020); (2) Lockdown (April 2020-June 2021); (3) Post-lockdown (July 2021–April 2022); (4) Normalization (May 2022-March 2023), and three refugee groups (Syrian in-camps, Syrian out-of-camps, non-Syrian out-of-camps). Study outcomes included health care utilization for acute and chronic conditions (average number of outpatient consultations per person per year) and self reported health care seeking behaviour. Acute care utilization declined sharply during the lockdown and recovered gradually to pre-pandemic level during the post-lockdown period. Diabetes care utilization was low before the pandemic across groups. After a reduction during lockdown, it increased significantly during the normalization phase to above pre-pandemic rates. A package of service adaptations was introduced to facilitate access to services and medicines: multi-months drug prescription; new distribution system for medication home delivery; home visits; telephonic follow-up; hotline for questions. Study participants reported different experiences in accessing care, from spontaneous support to perceived barriers and limited access. While challenges were highlighted (waiting time, transportation, cost), most participants appreciated the intervention package and praised the comprehensiveness of the provided services. This paper investigates changes in health care services utilization of acute and routine chronic care among refugees in Jordan during the COVID-19 pandemic. We learned that acute care will likely rebound back to pre-shock levels and that the utilization of chronic care benefitted from introduced changes in the approach of service delivery, namely a package of complementary interventions that proved helpful in facilitating access to care and medicines for NCD patients while reducing COVID-19 exposure. By documenting UNHCR’s and partners’ efforts, we provide examples of concrete interventions that should be implemented to improve future pandemic responses.